Checklist: Debridement

This checklist is intended to provide healthcare providers with a reference for use when responding to medical documentation requests for debridement. Healthcare providers retain responsibility to submit complete and accurate documentation.

Check	Documentation description
	Please submit a mandatory advanced beneficiary notice (ABN) if issued.
	Signed physician order for wound care/treatment.
	History & physical (H&P) with the initial wound description, location and measurements and response to prior treatment.
	Clinical documentation of diagnosis or symptoms to justify services .
	Current progress notes (including measurable signs of healing as well as causes of delayed wound healing or modification to the treatment plan).
	Operative note or procedure note for the debridement services including description of tissue debrided, instrumentation used, pre and post wound measurements.
	Plan of care containing treatment goals and physician follow -up.
	Documentation of the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.
	Consult reports as applicable.
	Reports of all testing/services billed.
	Itemized bill.

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.

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Last modified: 02/16/2023

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