Q&A: Improving skin substitute documentation
Q: What elements need to be in the documentation to ensure complete reimbursement for skin substitute claims?
A: Revenue integrity professionals should work with clinical and CDI staff to ensure documentation for skin substitute claims contains the necessary procedure details. Along with listing the applicable Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System codes, the documentation should include the skin substitute product name, National Drug Code, and applied size, says Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, senior consultant and owner of Compliant Health Care Solutions in Port Charlotte, Florida. She suggests recruiting IT staff to create electronic health record template prompts for any troublesome documentation elements at your organization.
Providers should be as detailed as possible when documenting drug waste, as their specificity will support the use of modifiers -JW and -JZ and prevent potential denials and audits. The documentation should list the amount of product used, the amount of product discarded, and the reason for the wastage.
It can also be beneficial to include the manufacturing information and unit identification number for the skin substitute product, she adds. If the manufacturer did not supply this information, it should be noted in the medical record.
Skin substitute documentation should clearly reflect the medical necessity of the product and procedure, which requires information on the wound size, location, and chronicity, according to Hovey. The history of the wound (i.e., onset, previous treatments, response to treatments) should also be reflected in the documentation, as well as a comprehensive description of the application.
If there are obvious signs of the wound worsening or not responding to the treatment, it would not be considered medically necessary to continue treating the wound with skin replacement surgery. If continuing treatment is necessary, the clinical rationale must be clearly stated in the documentation.
For certain claims, it may be necessary to document the patient’s smoking history. If applicable, the record should state that the patient has received counseling on the effects of smoking on surgical outcomes, list any provided smoking cessation treatment, and detail the outcomes of those services.
Editor’s note: This answer was excerpted from “Ensuring appropriate coding and documentation for skin substitute claims,” in the July 2025 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.