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Debridment

Triple-S Salud considers payment for debridement when provided by the surgeon for the management of ulcers or wounds of the skin and underlying tissue to promote optimal wound healing or to prepare the area for adequate surgical intervention.
The requirements to consider a reasonable and medically necessary service are the following:

•  Safe and effective debridement methods more appropriate for the type of wound, according to standard medicine therapy

•  That they take place in the appropriate setting: hospital, medical office, emergency room.

• Services must be ordered and performed by qualified medical personnel with Wound Care Certification by the American Board or Wound Healing or surgical  specialty.

The coverage of Triple-S Salud for wound care (continuously) in a patient depends on the evidence documented in the patient’s medical history that the wound is improving in response to the treatment being offered. It is not reasonable and medically necessary to follow a certain type of wound care if evidence of improvement of the wound cannot be documented.

Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

1.  Drainage (color, quantity, consistency)

2.  Discharge of secretion (color, quantity, consistency, odor, etc.)

3.  Inflammation of the wound or injury

4.  Edema of the anatomical area involved

5.  Pain

6.  Dimensions (wound diameter, depth, tunnels) – Cubic dimensions length, width and depth

7.  Presence of granulation tissue Necrotic tissue / slough

Such evidence must be documented with each visit.

A wound that does not improve after 30 days requires a new approach that may include a re-evaluation by the doctor, in terms of possible identification of underlying infection, metabolic or nutritional disorders or vascular problems that inhibit wound healing. A new care plan or treatment method must be formulated.

Rarely, the goal of wound care planned in the outpatient setting can only be to prevent the progression of the wound. This is because the underlying weakness of the patient (associated with comorbidity factors) is not expected to improve.

Documentation requirements

The medical record maintained by the provider must clearly indicate the medical necessity of the service that is invoiced. The medical record must include the following information and be available for audits by Triple-S Salud upon request:

A surgical report or progress note is necessary for when the debridement service is performed. This note should describe the anatomical location treated, instruments used, anesthesia used (if necessary), type of tissue removed from the wound, depth, area of the wound and immediate postoperative care and follow-up instructions.

The following information must be available when the other services are provided:

§ Identification of the location of the wound, size, depth and stage of evolution. It must include a drawing or a photograph.

§ A description of the type (s) of affected tissues, the severity of tissue destruction, scouring or tunnels, necrosis, infection or evidence of reduced circulation.

§ A tissue pathology report obtained after the debridement procedure described by CPT code 11044. The documentation of the clinical history must show:

§ The condition of the wound is such that the treatment is expected to achieve a significant improvement over a reasonable and generally predictable period of time.

§ There is an expectation that the treatment will substantially affect tissue healing and its viability, reduce or control tissue infection, eliminate necrotic tissue or prepare tissue for surgical management.

§ The expected restoration potential of the patient must be significant in relation to the scope and duration of the required treatment. If wound closure is not a goal, then the expectation is to optimize recovery and establish an adequate non-specialized maintenance program.

§ The management of active rehabilitation for wounds and / or burns must be carried out by a physical or occupational therapist and must be carried out under a work plan. This service plan must describe the specific objectives, duration, frequency, modalities, estimate the anticipated endpoint and any other relevant factors as applicable. Departing from this plan must be documented.

787-277-6653 787-474-6326