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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.77 Wound Care Management : Documentation Requirements
For all wound care management services, documentation that supports the medical necessity of the service must be maintained in the client’s medical records, including the following information:
Accurate diagnostic information that pertains to the underlying diagnosis and condition as well as any other medical diagnoses and conditions, which include the client’s overall health status.
Documentation maintained in the client’s medical record must support the level of debridement service provided.
Fewer than five surgical debridements that involve removal of muscle or bone are typically required for management of most wounds. Documentation that is maintained in the client’s medical record must support the number of debridements involving muscle or bone that are performed.

Texas Medicaid & Healthcare Partnership
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