Every wound care encounter should document Wound location (anatomical site, laterality) Wound healing progression compared to prior visits Clinical rationale for the procedure (medical necessity) Wound measurements (length width depth in centimeters) Deepest tissue level reached (for surgical debridement codes) Wound surface area treated (for selective debridement codes) Tissue type observed (necrotic, slough, granulation, epithelial) Procedure performed (selective debridement, surgical debridement, NPWT, non-selective cleaning) Missing wound measurements alone can trigger a denial payers require size documentation to validate the CPT code selected, especially for area-based codes (97597/97598) and NPWT (97605/97606)
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