What CPT codes are used for wound care visits?

Use E/M codes 99212-99215 for evaluation. Debridement codes: 97597 (selective, first 20 sq cm), 97598 (each additional 20 sq cm), 97602 (non-selective). Active wound care management uses 97605-97608 for negative pressure therapy. Application of skin substitutes uses 15271-15278. Document wound size and debridement extent to support code selection. Time-based codes require documentation of time spent.

What wound measurements are required for documentation?

Document: length (head-to-toe), width (side-to-side), and depth in centimeters, undermining/tunneling with clock-face location and depth, wound bed composition (percentage granulation, slough, eschar, epithelialization), and wound area calculation (L x W). Compare to prior measurements to document progress. Photographs support documentation but don't replace measurements.

How should debridement be documented for billing?

Document: type of debridement (sharp, mechanical, enzymatic, autolytic), tissue removed (necrotic, slough, biofilm, nonviable), total wound surface area debrided in square centimeters, depth of debridement, bleeding controlled, and instruments used for sharp debridement. Selective debridement (97597-97598) requires removal of devitalized tissue; non-selective (97602) is less specific.

What documentation supports wound healing progress?

Document: wound size changes (percentage reduction per week—expect 10-15% reduction weekly for healing wounds), wound bed improvement (increasing granulation, decreasing slough/eschar), periwound condition, drainage changes, pain trends, and barriers to healing (glucose control, pressure offloading compliance, edema management, nutrition status). Stalled wounds (no progress in 2-4 weeks) require treatment modification.

What documentation is needed for advanced wound therapies?

Document: wound etiology and duration, failed conservative treatment (type, duration), wound stagnation despite standard care, wound characteristics supporting advanced therapy, and medical necessity. For skin substitutes: wound size, preparation, application technique, and product details. For NPWT: wound measurements, VAC settings, seal integrity, and output. Most require prior authorization with documented treatment failure.

Wound Care Note Template - Assessment & Treatment

Wound Care — Progress Note Template

Specialty Wound Care Updated: 1/3/2026

The Wound Care Progress Note Template is designed for wound care specialists, nurses, and physical therapists managing chronic or acute wounds. This template captures detailed wound measurements (L x W x D), tissue types (granulation, necrotic), drainage (exudate), periwound condition, and response to treatment. Supports documentation for ulcers (venous, arterial, diabetic, pressure) and surgical wounds. Includes sections for debridement and dressing changes.

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

Patient Information

Date: [Date]
Visit Type: Progress Note
Diagnosis: [Type of Wound - e.g., Venous Stasis Ulcer, Pressure Injury Stage 3]

Subjective

Pain: Current [0-10]. Pre-treatment meds taken? Yes / No Patient Report: [Improving / Worsening / Stable] Adherence: [Off-loading, compression compliance]

Objective (Wound Assessment)

Wound Location: [Anatomic location] Measurements:

Length: [X] cm (Head-to-Toe)
Width: [X] cm (Side-to-Side)
Depth: [X] cm
Undermining/Tunneling: [Location using clock face, depth]

Wound Bed:

Granulation: [X]%
Slough: [X]%
Eschar: [X]%
Epithelialization: [X]%

Drainage (Exudate):

Amount: None / Scant / Moderate / Heavy
Type: Serous / Sanguineous / Purulent
Odor: None / Present

Periwound Skin:

Intact / Erythema / Macerated / Indurated / Edema

Infection Signs:

Warmth, Redness >2cm, Purulence, Malodor? Yes / No

Procedure / Treatment

Debridement (if performed):

Method: Sharp / Mechanical / Autolytic / Enzymatic
Tissue removed: Slough / Necrotic / Biofilm
Extent: [Sq cm] or [Depth]
Bleeding: Controlled / None

Cleaning: Cleansed with [Saline / Wound cleanser]. Dressing Applied:

Primary: [Alginate / Foam / Hydrogel / Antimicrobial]
Secondary: [Gauze / Wrap / Compression]

Assessment

Wound is [Improving / Stalled / Deteriorating].

Size change: [Decreased by X% / Increased]
Factors affecting healing: [Glucose control, pressure relief, edema]

Plan

Continue current treatment protocol.
Change dressing: [Frequency - e.g., Daily, QOD, 3x/week]
Referral needed: [Vascular / Surgery / Podiatry] if no improvement in 2 weeks.
Off-loading education provided.

Follow-up: [Date]

Wound Care — Progress Note Template

Quick-Use Checklist

Template

Patient Information

Subjective

Objective (Wound Assessment)

Procedure / Treatment

Assessment

Plan

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