Optimum Medical LLC

Advanced Wound Therapy Pre-Treatment Checklist

Membrane Wrap™ | Membrane Wrap - Lite™ | Microlyte® SAM™

Provider has documentation of the following in the patient’s medical record:

• Diagnosis of a chronic wound and the causation or etiology (i.e. Type II Diabetes)
• Primary (etiology) and Secondary (chronic ulcer) ICD-10 codes
• Failure to respond to good standard wound care for ≥4 weeks (Be specific about modalities such as debridement, advanced dressings, collagen, etc.)
• Underlying disease or condition is being treated by licensed physician and is under control:
  • Diabetes – HbA1c <12%
  • Venous stasis – Compression therapy
• Blood perfusion is adequate (ABI ≥0.65 or Toe pressure ≥30 mmHg)
• Venous reflux studies for venous stasis ulcer diagnosis
• Patient is compliant with off-loading or compression (document type)
• Absence of wound infection or osteomyelitis – must state in the record
• If the patient has a history of osteomyelitis, recent x-rays are negative for active osteomyelitis and the patient’s chart documents stating the osteomyelitis is not active
• For patients with history of Charcot neuroarthropathy, include documentation that acute Charcot foot is not present, and any history of acute Charcot foot has been treated
• Weekly wound measurements taken; wound size ≥1 cm² when initiating therapy
• Smoking Status – smokers counselled to stop and provided cessation resources to curb smoking
• The patient is adequately nourished to support wound healing
• Documented treatment plan; to include the use of advanced therapies

See also Medical Necessity Documentation for suggested items to record in the patient’s chart.