Wound Care Update: I Thought I Was Doing Everything Right…Until the Denials Came In

By Cassandre Voltaire, DO, ABWMS

I used to think documentation was the easy part. Write what you saw, describe what you did, keep it clear and detailed. I was trained well. I took pride in good notes—organized, clinical, complete. The kind you’d feel confident handing off to a colleague.

So when I started seeing denials for wound care visits, I was confused. Not for lack of improvement. Not for gaps in treatment. But because the notes—my notes—didn’t check the right boxes. It caught me off guard.

I had always thought of Medicare and other insurance reimbursement as a backend process, something for billing to figure out. It was a function of codes and clerical work, not something I needed to worry about as a clinician doing solid, evidence-based care. But when the same visit got flagged twice, and then a third time for a skin substitute denial, I knew I had to dig deeper.

The first time I looked at a Local Coverage Determination (LCD) closely—really looked at it—it wasn’t love at first sight.The language was dense. The formatting was dry. But in between the lines, I saw something important: They were telling me what they needed to see. And I hadn’t been showing it. Things like:

• Precise measurements at every visit
• Description of the tissue removed, not just “debrided as needed”
• Documentation that explained why the treatment was still medically necessary

I’d been doing all of that. But I hadn’t been saying it in the way the system recognizes. And it turns out, that language matters more than I realized.

Good Medicine Vs Approved Medicine

This is what I’ve come to understand: You can provide excellent care and still be denied. Denied not because what you did was wrong, but because how you documented what you did did not match the language of reimbursement.^1,2

I always thought “medical necessity” would be obvious from the clinical picture. But medical necessity, at least on paper, is a formula. It’s not enough to be right. You have to write it right. And the difference between “wound improved with debridement” and “continued presence of devitalized tissue, 20%, requiring selective sharp debridement per CPT 97597” can mean approval—or denial. This isn’t about gaming the system. It’s about understanding how the system reads what we write.

I expected to feel frustrated—and I did. But what I didn’t expect was how much clarity came from reading the LCDs and linking them back to my own notes.³ The denials weren’t random. They were following a playbook. I just hadn’t read the playbook yet. And once I did, it felt less like fighting an invisible enemy and more like learning a new language. Still medicine, just written with a different accent.

This Isn’t a Compliance Lecture

• I’m not writing this to give advice. Honestly, I’m still learning. I still overthink my phrasing. I still wonder if I’ve included enough detail. But here’s what I can say from the trenches of figuring this out:
• LCDs aren’t just policy—they’re prompts. If you follow the logic, you can reverse-engineer what your documentation needs to show.^1,4
• Coders can only code what we, the clinicians, document. If we’re vague, we tie their hands. If we’re precise, we give them the keys.
• “Medical necessity” isn’t assumed. It has to be spelled out, sometimes sentence by sentence.^2,5

There’s a strange kind of power in realizing that.

The Part I Never Learned in Training

I’ve had years of clinical education. I’ve practiced in hospitals, skilled nursing facilities, and wound clinics. I’ve memorized pressure ulcer stages, venous protocols and biofilm management strategies. But not once—not once—did anyone walk me through how documentation links to reimbursement denial risk. Or how Medicare’s language shapes the care our patients are allowed to receive.That knowledge wasn’t framed as part of my job.

And yet now I can see it clearly: If I don’t know how to document for coverage, I might unintentionally block access to care. That makes it my job whether I like it or not.

So where am I now?

I’m still working through it. I’ve started reviewing LCDs when new denials come in. I’ve rewritten templates and added prompts. I’ve asked coders questions I never used to ask. I’ve also become less embarrassed about not knowing these things sooner. Because here’s the truth: A lot of us don’t know. Not because we’re careless, but because this system is complicated and no one teaches us how to speak its language.

But I’m learning. Slowly. Deliberately. And sharing what I find, in case it makes someone else’s road a little less frustrating. Because in the end, the goal isn’t to be perfect. It’s to make sure the care we give actually reaches the patient. And if that means writing one extra sentence in the note, then that sentence might be the most important thing we do that day.

Cassandre Voltaire, DO, is a wound care physician specializing in advanced wound management and chronic wound healing. Based in Massachusetts, she combines her background in family medicine with holistic and evidence-based wound care. She is also the founder of WoundFit, dedicated to empowering healthcare providers with accessible wound care education and resources.