Business Briefs: Lack of Documentation May Cause Loss of Dollars

  Early in their medical/clinical training, wound care physicians and clinicians learn the caution, if it’s not documented, it’s not done. Few physicians and clinicians, however, realize the enormous financial consequences that the lack of documentation can have on their practices if:
    • they perform self-audits and find that their documentation did not support the codes that were billed and the payments they received and/or
    • they receive a Medicare audit and find that their lack of documentation resulted in false claim submissions.

  In wound care settings a variety of physicians and clinicians practice as a team to achieve excellence. Each member of that team should take personal responsibility for clearly documenting the work they perform. These professionals should not only use the documentation guidelines learned during their medical training, but should also follow the guidelines of the payers who review their claims for medical necessity. Most Medicare contractors provide educational seminars, webinars, online training, educational documents related to documentation, medical policies, and articles that include documentation requirements.

OIG Wound Care Related Reports

  In the middle of 2007, the Office of Inspector General (OIG) released several reports regarding the wound care industry:
    • May 2007: Medicare Payments for Surgical Debridement Services in 2004.
    • June 2007: Medicare Payments for Negative Pressure Wound Therapy Pumps in 2004.

  Unfortunately, both reports found that documentation in the medical records of wound care patients did not adequately support medical necessity of the procedure(s) performed and/or the product(s) ordered. The OIG found Medicare overpaid $64 million for false claims involving surgical excisional debridement and $27 million for false claims involving negative pressure wound therapy pumps and supplies.

Medicare Medical Reviews

  Numerous medical reviews have been conducted by Medicare contractors regarding surgical dressings that were not ordered according to the guidelines of the Surgical Dressing Local Coverage Determination (LCD) and its accompanying Article. Most recently, Medicare contractors have been requesting repayments due to the fact that providers have not documented the method of fixation for skin replacements and skin substitutes. Since these are considered surgical procedures, the payers expect to see fully documented procedure reports, including the method of fixation used to secure the skin replacements and skin substitutes. Some contractors recommend the minimal fixation (eg, steri-strips) they require while other contractors leave the decision up to the physician who applies the products. However, all Medicare contractors expect that the medical record will include documentation of the fixation method selected.

  Therefore, each wound care physician and clinician must take personal responsibility for reviewing the documentation guidelines that the payers provide. One should not become complacent with inadequate documentation just because all claims are currently paid. Remember, repayments can be enormous if medical records are audited and your documentation does not adequately support medical necessity for the fees that were paid.

Steps to Success

  The following are some steps to success for identifying payers’ policies that should be followed:
    • Identify the top payers for the wound care patients.
    • Identify the Medicare contractors that process the claims for the facility and for the physicians who practice there. (Please note: Currently the facility and the physicians could have different Medicare contractors who write similar or different policies. Over the next few years, the same Medicare contractor will process both the facility and the physician claims; the policies should be more closely aligned once that happens).
    • Visit the websites of all commercial payers and Medicare contractors who process claims for the facility and for the physicians who practice there. Search for educational materials, policies, newsletters, seminars, webinars, etc. regarding each of the services, procedures, and products that are on your charge sheets and that are eventually submitted as claims to the payers.
    • Review and compare the documentation guidance, which is provided for the facility and the physician, with the entire medical and clinical staff of your outpatient wound clinic.
    • Schedule frequent physician and clinician staff meetings to share every guidance policy that pertains to the services, procedures, and products performed/used.
    • Assign someone to regularly review the payers’ websites for new and/or updated guidance policies.
    • Schedule physician and clinician training every time new/updated guidance policies are released.
    • Conduct self-audits frequently; if compliance issues are found, report them to the corporate compliance officer immediately.

Documentation Guidance Examples

  Finally, let’s review some examples of the pertinent documentation guidance that physicians and clinicians will find when they review their Medicare contractor’s LCDs and Articles. Remember, documentation must be present to support medical necessity, which in turn supports your payment. (Please note: The examples provided are only pertinent to the clinicians and physicians under the jurisdiction of the Medicare contractor who developed the LCD/Article. Furthermore, these examples may be out-of-date by the time this column is published. Every clinician and physician should research the LCDs and Articles that are specifically pertinent to their payers and their geographical area. Do not follow the guidelines found in Tables I–IV; they are only provided as examples to show the type of documentation policies that currently exist.)

    • The DME MAC (Medicare Administrative Contractor) TrustSolutions provides documentation guidance (See Table I) in the LCD for Surgical Dressing (L11449), which can be found at: www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11449&lcd_version=36&show=all
  If surgical dressings are ordered for patient use at home, you should obtain the LCD for Surgical Dressings that pertains to the patients’ specific payers.

    • The MAC (Medicare Administrative Contractor) TrailBlazer Health Enterprise provides basic wound care and debridement documentation guidance (see Table II) in the LCD for Wound Care- Chronic Refractory Wounds (S-130B-R3), which can be found at: www.trailblazerhealth.com/Tools/Local%20Coverage%20Determinations/Default.aspx?ID=2811
  Clinicians and physicians should locate their respective payers’ policies regarding required chronic wound care and debridement documentation to prevent future repayments.

    • The Medicare Carrier First Coast Service Options provides documentation guidance for the application of various skin substitutes (see Table III) in their LCD for Skin Substitutes (L13381), which can be found at: www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=13381&lcd_version=13&basket=lcd. If your facility and physicians offer the state-of-the-art procedures/products, be sure to review the Medicare contractor’s pertinent LCDs and Articles.

    • The MAC (Medicare Administrative Contractor) Wisconsin Physician Services provides documentation guidance (see Table IV) in their Part A LCD for Hyperbaric Oxygen (HBO) Therapy (L26527), which can be found at: www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=26567&lcd_version=3&basket=lcd Facilities and physicians who provide HBO therapy should locate their payers’ documentation guidelines on this topic.

Summary

  Now that examples of documentation guidelines have been reviewed, which are provided by several Medicare contractors, one should be motivated to conduct research and find the medical policies that apply to the physicians and clinicians who work in the wound care center for excellence where they work. Educate oneself regarding the documentation requirements. If one needs assistance to interpret the guidance policies, contact the medical director of the payer who wrote the policy and/or request an in-service from the professional coder(s) in the facility and in the physicians’ practices. Ultimately, each physician and clinician should assume the responsibility for their own documentation. This high quality documentation should reduce the number and amounts of repayments that the facility and the physicians may incur. Remember that above all, documentation is essential for correct payment and clean claims.

  Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, Fla. Schaum can be reached for questions and consultations by calling (561) 964-2470 or through her email address: kathleendschaum@bellsouth.net.

  Information regarding coding, coverage, and payment is provided as a service to TWC readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies at the discretion of the reader.