Coder’s Insight: Documentation Elements & Audit Resource Guide for CTPs

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Many wound care professionals go about their day-to-day business unsure as to whether they would face a Medicare repayment if their claims for the application of cellular and/or tissue-based products (CTPs) for skin wounds were audited. Accurate, complete medical record documentation by the physician or other qualified healthcare professional (QHP) who applied the CTP is the best way to ensure appropriate payment and to reduce the risk of any repayment following an audit. Regular self-auditing of one’s medical records that include application of CTPs is the best way to catch and correct documentation errors. This article will offer related assistance.   

Document Application of CTPs

Some of the Medicare Administrative Contractors (MACs) have active local coverage determinations (LCDs) and articles that provide excellent guidance regarding covered indications, limitations of use, and documentation requirements for the application of CTPs. Other MACs have retired their LCDs and articles on this topic, but wound care professionals can still view those documents in the Medicare Coverage Database Archive.¹ Wound care professionals should take the time to read either their MAC’s active or retired LCDs/articles and use the guidelines to design a documentation template for the application of CTPs. Additionally, wound care physicians and QHPs should follow these general medical record documentation guidelines for the application of CTPs:

1. Include a current “problem list” and medication list in the medical record. Do not include discontinued medications and diagnoses that have been resolved or are no longer treated.
2. Create a plan of care.
3. Document the medical necessity for the application of the CTP.
4. Describe (in detail) the rationale for the specific CTP selected.
5. Sign (by physician/QHP) the order for application of the CTP. (Unsigned orders will result in a Medicare repayment following an audit.)
6. Document the entire CTP application procedure completely and legibly.
7. Document (in detail) all wound care and CTP treatments, as well as test results from visit to visit.
8. Document and compare the wound size from visit to visit after the first CTP application.
9. Ensure that any quality measures that the wound care professionals are reporting are reflected in the documentation.
10. Document all required elements for each encounter.

Audit of CTP Application Documentation

The purpose of a self-audit is to verify that physicians and other QHPs accurately and completely document all elements required in the medical record to support their application of CTPs. The audits can be performed on both manual and electronic health records and should be performed on a regular schedule. This author recommends conducting a predetermined number of quarterly audits on randomly selected medical records from all physicians/QHPs who perform the procedure. In addition, all claims denied for the application of CTPs should be included in the quarterly audit because denied claims help identify problematic documentation trends and patterns. Before beginning the audit, the denied claims should be categorized according to the reasons for the denials. When claims are denied because application of the CTP is not deemed medically necessary by the payer, the physician/QHP who performed the procedure should review the medical record to determine if the payer missed some pertinent documentation or if the required documentation elements were simply not in the medical record. If the physician/QHP, as well as the auditor, determine that the claim denials were warranted, the auditor should take the time to teach these wound care professionals the documentation deficiencies that led to nonpayment. Auditors should also track each physician’s/QHP’s type of denials. As physicians/QHPs improve their documentation and reduce the number of denied claims for the application of CTPs, the auditor should compliment them for work well done. NOTE: This author is consistently surprised at the number of physicians, other QHPs, and program directors who do not review their denied claims. A process should be established in which someone, who has access to the medical record and is qualified to assist in the denied-claim appeal routinely reviews the denied claims with the pertinent stakeholder(s). In response to numerous requests, this author has created a sample auditing resource guide that can be used to audit medical record documentation when CTPs are applied (Table). This sample audit guide was created by reviewing the active and retired LCDs and articles, and by including documentation elements that are or have been required in all MAC jurisdictions. The guide contains numerous elements and is divided into sections that can be audited at different review periods. The guide itself should be used as a teaching method to remind all physicians and other QHPs who apply CTPs of what is expected in good documentation for this procedure.   

Summary

When CTPs are applied, a well-documented medical record should enable PBDs, physicians, and QHPs to keep their payments rather than face Medicare repayments due to poor documentation practices. In addition, excellent documentation is the best defense when appealing a denied claim. Wound care professionals should conduct self-audits to identify documentation deficiencies and to improve their documentation before a Medicare auditor identifies the deficient documentation. Utilize the audit guide accompanying this article to assist application of CTP documentation self-audits. 

Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is approved as a certified trainer on ICD-10-CM by the American Health Information Management Association and she has been designated as a fellow of the American Health Information Management Association.

Reference

1. Medicare coverage database archive. CMS. No date. Accessed online: https://localcoverage.cms.gov/mcd_archive