Reader Report: Tell Us Your Auditing Story

For our most recent reader survey, Today’s Wound Clinic asked readers to share their experiences regarding audits that have occurred in their outpatient wound clinics. Here, we offer some of your anonymous stories. Thanks to all those who participated!

“I have worked in the hospital outpatient wound care arena for the past 12 years as a reimbursement director. I am a certified coder and certified medical auditor.  Audits were done routinely to assure correct, timely coding and payment as well as when payment issues arose. The most common occurrences and issues found in the audits were essentially two: the overuse of evaluation and management services billing and the issue of documentation not supporting services billed. This last example will become even more important with the implementation of ICD-10-CM, as diagnostic coding is what supports medical necessity. I have been told payers will not pay claims where unspecified codes are used when laterality is needed. If the documentation does not include that laterality, then there is doubt that the patient was examined. I found this comment interesting, to say the least.” 

“Wagner Scale audits! We found we were getting denials from payers because we did not have the correct level indicated in the electronic health record. This information is inputted by the nurse and crossed over into the ‘physician progress note’ on the backend. Providers were not reviewing the entire assessment details before signing off their documentation. An audit revealed it was a systemic (provider and nursing) process issue and helped us to identify ways to avoid future problems. We also perform monthly audits for hand hygiene, universal protocols during debridement procedures, and expired product audits. We are protocol driven with our practices, so audits also help us with staying on track to ensure patients are receiving the correct diagnostics, procedures, and assessments in a timely manner for optimal healing results. If you work in an environment of proactive audits, you can keep the regulators off your back.”

“Around 2006, my claims for hyperbaric oxygen therapy (HBOT) were not being paid by Medicare. When Medicare was contacted by my billing staff members, they were instructed to use another modifier with the HBOT billing code as opposed to the modifier we had been using for the previous year or so. After no payment again for more than 30 days, my billers contacted Medicare and were instructed to return to the modifier we had already been using. This flip-flopping modifier changing continued for almost six months. I finally became involved and called Medicare. My call was returned a few days later. I was told my HBOT claims would not be paid because I am a podiatrist. I told the individual that I had an official letter of recognition acknowledging that, in the state of Georgia, I was within my scope of practice and Medicare would pay me for appropriate HBOT claims. After going another 60 days with no payment for HBOT, I again called. It took 18 months to get paid, and that was only 50 percent. I had to appeal all my outstanding claims, as Medicare then rejected my refiled claims because they “had not been filed timely”! I ended up filing chapter 7 bankruptcy and lost everything I owned, including my life insurance. When Medicare knocks on your door, be scared.”