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Lessons Learned During Recent SMRC Audits
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.
As a Certified Professional Medical Auditor (CPMA) and reimbursement consultant, I occasionally receive requests from wound care providers (physicians/qualified healthcare professionals) to help respond to Medicare and other insurance audits. Such was the case recently when asked to help two separate physician practices (one in California and another in Michigan) respond to a Supplemental Medical Review Contractor (SMRC) post-payment audit for the hyperbaric oxygen therapy (HBOT) indication: Diabetic Wounds of the Lower Extremity (DWLE). This was part of a SMRC project titled ID#: 01-083.4
The first client’s request was to ensure that all essential and supporting information was present in their response to an additional documentation request (ADR) made by the SMRC. The ADR included 10 individual patient accounts, which consisted of 39 claims and 94 dates of service (DOS). The second client’s request was slightly different in that they had already submitted their documentation packets to the SMRC and only required assistance in responding to the "Postpayment Claim Review Results." Their ADR included 14 individual patient accounts, which consisted of 40 claims and 40 DOS.
Provider Response Requirements
Response instructions for documentation submission were easy to follow and clearly indicated that each claim number required its own medical record packet, which should stand alone in supporting charges for each DOS. According to the "SMRC Response Cover Sheet Form," a minimum of 14 items was required for each medical record packet, if/when applicable:
1. Physician documentation to support a systemic condition, neuropathy, vascular impairment.
2. Physician documentation detailing the prior course of treatment, including all interventions and/or evaluations.
3. Documentation to support that the patient’s entire body was exposed to the oxygen under increased atmospheric pressure and administered in a chamber.
4. Wound care assessment(s) and supporting documentation.
5. Nursing documentation (i.e., nursing notes and admission assessment—lines; medication and IV administration records; nursing treatment sheets such as skin care/wound care treatment sheets; respiratory treatments and oxygen therapy records).
6. Wound care notes.
7. Wagner grade classification (III or higher) for diabetic lower extremity wounds, diagnostic testing to support the Wagner grade and documentation of prior failed treatment(s).
8. Initial HBOT evaluation/consultation.
9. Documentation to support National Coverage Determination (NCD) 20.29, Local Coverage Determination (LCD) and/or Local Coverage Article (LCA) requirements, if applicable.
10. Signature log or attestation for any missing/illegible signatures within the medical record for all personnel providing services.
11. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
12. Any other supporting documentation.
13. If submitting medical record documentation via esMD, beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the documentation.
14. It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met.
SMRC Audit Results
For the first client, 26 of the 39 claims were denied, 6 were approved, and 7 were excluded. Interestingly, of the 26 denied claims, only 49 of the 63 dates of service were denied, a discrepancy not noted in the results. The reported error rate (total dollar amount of services paid in error divided by the total dollar amount of services reviewed) equaled 50.67%. The second client experienced a similar fate in that 32 of the 40 claims were denied and 8 were excluded. Their error rate equaled 66.81%. "Excluded" means the patient’s treatment indication was not DWLE (the focus of the SMRC audit), but instead a compromised graft/flap, radiation injury, or other. In such cases, the patient also had a diagnosis of diabetes (which is presumably how the claims were selected for review).
The SMRC denial rationale applied to the claims included the following (not all reasons applied to every denied account):
✓ There is insufficient documentation showing no measurable signs of healing after 30 consecutive days of standard wound care to support that the beneficiary failed to respond to standard wound care.
✓ There is insufficient documentation of a lower extremity wound due to diabetes—the operative note states that the toes were amputated; therefore, it is now a surgical wound.
✓ Documentation did not support the diabetic wound to be a Wagner grade III or higher—the submitted documentation supports a Wagner grade II.
✓ There is insufficient documentation indicating debridement of devitalized tissue was completed for diabetic wound management.
✓ There is insufficient documentation indicating optimal glucose control for diabetic wound management—no documented blood glucose readings or A1C value.
✓ There is insufficient documentation that a clean, moist bed of granulation tissue, with appropriate moist dressing, was provided.
✓ There is insufficient documentation addressing the patient’s nutritional status.
✓ Documentation indicates that the patient had a compromised vascular status, but did not address it. Documentation supports that a revascularization was completed, but there were no results of the procedure and/or status of the patient’s blood flow.
✓ Documentation did not indicate the patient’s entire body was exposed to oxygen under increased atmospheric pressure.
Providers’ Response to the Audit
If a provider disagrees with the initial findings, they can submit additional documentation supporting the denied claim(s). An alternate option is to request a voluntary D&E session (call) prior to submitting additional/missing documentation. The D&E session allows for:
✓ Communication of the audit results and payment recommendations,
✓ Discussion of the rationale for the findings,
✓ Education about coverage, coding, and payment policies to avoid future denials, and
✓ Identifying supporting documentation that is missing.
The primary advantage of requesting a D&E session is the opportunity to reduce monies recouped in error and/or any assessed penalties (interest, fines, etc.). Another advantage includes giving the provider an opportunity to have a peer-to-peer conversation to clear up any confusion about the rationale used in issuing an overpayment finding. Requesting a discussion with the SMRC does not limit the provider’s right to appeal the findings to the local MAC.
My first client requested a D&E session prior to the re-review process and learned that some of the accounts and dates of service were missing required documentation. In addition, it was determined that some of the accounts could be submitted with documentation supporting a different diagnosis (e.g., compromised graft/flap), which meant they would be excluded from the review and no monies forfeited. However, my second client chose to just submit additional documentation and have the D&E call after the re-review.
When submitting additional documentation for re-review, the efforts are often unsuccessful in getting any denied claims overturned and/or excluded. Unfortunately, the rationale for such decisions is not clearly defined by the SMRC. It appears as if the auditors are simply following a designated checklist and when any required item is missing, the claim is denied once again. Once additional/missing documentation is submitted and the re-review is completed, a new final review results letter is sent to the provider.
The SMRC will then send the provider’s MAC a letter indicating the final results, if monies are due. At this point, the audit process is over. If the provider still disagrees with the findings, they can begin the Medicare appeals process.
What You Should Know About the Medicare Appeals Process
A redetermination is the first level of the Medicare appeals process. Providers must request a redetermination within 120 days of the overpayment determination, as indicated in the demand letter. Additionally, if a provider wants to delay the recoupment payment, they must submit the redetermination request within 30 days of the demand letter date. If the request is submitted within the timeframe, the MAC will halt collection of the overpayment until it makes a redetermination decision. If the outcome of the redetermination is favorable, the MAC will cancel the overpayment and return monies already recouped, if any. If the outcome is unfavorable, the provider can then proceed to the next level of the Medicare appeals process—reconsideration. For more information about the appeal process, click here.
Top Ten Lessons Learned and Recommendations for Compliance
1. Diabetic Wounds of the Lower Extremities is an indication that receives considerable attention from insurance auditors/coders because of the strict coverage and dual diagnosis requirements. Pay close attention to those requirements and ensure that documentation clearly supports the indication. The SMRC auditors strictly adhered to 30 days of standard wound care (with no measurable improvement) and were looking for evidence of wound infection/deep abscess/osteomyelitis, debridement of devitalized tissue, offloading efforts, hemoglobin A1C values, nutritional assessments, moist wound environments, and more.
2. When submitting documentation in response to an ADR, arrange it in chronological order so that the auditing reviewer(s) can follow the complete story and timeline of care provided in a logical fashion. This also allows the provider an opportunity to ensure that there are no missing gaps in time and/or information.
3. During the D&E session, don’t hesitate to ask detailed questions about the audit process, specific dates of service, and rationale used to deny the claims. This author found the SMRC reviewers to be extremely helpful and willing to educate the provider accordingly.
4. The provider should be on the D&E call to better understand the rationale used in denying his/her medical decision making. If available, consider having a coder, biller, and compliance personnel on the call as well.
Note: SMRC auditors cannot reverse a payment determination during the D&E session. A reversal can only occur during a re-review, if warranted.
5. The SMRC (Noridian) used retired LCDs and LCAs from two different MACs—Novitas (L35021/A56714) and First Coast (L36504/A57800/A55788) as references for documentation and coverage requirements. Even though this is technically not allowed, it would still be prudent for providers to have a copy of these policies/articles and adhere to the documentation requirements found within. At a minimum, follow the guidelines posted on each MAC’s website.1–7
6. When submitting additional documentation for a re-review, use a cover letter for each account explaining which DOS are relevant, as well as the reason for the additional documents. This makes it easier for the SMRC reviewer(s) to understand what you are submitting and the reasons why. It is also helpful to indicate any DOS not being contested, if any.
7. Ensure that the diagnosis listed on the HBOT treatment logs matches the current diagnosis—this was noted by the SMRC as a discrepancy for most of the records.
8. It is important to check total treatment times for the HBOT therapy sessions to determine if the claims have accurate charges for the technical fee (G0277). One client left a considerable amount of money on the table by only billing 3 HBOT units, even though the total treatment time supported billing 4 units. The reverse was true for the other client—their treatment times were less than 106 minutes and they were billing 4 units.
9. Include HBOT consents (or other documents) with the treatment records to provide evidence that the patient’s entire body was exposed to increased atmospheric pressure. Typically, consents include language indicating that the patient will need to equalize the pressure in their ears during pressurization of the chamber.
10. Signature requirements are strictly enforced by the SMRC and stamp signatures are not accepted! When signature requirements are not met, the reviewer is required to dismiss any documentation that has missing or illegible signatures. For detailed guidance regarding Medicare signature requirements, refer to the IOM, Publication 100-08, Chapter 3, Section 3.3.2.4 and click here.
In Conclusion
It is noteworthy that the reference material used by the SMRC included retired HBOT policies (LCDs) and billing articles (LCAs). This certainly lends credibility to the argument that a policy is still referred to long after it is retired. In addition, while drafting this article, the author was contacted by a third client who had also been "Smirked" and was requesting assistance with denied DWLE claims. The client was an office-based practice, as were my two other clients, which poses the question: Are office-based practices the primary target of this project? If the reader is aware of any provider-based (hospital) departments being targeted with such a probe, this author would appreciate being notified.
SMRC audits are here to stay and until medical necessity and documentation gets better, expect to see an increase in audit activity. The effects of these audits could also possibly shift Medicare’s focus to other HBOT indications. For additional information about documentation requirements, see retired policies and billing articles mentioned in item #5 of the top ten list above, as well as the references below. Also, consider looking at all of them, not just your local MAC. For example, WPS has excellent guidelines.7
Michael Crouch is a Certified Professional Coder (CPC) and Medical Auditor (CPMA) with more than 30 years’ experience in the Wound Care and Hyperbaric Medicine industry. Mr. Crouch has authored several articles and textbook chapters. He is the founder of C+ Consulting, LLC, a consulting firm which specializes in providing support for outpatient wound management programs.
Acknowledgment: Robert Sheffield, who has experience with SMRC audits, offered invaluable editorial advice for the content and structure of the article, for which this author is forever grateful.
References
1. CGS Administrators. Hyperbaric oxygen therapy (HBOT) ADR checklist.
2. First Coast Service Options. Hyperbaric oxygen (HBO) therapy documentation.
3. National Government Services. Hyperbaric oxygen therapy treatment.
4. Noridian Healthcare Solutions. 01-083 Hyperbaric Oxygen for Lower Extremities Diabetic Wounds Notification of Medical Review.
5. Centers for Medicare and Medicaid Services. Hyperbaric oxygen (HBO) therapy.
6. Palmetto GBA. Hyperbaric oxygen checklist.
7. WPS Government Health Administrators. Hyperbaric oxygen therapy.
