1. Schaum, Kathleen D. MS

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Happy New Year to all Payment Strategies readers! As I reflect on 2014 and look forward to the opportunities and challenges facing the wound care industry in 2015, one key word is vital to your wound care business success. In fact, this key word has been and continues to be the subject of many Medicare contractor articles and directives. You may be wondering if it is a new fancy key word. Actually, it is a key word that every wound care professional has been taught in college, but sometimes minimizes its importance. In a recent presentation, one of the Medicare Administrative Contractors (MACs) referred to the key word documentation as the golden rule and reiterated these common documentation statements:


"If it isn't documented, then it wasn't done."


"You are paid for what you document, not what you did."


"Document, document, document!"


"More is better."


Those of you who have attended "Wound Clinic Business" or one of my ICD-10-CM preparation seminars should understand that reading your MAC's Local Coverage Determinations (LCDs), articles, and newsletters for documentation guidance is very important. You also should know that improving your clinical documentation is essential to "receive your Medicare payment" and to "keep your Medicare payment" after an audit. However, what I teach is not as important as what the payers are teaching. Therefore, let's start out 2015 by reviewing some very important documentation instructions that the Centers for Medicare & Medicaid Services (CMS) and the MACs have been providing. All wound care professionals should take these instructions very seriously.


MAC Education Pertaining to the "Key Word" Documentation

In an excellent educational program, one of the MACs provided many documentation messages. Following are a few that you should take seriously. The key word documentation[horizontal ellipsis]


* is a legal requirement.


* provides a historical account of the wound care you provide.


* should meet Medicare regulations.


* serves as a communication tool to other disciplines and/or other professionals.


* is a measurement of your patient's outcomes.


* provides the medical necessity for your wound care services.


* justifies your treatment plan.


* is the basis for quality care.


* drives reimbursement for your services.



The MACs shared that the 2 major categories of documentation errors are as follows:


1. Insufficient documentation, for example,


a. failure to respond to medical record requests


b. documentation is missing important facts


c. documentation is missing signatures or has invalid signatures


d. documentation is illegible


Medically unnecessary services, for example,


documentation is incomplete


documentation does not support the services billed


Documentation does not substantiate the medical need for the services



The MACs also provided some documentation tips:


* The medical record should be complete and legible.


* Documentation should support the level of care and treatment provided.


* Codes on the claim should be reflected in the medical record.


* Document the patient's progress, patient's response to the treatment, change in diagnosis or treatment, and patient's noncompliance with any services offered.


* Document each encounter with the patient's name and date of service; reason for the encounter or service; history, physical examination findings, and relevant health risks; reasons and results of diagnostic tests and ancillary services; assessment, treatment, and discharge plans; medication records; laboratories and tests; referrals and consultations; patient/family education and counseling; and follow-up instructions.


* The author of the record needs to be clearly identified (professional credentials should be noted).


* All professionals involved with the patient's care or who contributed to the service(s) provided should be documented in the medical record.



CERT Task Force Education Pertaining to the Key Word Documentation

Because the Medicare Fee-for-Service (FFS) programs make billions of dollars in estimated improper payments, the CMS now uses several types of Medicare review contractors to measure, prevent, identify, and correct these improper payments. These review contractors manually review claims against the submitted medical documentation to verify the providers' compliance with Medicare's rules and guidelines. The CMS also contracts with other entities to review if the MACs are paying claims correctly.


Recently, the Comprehensive Error Rate Testing (CERT) Contractor A/B MAC Outreach & Education Task Force created an educational guide to explain the CERT program and to share information with professionals on how to provide accurate and supportive medical record documentation. In this guide, the CERT Task Force explained that claims are determined to have "insufficient documentation errors" when the medical documentation submitted is inadequate to support payment for the services billed; that is, the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety. The guidance document listed some of the "insufficient documentation errors":


* Incomplete progress notes (eg, unsigned, undated, insufficient detail, and so on)


* Unauthenticated medical records (eg, no physician signature, no supervising physician signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures)


* No documentation of intent to order services and procedures (eg, incomplete or missing signed order or progress note describing intent for services to be provided)


* Insufficient medical record documentation supporting that conservative medical management was tried and failed (eg, medication administration records, therapy discharge summary) or was contraindicated


* No signed and dated attestation statement for the operative report if a physician signature was missing or illegible. Note: If the operative report is electronically signed, the protocol should also be submitted to the CERT auditor.


* Documentation did not support certification of the plan of care for physical therapy services. The physician's/nonphysician practitioner signature and date of certification of the plan of care or progress note indicating the physician/nonphysician practitioner reviewed and approved the plan of care are required.


* Evaluation and Management (E&M) services for Office Visit Established, Hospital Initial, and Hospital Subsequent were identified as the top 3 CERT errors in the E&M services categories. High errors consisted of insufficient documentation, no documentation, and incorrect coding of E&M services to support medical necessity and accurate billing of E&M services.


* A valid detailed written order with the physician's National Provider Identifier must be on file prior to delivery of certain durable medical equipment (DME) to a patient's home.



To review all of the educational information released by the CERT A/B MAC Provider Outreach and Education Task Force, visit


Standard Documentation Language for Durable Medical Equipment Medicare Administrative Contractor Local Coverage Determinations and Related Policy Articles

The 4 DME MACs are so concerned about the many documentation errors reported in the various medical record reviews and CERT audits that they created standardized language modules that will be inserted in the applicable LCDs and related Policy Articles. The modular format will allow each policy/article to contain information relevant to that policy/article while not including material that does not apply. Most important, this standardized documentation language will decrease the documentation requirements confusion for wound care professionals. This author applauds the DME MACs for this work. Wound care professionals should take the time to read all the new language in the relevant DME MAC LCDs and Policy Articles. Following are some standard language excerpts from sections of the LCDs that are especially pertinent to wound care documentation:


Coverage Indications, Limitations, and/or Medical Necessity


"For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements[horizontal ellipsis]


Medicare does not automatically assume payment for a DME, prosthetics, orthotics, and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare FFS program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding, and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary may be required upon request of the DME MAC."


Documentation Requirements

"Section 1833(e) of the Social Security Act precludes payment to any provider of services unless 'there has been furnished such information as may be necessary in order to determine the amounts due such provider.' It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals, and test reports. This documentation must be available upon request."


Prescription (Order) Requirements

"A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record (Program Integrity Manual 5.2.3)."


Medical Records Information: General

"Supplier-produced records, even if signed by the ordering physician, and attestation letters (eg, letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.


Templates and forms, including CMS Certificates of Medical Necessity (CMN), are subject to corroboration with information in the medical record.


Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, and so on (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary."


Medical Records Information: Continued Medical Need

"For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this initial time period. Entries in the beneficiary's medical record must have been created prior to, or at the time of, the initial date of service (DOS) to establish whether the initial reimbursement was justified based upon the applicable coverage policy.


For ongoing supplies and rental DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiary's medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Any of the following may service as documentation justifying continued medical need:


* a recent order by the treating physician for refills


* a recent change in prescription


* a properly completed CMN or DME Information Form with an appropriate length of need specified


* timely documentation in the beneficiary's medical record showing usage of the item



Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy."



Wound care professionals should consider all this attention to the key word documentation as your 2015 "heads-up." You should conduct a self-audit and request an external audit of your own documentation against all the regulations, LCDs, Policy Articles, newsletters, and educational programs that CMS and your MACs are providing. You should also embrace the questioning and assistance, pertaining to your documentation, which you may receive from your coders and billers. These coding and billing professionals should be your "best friends" to help you improve your clinical documentation as soon as possible. You cannot afford to be one of the professionals who are requested to repay for services you actually provided just because you did not take the time to document your excellent wound care work.