1. Hess, Cathy Thomas BSN, RN, CWCN

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There are many important reasons for auditing documentation, including determining its accuracy, assessing the completeness of a medical record, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine whether it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, and poor compliance with policies and procedures and/or payer regulations may not be identified.


Each clinician must understand the rules and regulations guiding the wound care department's documentation and billing processes. The rules within the wound care department are generated from your Fiscal Intermediary, Carriers, and Medicare Administrative Contractors; National Coverage Determination and respective Local Coverage Determinations; the Centers for Medicare & Medicaid Services, The Joint Commission, and the American Medical Association; and so on. With so many rules and regulations governing your work, it is important to have an audit process in place to ensure your documentation supports them.


Proactive monitoring and auditing are designed to test and confirm compliance with legal requirements. These implementation and monitoring strategies include:


* defining risk areas and establishing the need for self-audit;


* considering your departmental resources for practicable auditing;


* determining the subject, method, and frequency of audits;


* reviewing medical and financial records that support claims for reimbursement;


* preparing the internal audit report;


* presenting findings to applicable parties;


* developing corrective action plan; and


* continuing ongoing monitoring.



Steps specifically outlining Internal Auditing strategies include:


* establishing and identifying the need for an internal audit;


* defining the specific issues of the audit;


* determining an appropriate sample size;


* establishing an audit schedule;


* preparing a concise audit report;


* presenting audit results to applicable personnel;


* developing an action plan; and


* performing ongoing monitoring.



Specific strategies to consider when performing a wound care audit may include:


* reviewing the Fiscal Intermediary's website for language that supports wound care services;


* interviewing the staff to ensure a clear understanding of the documentation process, as well as the policies and procedures that support the department's work;


* optimizing thought flow and workflow to ensure proper documentation elements are defined for the medical record;


* meeting with the compliance officer to review any previous audits for possible trends;


* reviewing the most frequently documented procedures, such as debridements, and knowing how your Local Coverage Determination links to utilization and payment of these services;


* reviewing the assignment of the Current Procedural Terminology (CPT) codes* and procedure documentation to ensure it supports the work performed;


* ensuring the procedure meets medical necessity and supports the physicians order, and that the service, procedure, and/or product used is mapped to a signed order;


* reviewing the number of procedures completed within a given time frame for each patient audited;


* reviewing the Charge Description Master and summary report/superbill used for billing at least annually; and


* following the billing for services performed to understand your denial process and the time-sensitive nature of reviewing denied claims.



Now let us turn to the documentation in the medical record. Documentation comprising the medical record provides the platform for medical necessity and continuity of care. Skin and wound care documentation can combine a variety of information-gathering tools, reflecting the wound's status across the healing continuum. When assessing the patient with a skin or wound condition, the details of the documentation need to reflect accurate patient information. A few of these details are described as follows:


* Chief complaint. This is the first step toward complete documentation for the skin and wound care patient and captures the medical necessity for the visit. This statement should be clearly written, describing the reason for the visit in the patient's own words.


* History of present illness. This provides necessary subjective information for the practitioner to review in conjunction with other data. It should include a complete chronologic account of the presenting problem to date. The majority of this information is subjective, based on patient interview. If there is more than one chronic condition discussed (ie, lower leg pain, headaches), make sure to document this to assist in justifying the needed orders.


* Past medical, family, and social history. A review of the patient's past medical history, family events, and social activities should be captured. The clinician should pay particular attention to chronic illnesses, medications, allergies, vascular tests, radiology, dressing and ostomy history, modality history, laboratory values, and activities of daily living.


* Review of systems;


* Physical assessment;


* Risk assessment tools;


* Manual assessments tools;


* Skin and wound assessment tools;


* Procedures;


* Provider orders and ordering of supplies and tests;


* Patient education details;


* Plan of care; and


* Discharge plan and instructions.



As we know, the medical record serves multiple purposes. Healthcare providers should understand that its most critical function is to plan and provide continuity of care for a patient's medical treatment. Training should be designed to promote the understanding of the medical record's purpose, internal standards, and the requirements of external laws and regulations. This planning process may include:


* Developing department-specific educational sessions, including admitting/registration requirements, documentation requirements, privacy/confidentiality issues, coverage and billing rules, medical necessity, charge entry risks, and coding requirements. This is not an exhaustive list and issues specific to the department should be addressed;


* Providing sufficient time and resources for staff to attend educational sessions; and


* Documenting that staff training and education has occurred.



At the end of the day, compliance is imperative, and documentation is the key. Thorough documentation will provide the complete information clinicians need to link any and all disorders to the patient with a chronic wound.


* CPT is a registered trademark of the American Medical Association, Chicago, Illinois. [Context Link]