How to Conduct Internal Audits in the Wound Care Clinic Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA & Kathleen D. Schaum, MS A IC D T N O O D 6 The new coding system allows for more granularity (specificity) of disease states and, therefore, will require refinement of your documentation in order to select the appropriate ICD-10-CM Diagnosis code(s). Some of the changes that ICD-10-CM will bring are: • I nformation relevant to ambulatory and managed care encounters • Expanded injury codes •C reation of combination codes to reduce the number of codes needed to fully describe a condition • Addition of 6th and 7th characters to the existing 5 characters •C lassifications specific to laterality (right, left, bilateral) •C lassification refinement for increased granularity of data. The adage, “Old habits die slow,” applies to teaching medical professionals to change their documentation habits. Therefore, wound care professionals should start transitioning documentation one disease state at a time. Then, begin conducting internal audits of that documentation. We must begin now to improve our documentation to meet today’s requirements and to prepare for the ICD-10-CM requirements of the near future. n PL D uring the first 6 months of 2012, Today’s Wound Clinic editorial board members Donna Cartwright and Kathleen Schaum offered Clinical Documentation Improvement (CDI) webinars that stressed the importance of thoroughly documenting the important work that wound care professionals provide to patients. If you missed the CDI webinars, you can still register to listen to the archived programs, which will help you and your team build a strong “documentation house” as opposed to a “documentation house made of cards” (www.icd10codingworkshop.com). In addition, the one-day Wound Clinic Business seminar taught by Andrea Clark, RHIA, CCS, CPCH, chairman, chief executive officer, and founder of Health Revenue Assurance Associates, Plantation, FL, and Schaum has received excellent evaluations from attending physicians, podiatrists, non-physician practitioners, program directors, clinical managers, coders, billers, revenue integrity directors, compliance officers, and other support personnel for wound clinics throughout the country. This year’s theme is “Investigate Your Team’s Wound Care Revenue Cycle.” In this action-packed seminar, Clark and Schaum discuss organizational pro- cesses, physician orders and signatures, documentation, coding, billing, coverage, auditing, and much more. Both speakers emphasize they are concerned more about wound care professionals keeping payments they’ve already received than they are about the wound care professionals “getting paid.” If you and/or your wound care management team wish to take part in this timely seminar, you can register at www.woundclinicbusiness.com. By participating in one or both of these educational opportunities, you will clearly learn the importance of conducting internal audits of your documentation, coding, and billing before external auditors come knocking at your door. One of the most frequently asked questions that wound care professionals ask at these programs is: “What wound carerelated topics should we audit?” Beginning on page 8 you’ll find audit topics and documentation you should expect to encounter in order to pass your audit and keep payments that you already received. These audit topics and documentation needed to pass an audit should be some of the first items on your internal audit to-do list. Even topics that you think are not questionable in your facility are often found to be problematic during internal and external audits. By now you know the implementation of ICD-10-CM has been extended until Oct. 1, 2014, by the Centers for Medicare & Medicaid Services. While the information provided to you in this article is pertinent to auditing your documentation at the present time, you should begin to further refine your documentation to support the ICD-10CM diagnosis coding system. U Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader. TE businessbriefs August 2012 Today’s Wound Clinic® Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She can be reached at 609-936-2265 or via donna.cartwright@ integralife.com. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at561-9642470 or kathleendschaum@bellsouth.net. www.todayswoundclinic.com businessbriefs Physician Supervision of HospitalBased Outpatient Wound Care Department (HOPD) Basic Rules Documentation to Support the Rule During an Audit HOPDs must have “direct supervision” for every patient encounter. The supervision can be provided by physicians, podiatrists, and non-physician practitioners. HOPDs should post a schedule of physicians, podiatrists, and/ or non-physician practitioners who will provide “direct supervision” for every patient encounter. Schedules should be filed for at least 7 years in case they are needed for an audit. TE Internal Audit Topic HOPDs are not one of the departments that should use monthly series bills. Each patient encounter should begin with a new registration and should be billed after each visit. Registration records should show a new HOPD registration for each patient. The physician should document, in the medical record, the exact reason for each patient encounter and the exact diagnosis code(s) that pertain(s) to that encounter: the reason for the visit and the diagnosis code are often different from visit to visit. PL Monthly Series Bills vs. Single-Visit Bills IC A NOTE: Providers who are scheduled to provide “direct supervision” should have appropriate hospital credentialing and should be practicing within their respective state’s scope of practice. The person who creates the “direct supervision” schedule should ensure the wound care professional scheduled for “direct supervision” will not be performing another procedure or service that cannot be interrupted during the time he/she is responsible for “direct supervision.” In addition to schedules, key entry systems [that log physicians in and out of the facility on a time clock] may be able to demonstrate the physician is/was on site and is/was available to immediately assist. D For a patient’s first visit to the HOPD, a new patient clinic visit should only be billed if the patient has not been registered anywhere in the entire hospital system for the past 3 years. T New vs. Established Clinic Visit Codes U NOTE: Audits should reveal an individual medical record and a claim for each patient encounter. Be sure that the auditors are aware of how your medical records are organized: help them easily find the information needed. N O NOTE: The HOPD clinic visit level may vary from the physician’s evaluation and management (E/M) level: Physicians can bill for a new patient E/M as long as the patient has not been seen by any physician of the same specialty who belongs to the same group practice within the past 3 years. D O Diagnosis Codes That DO NOT Reflect Documentation Diagnosis codes submitted on insurance claims should match the documentation found in the patient’s medical record. Diagnosis codes should not be selected just to cause payment of the claim. By using the Master Patient Index during the patient’s registration, the Registrar should verify whether the patient has a medical record number anywhere in the health system for the past 3 years. If the patient has previously received a diagnostic service that does not require a face-to-face encounter with the patient (eg, an X-ray), this patient is still considered a new patient. NOTE: Audits should reveal the appropriate “new“ or “established“ clinic visit levels for HOPDs and evaluation and management levels for physicians. Even though the HOPDs and physicians use the same CPT® codes to represent these services, the coding rules are different. Therefore, the HOPD and physician clinic visit codes will rarely match. The physician, podiatrist, or non-physician practitioner should diagnosis the patient’s condition at each encounter. That diagnosis should be validated in that day’s documentation (ie, history and physical, progress notes, orders, and procedures or services). Although this seems like common sense, some hospital billing systems obtain the diagnosis code from the registrar and fail to go back and obtain the actual diagnosis code from the documentation in the medical record. In some electronic medical records, previous diagnoses are brought forward to the current encounter even though they may not be pertinent to the current encounter. These diagnoses should be removed or inactivated on the problem list. NOTE: Audits should reveal that the diagnosis code is supported by the documentation in the medical record for a specific patient encounter. The diagnosis in the medical record should exactly match the diagnosis on the claim for that encounter. 8 August 2012 Today’s Wound Clinic® www.todayswoundclinic.com businessbriefs Modifiers That DO NOT Reflect Documentation Basic Rules Documentation to Support the Rule During an Audit A modifier should only be used when the documentation in the medical record justifies the use of the modifier. Modifiers should not be used just to cause payment of the claim. The modifiers that are often used without adequate documentation are: Modifier 25 - Significant, separately identifiable E/M service by the same physician on the same day as the procedure or other service. Reporting an E/M service with modifier 25 is only appropriate if one of the following conditions has been met and clearly documented in the medical record: TE Internal Audit Topic IC A A. T he patient requires evaluation “above and beyond” what is typically expected as part of the evaluation prior to the procedure. B. The patient’s condition has changed or worsened and the patient needs to be re-evaluated. C. The patient presents with a new, separate problem than what prompted the procedure. PL Modifier 22 - Increased Procedural Service should be billed with supporting documentation. The documentation should reflect the work was substantially greater than normal. It must also state the reason causing the additional work, such as increased time, intensity, technical difficulty, or severity of the patient’s condition. U Modifier 24 - Unrelated E/M service by the same physician during the postoperative period. Practitioners should clearly document the reason the service is unrelated to the original procedure, such as a new problem. NOTE: Auditor should be able to identify documentation in the medical record to warrant use of the appropriate modifiers. N O O D The physician, podiatrist, or non-physician practitioner who performed the surgical procedure in an HOPD must thoroughly document his/her work just as if it were performed in the operating room. The operative report or procedure progress note should contain the following information: D Surgical procedures such as surgical debridement (11042-11047) and application of skin substitute grafts (15271-15278) should only be used when appropriate surgical procedure notes that meet the payer’s requirements are documented in the patient’s medical record. T Surgical Procedures That ARE NOT Appropriately Documented • Preoperative and postoperative diagnosis • Wound location • Wound stage or grade, if appropriate • Wound appearance (color, texture, temperature, or signs of infection) • Wound margin description • Anesthesia used • Instruments used • Type of tissue removed, if any • Wound size before and after debridement, if performed • Blood loss or fluid replacements • Product name and size • Amount of product used (in sq cm) • Amount of product discarded (in sq cm) • Method of fixation • Dressings applied • Complications, if any • Postoperative orders such as offloading, dressing-change frequency, medications, etc. NOTE: The audit should reveal a thorough operative report or procedure progress note from the physician, podiatrist, or non-physician practitioner who performed each surgical procedure. Documentation with words such as “debrided wound” or “applied skin substitute” is not adequate. www.todayswoundclinic.com Today’s Wound Clinic® August 2012 9 businessbriefs Documentation to Support the Rule During an Audit When products and/or procedures are provided that include units of measure in their descriptions, the medical record should document the units of measure provided/performed. In addition, the insurance claim should match the documented units of measure. Units of measure documented in the medical record must match the units billed on a claim. Many CPT® and Healthcare Common Procedure Coding System codes for procedures and products involve units of measure such as: Sq cm for debridements/application of skin substitutes. Per sq cm for skin substitute products. (NOTE: Remember to document amount of product used and product wasted.) A Inappropriate Number of Billing Units Basic Rules TE Internal Audit Topic Per treatment time (ie, every 15 minutes). Per session for physician coding of hyperbaric oxygen therapy. IC Be sure to check your Charge Description Master (CDM) to ensure proper units of measure are listed for each code. Improper units on the CDM will cause claims to be over- or under-billed. HOPD personnel cannot perform any services/procedures or provide any products without a physician’s order and signature. Because HOPDs are required to have “direct supervision,” physicians, podiatrists, or non-physician practitioners must write and sign an order in the medical record before HOPD nurses (even when wound care certified) can perform a service or procedure, or can apply a different dressing or apply a piece of equipment. The signature must be legible and must match the hospital’s signature authentication document. U Physician Orders and Signatures PL NOTE: The auditor should be able to match the units documented in the medical record to the units submitted on the insurance claim. D Authentication requirements, rules, and responsibilities for orders should be documented in the medical staff’s bylaws, rules, and regulations. When physicians, podiatrists, and non-physician practitioners perform work in an HOPD, they should use the Place of Service code 22, outpatient hospital, on their Medicare claims. They should not use Place of Service code 11, office. D O N O Place of Service on Physician, Podiatrist, and Non-Physician Practitioner Claims T NOTE: The auditor should be able to match every service and/or procedure and every new product used back to a legible order signed by the physician, podiatrist, or non-physician practitioner. 10 “It is extremely important that you correctly code the place of service on Part B claims. Using non-facility Place of Service codes for services that are actually performed in hospital outpatient departments or Ambulatory Surgical Centers (ASCs) often results in overpayments. You must ensure that you have adequate controls in your (or your billing agent’s) billing routines to identify potential Place of Service coding errors.” Audit Finding of the Office of the Inspector General (OIG) The OIG conducted an audit to determine whether physicians correctly coded non-facility Places of Service on selected Part B claims submitted to and paid by Medicare contractors. That report, “Review of Placeof-Service Coding for Physician Services Processed by Medicare Part B Carriers During Calendar Year 2007,” is available to the public at http:// oig.hhs.gov/oas/reports/region1/10900503.asp on the OIG website. The OIG found, in many instances, physicians are incorrectly coding the Place of Service code. Specifically, in a very large portion of the claims audited, physicians used non-facility Place of Ser heir claims for services that were actually performed in hospital outpatient departments or ASCs. This led to overpayments by Medicare on these claims. Medicare does recover these overpayments, so it is critical to code correctly and avoid overpayments.” Source: MLN Matters® Number: SE1104 August 2012 Today’s Wound Clinic® www.todayswoundclinic.com businessbriefs HOPDs, physicians, podiatrists, and non-physician practitioners should verify the name of the Medicare contractor who processes their claims. They should keep in mind the contractor who processes HOPD claims may be different than the contractor who processes the claims of the physicians, podiatrists, and non-physician practitioners. It is extremely important to download all associated medical coverage policies for your wound care business. The medical policies contain a large amount of information relative to coverage, coding, documentation, and billing instructions. Once the Medicare contractor(s) is/are identified, someone should be assigned to obtain the Local Coverage Determinations (LCDs) pertaining to all services, procedures, and products provided to patients in the HOPDs. The person designated to this task should check for updates, drafts, and new LCDs on a monthly basis. The HOPD manager, coding staff, or other qualified individual should do a complete search for all insurance medical policies affecting their business, especially your top 10 procedures). The search for each payer’s medical policy (ie, Medicare parts A and B, Medicaid, private payers, etc.) should include policies that mention the following terms: wound care, debridement, skin substitutes, bioengineered or tissue-engineered skin, human skin equivalents (research each type used in the HOPD), wound dressings (research each type used in the HOPD), negative pressure wound therapy, non-covered services, use of CPT® modifier rules, enzymatic debriders, and any other types of specialized therapies provided by the HOPD. TE Documentation to Support the Rule During an Audit IC A Medicare has 15 Medicare Administrative Contractor (MAC) jurisdictions. Each MAC has one or more medical director who creates his/her own medical policies for their jurisdiction. Likewise, on the private payer side: all private payers have their own medical directors who write their own medical policies. It is important to remember that many private payers have a variety of medical plans with varying levels of benefits. Therefore, the private payer benefits may widely vary based on the specific plan purchased by the individual or the employer. For example, one plan may cover a certain treatment while another may not cover the same treatment. The following link goes to the Medicare Coverage Database, where you can begin your search for LCDs: www.cms.gov/medicare-coverage-database/ overview-and-quick-search. Many private payers’ policies can only be viewed by providers via their provider ID number. HOPDs can obtain their provider ID number by requesting it from the billing or coding department. U Compliance with Medicare Local Coverage Determinations Basic Rules PL Internal Audit Topic As you locate the pertinent LCDs and medical policies, print them and place them in a binder(s) that is/are easily accessed by the physicians and HOPD staff. D O N O T D The entire professional team that works in the HOPD should review all LCDs and should have easy access to them when they are providing wound care to their patients. If the patient does not meet the LCD medical necessity requirements, the wound care professional should be prepared to provide the patient with an Advanced Beneficiary Notice of Non-Coverage (ABN). By reading and frequently referring to the LCDs and medical policies, healthcare providers will be able to identify procedures and products that are covered and not covered. Most LCDs and medical policies specify the documentation requirements that must be followed carefully to stand up under audit. If coverage is only provided for certain disease processes, the covered ICD-9-CM diagnosis codes will be listed in the LCD or policy. The policies may outline the frequency of treatments allowed for certain products, and may even give guidance on the use of CPT® modifiers. For instance, policies for skin substitutes may require specific modifiers for wastage and define modifiers for “used as a graft” or “not used as a graft.” Toward the end of the policy, the medical directors often provide the reference sources that were used. CAUTION: Some LCDs and medical policies have related articles and attachments. Hyperlinks to these important guidance documents are usually found toward the end of the LCD and policy. It is very important to read and print each article/attachment. If the physician has information about the patient’s insurance medical policies, they can discuss all options for care. If, for any reason, the recommendation for treatment is not covered by Medicare, the physician should take the time to discuss the non-coverage with the patient and give the patient the opportunity to accept the treatment and agree to pay for the treatment or to decline the treatment. The physician should also obtain a signed ABN from the patient. A copy of the HOPD and physician charge sheets should be available to assist the physician or practitioner to advise the patient on exactly what they may be responsible for paying out-of-pocket. This charge information is also required on the ABN. The following is the link to the Medicare ABN and instructions completion: www.cms.gov/BNI/Downloads/ABNFormInstructions.zip. www.todayswoundclinic.com Today’s Wound Clinic® August 2012 11