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Audit Checklist for Medical Necessity of Provided Services

Thomas Hess, Cathy BSN, RN, CWOCN

Advances in Skin & Wound Care: July 2010 - Volume 23 - Issue 7 - p 336
doi: 10.1097/01.ASW.0000383759.15457.c1
Departments: Practice Points

Cathy Thomas Hess, BSN, RN, CWOCN, is President and Director of Clinical Operations, Wound Care Strategies Inc (WCS), Harrisburg, Pennsylvania. WCS focuses on clinical operational, regulatory, and compliance/auditing aspects of skin and wound care in all healthcare settings. Please address correspondence to Cathy Thomas Hess, BSN, RN, CWOCN, 4080 Deer Run Court, Suite 1114, Harrisburg, PA 17112; e-mail:

As healthcare providers, we believe the most critical function of the medical record is to plan and provide continuity of care for a patient's medical treatment. The documentation in the medical record does provide for this function, but its function also includes

  • providing information for the financial reimbursement to hospitals, healthcare providers, skilled nursing facilities, and patients;
  • providing legal documentation in cases of injury or other legal proceedings;
  • providing information for quality-assurance and peer-review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and
  • providing the critical information in an accreditation process, such as The Joint Commission, Centers for Medicare & Medicaid Services, or the Undersea & Hyperbaric Medical Society.

The wound care section can promote concerns related to compliance, reimbursement, guidelines, and regulations. These elements can be met only through the appropriate documentation in the medical record. No matter the healthcare setting in which one provides care for wound and skin issues, the critical element becomes the documentation in the medical record.

In the hospital outpatient wound care setting, both the facility and the professional receive payment from Medicare for the services rendered. Each entity must maintain its documentation standards to allow for payment of its services. This checklist is provided as the first step in the review audit process to identify obvious discrepancies and prompt a more intense compliance review.

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Facility Review Audit Checklist

  • (1) Has your facility developed a requirement crosswalk between the Evaluation/Management (E/M) level and the Ambulatory Payment Classification (APC) level?
  • (2) Does the medical record documentation support the requirements from the facility-developed crosswalk?
  • (3) Does the departmental staff understand the requirements for medical record documentation to support the facility-developed crosswalk?
  • (4) Has the department staff received the appropriate education and training in the utilization of the crosswalk?
  • (5) Are the appropriate modifiers being utilized in the department?
  • (6) Has the staff been trained in the use of modifiers?
  • (7) Does the medical record documentation support the utilization of a modifier?
  • (8) Does the wound care department have a tool that provides the facility billing entity with a listing of the services rendered?
  • (9) Is there appropriate communication between the departmental staff and the billing entity of the facility (ie, coding/billing updates, revisions to facility crosswalk, and so on)?
  • (10) Does the facility billing entity audit the wound care department's documentation to support the APC levels billed?
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Professional Review Audit Checklist

  • (1) Is there an appropriate tool to correspond the services rendered to the professional billing entity?
  • (2) Does the professional billing entity audit the medical record documentation to ensure that the appropriate E/M level has been billed?
  • (3) Does the professional billing entity provide the practicing professional with necessary updates to determine service codes?
  • (4) When modifiers are appended, is there supporting medical record documentation?
  • (5) Does the practicing professional provide supporting medical record documentation to correspond with the level of E/M billed for his/her professional service?
  • (6) If templates are utilized, does the practicing professional document utilizing the guidelines for the template?
  • (7) Does the documentation require the date and the signature of the practicing professional providing the service?
  • (8) Has the practicing professional identified the appropriate diagnosis code for the services rendered?
  • (9) Has the practicing professional identified the appropriate diagnosis coding for ancillary services ordered?
  • (10) Does the medical record documentation for the wound assessment and description support the dressing ordered (following appropriate Medicare Part B Surgical Dressing Policy for specific region)?
  • (11) Are procedures appropriately documented in the medical record to support the service code identified and billed?
  • (12) Are the services being rendered by the professional appropriate for the wound care department setting?

In any healthcare setting, wound care requires concise assessments, documentation, and specialized care. Proactive monitoring and auditing are essential to test and confirm compliance with legal requirements. Auditing is done to assess the completeness of a medical record, determine the accuracy of documentation, and discover lost revenue. The auditing function is the check and balance for your documentation.

If you have a checklist to share with our readership, please e-mail Good luck!

Source: Hess CT. Clinical Guide to Skin and Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

© 2010 Lippincott Williams & Wilkins, Inc.