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DEPARTMENTS: Practice Points

The Art of Auditing Documentation

Thomas Hess, Cathy BSN, RN, CWOCN

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Advances in Skin & Wound Care: October 2011 - Volume 24 - Issue 10 - p 488
doi: 10.1097/01.ASW.0000406480.43800.c1
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The mandatory integration of electronic medical records (EMRs) into the wound care practice is here to stay. The EMR has revolutionized the way data are collected, collated, and delivered. With the click of a mouse or the tap of your iPad, your documentation is captured. Clinicians must embrace this technology as it demonstrates and supports work performed, services provided for facility and professional billing, and regulatory standards.

Each clinician must understand the rules and regulations that guide 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, respective Local Coverage Decisions, Centers for Medicare & Medicaid Services, The Joint Commission, 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 the rules and regulations.

There are many important reasons for auditing documentation including assessing the completeness of a medical record, determining the accuracy of documentation, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine if 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, compliance with the organization's policies and procedures, and compliance with payer regulations may not be identified.

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

  • defining risk areas and establishing need for self-audit,
  • considering your departmental resources for practicable auditing,
  • determining subject, method, and frequency of audits,
  • reviewing records such as medical and financial records that support claims for reimbursement,
  • preparing the internal audit report,
  • presenting findings to applicable parties,
  • developing a corrective action plan, and
  • continuing ongoing monitoring.

Steps specifically outlining internal auditing strategies include the following:

  • 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,
  • performing the audit,
  • preparing a concise audit report,
  • presenting audit results to applicable personnel,
  • developing action plan, and
  • performing ongoing monitoring.

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

  • reviewing the Fiscal Intermediary's Web site for the 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;
  • meeting with the compliance officer to review any audits that may have been completed in the wound care department previously, reviewing trends;
  • reviewing the most frequently documented procedures such as debridements or application of skin substitutes;
  • reviewing the assignment of the CPT codes;
  • reviewing the documentation for the procedure to ensure it supports the work performed;
  • ensuring the procedure meets medical necessity and supports the physician's order;
  • reviewing the number of procedures completed within a given time frame for each patient audited;
  • reviewing the Chargemaster (CDM) and summary report/superbill used for billing; and
  • following the billing for the services performed from the beginning of the documentation process through the billing process; asking about any denials.

As we all know, the medical record serves multiple purposes. As healthcare providers, we believe that the medical record's 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 the following:

  • developing departmental 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 training and education of staff have occurred.

At the end of each day, documentation is imperative. Compliance is the key.

© 2011 Lippincott Williams & Wilkins, Inc.