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Owning and Auditing Your Documentation

Hess, Cathy Thomas BSN, RN, CWCN

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doi: 10.1097/01.ASW.0000604052.66570.e4
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The most critical function of the medical record’s multiple purposes is to plan and provide continuity of care for a patient’s medical treatment. However, in many instances, we as healthcare providers forget that the medical record offers additional provisions including the following:

  • information for financial reimbursement to hospitals, healthcare providers, skilled nursing facilities, and patients;
  • legal documentation in cases of injury or other legal proceedings;
  • information to support quality assurance and peer review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and
  • critical information for accreditation processes.

The underpinning of the documentation must support rules and regulations based on your Medicare carrier and other insurers. The importance of understanding and self-auditing the rules and regulations governing your place of service is paramount. For example, Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process with opportunities for public participation. In some cases, CMS’s own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).3

The Medicare Coverage Database (MCD) contains all NCDs and LCDs, local articles, and proposed NCD decisions. The database also includes several other types of National Coverage policy-related documents, such as National Coverage Analyses, Coding Analyses for Labs, MEDCAC proceedings, and Medicare coverage guidance documents.2

Local coverage determinations are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states:4

For purposes of this section, the term “local coverage determination” means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).

Let’s take a look at one LCD and how the utilization guidelines within the LCD establish parameters for typical or expected use of specific services in the outpatient wound care department:5

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The appropriate interval and frequency of debridement depend on the individual clinical characteristics of the patient and the extent of the wound. The extent and number of services provided should be medically necessary and reasonable based on the documented medical evaluation of the patient's condition, diagnosis, and plan.

With the above in mind, only a minority of beneficiaries who undergo debridements for wound care appear to require more than eight total surgical excisional debridement services involving subcutaneous tissue, muscle/fascia, or bone in a 360-day period (five debridements of which involve removal of muscle/fascia, and/or bone) in order to accomplish the desired objective of the treatment plan of the wound. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the debridements already provided should debridement services be continued beyond this frequency or time frame.

Also with the above in mind, of the beneficiaries who undergo treatment utilizing negative-pressure wound therapy, only a minority appears to require more than six NPWT services in a 120-day period to accomplish the desired objective of the treatment plan of the wound. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the NPWT treatment already provided should NPWT services be continued beyond this frequency or time frame.

The number of debridements and NPWT for a wound within the context of a palliative treatment plan (ie, when wounds are not expected to heal or when patients are in an end-of-life situation) would be expected to be of a limited frequency and duration consistent with that of palliative care.

Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. When services are performed in excess of anticipated peer norms, based on data analysis, the services may be subject to prepay or postpay medical review.

Knowing what services have been highlighted within the LCD affords clinical staff the opportunity to understand the documentation parameters and thereby document appropriately for the services performed. In addition, knowing the utilization guidelines allows the outpatient department to build specific audit tools based on the rules and regulations and use them proactively.

Assessing and defining “complete documentation” in the context of the medical record are imperative. Ultimately, auditing documentation for completeness, determining the accuracy of documentation, and potentially discovering lost revenues should be a routine part of your clinical and operational process.

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/or poor compliance with the organizational policies and procedures/payer regulations may not be identified. Knowing the principles of medical record success provides the basis for performing an internal audit of the medical record. Specific strategies to consider when performing a wound care audit may include the following:

  • reviewing the Fiscal Intermediary's website for the language that supports wound care services and medical necessity requirements;
  • interviewing the staff to ensure a clear understanding of the documentation process and workflow that define the medical record;
  • reviewing the policies and procedures that support the department's work;
  • meeting with the compliance officer to review trends and any audits that may have been completed in the wound care department previously;
  • ensuring the patient’s visit is supported by the physician’s order;
  • reviewing the most frequently documented procedures such as debridement or dressing application;
  • reviewing the assignment of the Current Procedural Terminology* 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 and summary report/superbill used for billing;
  • working with the medical records department to define “timeliness of documentation” and the procedure for closing a record;
  • following the billing for services performed from documentation to payment, asking about any denials; and
  • understanding the denial management process and ensuring the wound care department are a part of this process.

The final health record is ultimately defined by your organization. It remains the clinician’s responsibility to understand the documentation elements comprising the legal medical record. Can you define the documentation elements necessary for compliance in your wound care department?


1. Centers for Medicare & Medicaid Services. Medicare Coverage Determination Process. 2019. Last accessed September 19, 2019.
    2. Centers for Medicare & Medicaid Services. Medicare Coverage Database. Last accessed September 19, 2019.
    3. Centers for Medicare & Medicaid Services. How to Request an NCD. 2018. Last accessed September 19, 2019.
    4. Centers for Medicare & Medicaid Services. Local Coverage Determinations. 2019. Last accessed September 19, 2019.
    5. Centers for Medicare & Medicaid Services. Local Coverage Determination: Wound Care (L35125). 2019. Last accessed September 19, 2019.

    *CPT is a registered trademark of the American Medical Association.

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