How to Conduct Internal Audits in the Wound Care Clinic

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Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA & Kathleen D. Schaum, MS

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.

  During 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” (

  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 processes, 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

  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 care-related 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-10-CM diagnosis coding system.

  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:
    • Information relevant to ambulatory and managed care encounters

    • Expanded injury codes

    • Creation 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

    • Classifications specific to laterality (right, left, bilateral)

    • Classification 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.

Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She can be reached at 609-936-2265 or via

Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at561-964-2470 or

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