Lack of Documentation May Cause Loss of Dollars
May 12, 2008 | Leave a Comment
Kathleen D. Schaum, MS
E arly in their medical/clinical training, wound care physicians and clinicians learn the caution, if it’s not documented, it’s not done. Few physicians and clinicians, however, realize the enormous financial consequences that the lack of documentation can have on their practices if:
• they perform self-audits and find that their documentation did not support the codes that were billed and the payments they received and/or
•they receive a Medicare audit and find that their lack of documentation resulted in false claim submissions.
In wound care settings a variety of physicians and clinicians practice as a team to achieve excellence. Each member of that team should take personal responsibility for clearly documenting the work they perform. These professionals should not only use the documentation guidelines learned during their medical training, but should also follow the guidelines of the payers who review their claims for medical necessity. Most Medicare contractors provide educational seminars, webinars, online training, educational documents related to documentation, medical policies, and articles that include documentation requirements.
In the middle of 2007, the Office of Inspector General (OIG) released several reports regarding the wound care industry:
• May 2007: Medicare Payments for Surgical Debridement Services in 2004.
•June 2007: Medicare Payments for Negative Pressure Wound Therapy Pumps in 2004.
Unfortunately, both reports found that documentation in the medical records of wound care patients did not adequately support medical necessity of the procedure(s) performed and/or the product(s) ordered. The OIG found Medicare overpaid $64 million for false claims involving surgical excisional debridement and $27 million for false claims involving negative pressure wound therapy pumps and supplies.
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Coding and Medicare Coverage Review
March 17, 2008 | Leave a Comment
Unna Boot and Multilayered, Sustained,
Graduated High Compression Systems
Kathleen D. Schaum, MS
Hospital-owned outpatient wound care departments (HOPDs) must routinely check their Medicare contractors’ websites for updates to their Local Coverage Determinations (LCDs) and Articles that pertain to the application of compression systems. All of the Medicare contractors seem to agree that CPT® code 29580 is the appropriate code to use when applying a zinc paste Unna Boot. However, there is great disparity among the Medicare contractors regarding the appropriate CPT® code for the application of multilayered, sustained, graduated high compression systems. This author reviewed all the available LCDs and Articles on this topic (see Table 1).
(Please note: Medicare contractors may write new and/or change existing LCDs and Articles at any time. The information in Table 1 was only accurate on the day the author drafted this column. Any or all of the Medicare contractors could have released new policies while this column was awaiting publication. Therefore, providers should assign someone to monitor all pertinent changes that are released by their Medicare contractor.)
When the HOPD program directors and physicians review the compression guidelines that pertain to them, they should ascertain the:
• Description of product applications covered by the CPT® code 29580
• Alternative CPT® code(s) recommended for non-zinc paste compression systems
• Professionals who are covered to apply the various compression systems
• Diagnoses that support medical necessity of application of the various compression systems.
Some Medicare contractors followed the American Medical Association’s coding guidelines; some followed the American Hospital Association Coding Clinic guidelines; and others chose to discount both sets of guidelines and wrote their own opposing guidelines. If providers disagree with their Medicare contractor’s LCD, they should take advantage of Medicare’s Reconsideration Process. This is a formal process to request updates to LCDs by providing clinical evidence to the contractor’s medical director. The exact steps in the Reconsideration Process are outlined on each Medicare contractor’s website. Providers also should enlist assistance from their professional society’s representative to the Carrier Advisory Committee (CAC).
The author suggests noting that the Reconsideration Process is applicable only to LCDs. It is not applicable to Articles released by the Medicare contractors. Therefore, if your Medicare contractor only wrote an Article regarding this issue, providers cannot challenge the Article. However, providers can request that their Medicare contractor create an LCD.
For a preview of this article in TWC’s digital edition, visit
InBusiness
Debridement Reminders Issued by OIG and Payors
October 31, 2007 | Leave a Comment
Keeping Abreast of Recent Developments
KATHLEEN D. SCHAUM, MS
The Office of Inspector General (OIG) Work Plans for the past few years include a study to determine the extent to which Medical Part B surgical debridement services met Medicare program requirements. The findings from the May 2007 OIG Report, Medicare Payments for Surgical Debridement Services in 2004 (available at: http//:oig.hhs.gov/oei/reports/oei/02-05-00390.pdf) offer several important insights.
In 2004, 64% of surgical debridement services did not meet Medicare program requirements, resulting in approximately $64 million in improper payments. Of these, 39% were miscoded, 29% had insufficient documentation, and 1% were deemed medically unnecessary (overlapping errors = 5%). In addition, most carriers had local coverage determinations (LCDs) and edits in place but conducted limited medical review of surgical debridement services.
Top 10 Concerns - Challenges to consider as you’re getting started
June 18, 2007 | Leave a Comment
Several times a week, wound care professionals call with questions about their wound clinics. Following are the top 10 questions that were asked in 2006 — common concerns among wound care centers. We present these questions as reassurance: if you have these dilemmas, you are not alone.
