Transcript

David Charash DO, CWS, FACEP, FUHM:

Hi, I'm Dr. David Charash. I'm a physician, wound care provider, I'm board certified in emergency medicine, undersea hyperbaric medicine, and a certified wound specialist. I'm the medical director with Intellicure. I'm also the owner and medical director of a consulting group called Dive Medicine and Hyperbaric Consultants.

Well, I think that proper documentation, at a very basic level, is a record of what we did, why we did it, where we did it, when we did it, and who we did it to. The medical record serves as both a medical legal document and a vehicle to communicate medical information to other healthcare providers. In addition, patients have a fundamental right to their medical information under the protection from the HIPAA law. Patients have the right to access, inspect, and obtain copies of their health records from providers and insurers. And, of course, a critical understanding of the importance of and why we need proper documentation is that it is a very basis for the effective and proper coding, billing, and compliance. It is actually the quality of our documentation, therefore, that ensures appropriate reimbursement.

Well, thinking about documentation through the eyes of an auditor, in general, an auditor looks at the medical record to determine first if the medical condition or procedure is a covered event by the insurer. Every insurer, whether it be Medicare or a third-party private insurer, has a policy book that essentially defines what is a covered condition, episode of care, or procedure. So, the importance of a proper ICD-10 code is the key to beginning the documentation process. The auditor then looks through the medical record to determine if documentation supports meeting medical necessity. Does the documentation support that medical need for the services or service rendered? And then those documents can include a variety of actions, including clinical evaluations, consultations, progress notes, laboratory evaluations, and consultations from outside providers.

Understanding then what is medically necessary, it's actually something that is defined by the Center for Medicare Services as reasonable and necessary for the diagnosis or treatment of illness. This is actually defined from a section of Social Security Act, Section 1862A1A. This is actually a core statutory authority that Medicare uses to decide on whether they pay or deny claims based on whether you have met the items necessary to meet medical necessity. So, they have a test that asks 4 questions, whether it's reasonable or necessary, if 1, that it's appropriate for the patient's condition, that it's consistent with accepted standards of medical practice, that it's furnished at the proper level, frequency and duration, that it's expected to produce a meaningful outcome. So, those are sort of the necessary elements to document medical necessity, and that is the requirement by statutory law through the Social Security Act that requires us to define and meet medical necessity.

Medicare and other insurers also define what is not medically necessary, and they look at aspects such as services that are provided solely for screening, services that are provided for patient, provider, and or family convenience, services that are excessive in frequency or duration, and that treatment that lacks documentation of clinical response. So, if you fail to document clinical response, even though you have done everything that potentially would have met medical necessity, you will be denied your claim.

Now, CMS enforces medical necessity by following the guidelines through the National Coverage Determinations, NCDs, or the Local Coverage Determinations, LCDs, and certainly by what are the requirements for each covered event or episode through the Medicare Benefit Policy Manual. And it is these 3 areas of the NCD, LCD, and the Medicare Benefit Policy Manual that defines what medical necessity is, that the pre- and post-payment audits through the various government agencies use to determine if we've met medical necessity and whether we will pass or fail an audit. And I would say also that it's important to understand the, understanding that an audit’s documentation, not intent, decides medical necessity. So, medical necessity is a definition that comes right out of the Medicare Benefit Policy Manual.

Documentation to support advanced treatments such as debridements or the application of cellular tissue products require that you need to make sure that the wound that you're treating or the patient that you're treating meets coverage criteria by the CMS guidelines, that they have failed the standard wound care—they’ve got to demonstrate that in your medical documentation—that your selective intervention must match the wound. And what I mean by that is that if I have a diabetic foot ulcer that is defined as a wound that is through the bone, so a Wagner Grade 3 diabetic foot ulcer, and I am debriding that wound using a sharp instrument down to the bone, but in my photographs, in my actual physical description of the wound, I have a photograph that shows only subcutaneous tissue, and that my wound description shows descriptions of a wound that is to the subcutaneous level, then I fail to define an intervention that doesn't match all other levels of my description in my photograph and in my diagnosis.

Also, you need, for example, improvement in the qualitative or quantitative aspect of the wound. And specifically for cellular tissue products, you need to include the rationale for using the product of choice and that your surface area is applied to the lowest level of the surface area for the product used. And I think we're all aware that, effective January 1st, the significant changes with the application of skin substitutes or cellular tissue products, the 5 areas that we need to be really cognizant of are the incident-to supplies, the payment rate, the withdrawal of the LCD for the venous leg ulcers and diabetic foot ulcers, the fact that there is no covered product list, and that there is no reimbursement for wastage. Operationally, then, these changes affect issues related to reimbursement of the cellular tissue product, but you still, in addition, need to respond to the requirements to meet medical necessity in your documentation.

Adequate documentation includes both the quantitative as well as qualitative assessment of the wound. So it's not just length, width, and depth, but also things like undermining, sinus tracts and the qualitative description of the wound. So, for example, necrosis, exudate, erythema, smell, drainage, evidence of secondary infection. It's also very important to document both pre- and post-debridement measurements, as well as photographs with each visit. Keep in mind, we are treating the whole patient, not just the hole in the patient. So, when we document lack of progress, it is important to address those things that contribute to poor wound healing, including nutrition, smoking, offloading, compression, infection control, circulation, diabetes management, socioeconomic factors, and the effects of the patient's comorbid illness and how that might impact wound healing.

Best practices in documentation are having an integrated electronic medical record that is wound care specific, that includes care plans that are aligned with the ICD-10 codes, that throughout the medical record there is a mapping between these ICD-10 codes, the care plans, and all procedures, and that it reflects the level of service provided. Your documentation system is a tool that can help you or hinder your quality and efficiency of your documentation. Once documentation is completed, then having a formal process to review adequacy and completeness of documentation that involves the wound care team is essential. This team not only includes the medical provider and the nursing staff but also the coding, billing, and compliance team members. Developing an effective chart review process can help reduce the chance of denials and minimize the impact of a failed chart audit.

Remember, it is not if you will be audited but when you will be audited. Ultimately, I would say that there are no shortcuts to best practices in documentation. Remember, it is your documentation that will be audited, not your best intentions for the patient. We are treating the whole patient, not the hole in the patient. Our documentation must include what you did, why you did it, where you did it, when you did it, and who you did it to for the documentation to meet medical necessity.