Today's Wound Clinic - Spring 2008 - (Page 9)

inbusiness TABLE 1. Example: Surgical Dressing Documentation Guidance • Section 1833(e) of the Social Security Act precludes payment to any provider of services unless there has been furnished such information as may be necessary in order to determine the amounts due such provider. It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. • An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code. • The order must specify (a) the type of dressing (eg, hydrocolloid wound cover, hydrogel wound filler, etc.), (b) the size of the dressing (if appropriate), (c) the number/amount to be used at one time (if more than one), (d) the frequency of dressing change, and (e) the expected duration of need • A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. A new order is not routinely needed if the quantity of dressings used is decreased. However, a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same or decreased. • Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (eg, surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (eg, wound cleansing) must be obtained from the physician, nursing home, or home care nurse. The source of that information and date obtained must be documented in the supplier's records. • Current clinical information, which supports the sensibility and necessity of the type and quantity of surgical dressings provided, must be present in the patient's medical records. Evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. Evaluation is expected on a more frequent basis (eg, weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional. This evaluation must include the type of each wound (eg, surgical wound, pressure ulcer, burn, etc.), its location, its size (length x width in cm.) and depth, the amount of drainage, and any other relevant information. This information must be available upon request. STEPS TO SUCCESS The following are some steps to success for identifying payers’ policies that should be followed: • Identify the top payers for the wound care patients. • Identify the Medicare contractors that process the claims for the facility and for the physicians who practice there. (Please note: Currently the facility and the physicians could have different Medicare contractors who write similar or different policies. Over the next few years, the same Medicare contractor will process both the facility and the physician claims; the policies should be more closely aligned once that happens). • Visit the websites of all commercial payers and Medicare contractors who process claims for the facility and for the physicians who practice there. Search for educational materials, policies, newsletters, seminars, webinars, etc. regarding each of the services, procedures, and products that are on your charge sheets and that are eventually submitted as claims to the payers. • Review and compare the documentation guidance, which is provided for the facility and the physician, with the entire medical and clinical staff of your outpatient wound clinic. • Schedule frequent physician and clinician staff meetings to share every guidance policy that pertains to the services, procedures, and products performed/used. • Assign someone to regularly review the payers’ websites for new and/or updated guidance policies. • Schedule physician and clinician training every time new/updated guidance policies are released. • Conduct self-audits frequently; if compliance issues are found, report them to the corporate compliance officer immediately. that physicians and clinicians will find when they review their Medicare contractor’s LCDs and Articles. Remember, documentation must be present to support medical necessity, which in turn supports your payment. (Please note:The examples provided are only pertinent to the clinicians and physicians under the jurisdiction of the Medicare contractor who developed the LCD/Article. Furthermore, these examples may be out-of-date by the time this column is published. Every clinician and physician should research the LCDs and Articles that are specifically pertinent to their payers and their geographical area. Do not follow the guidelines found in Tables I–IV; they are only provided as examples to show the type of documentation policies that currently exist.) • The DME MAC (Medicare Administrative Contractor) TrustSolutions provides documentation guidance (See Table I) in the LCD for Surgical Dressing (L11449), which can be found at: Today’s Wound Clinic Spring 2008 DOCUMENTATION GUIDANCE EXAMPLES Finally, let’s review some examples of the pertinent documentation guidance 9

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Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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