Wound/ulcer management professionals work hard and often heal wounds that have been in existence for many months or years. They deserve to be paid for their work. Unfortunately, the payers do not have the same insight into the patient's condition because they do not see the patient in person. They only see the patient through the lens of each professional's documentation. One would think that wound/ulcer management professionals would want to take the time to "paint the picture" of their fabulous work by documenting each patient's condition, their medical decision-making, their plan of care, and the patient's progress, in addition to meticulously signing all of their documentation and orders. This attention to detail would lead to appropriate payment when claims are submitted and prevent repayments during postpayment audits.

Over the past 23 years, this author has done everything possible to educate wound/ulcer management professionals about ways to prevent denials and repayments. For example, the December 2020 column informed readers that the various Medicare audits paused at the beginning of the COVID-19 public health emergency were restarted. Then in May 2021, this column reminded readers to follow the various Medicare coverage policies that should help prevent claim denials and repayments. However, wound/ulcer management professionals continue to provide the various Medicare auditing contractors with opportunities to deny their claims and request repayments for services such as debridement, application of cellular and/or tissue-based products for skin wounds, evaluation and management services performed on the same day as minor procedures, surgical dressings, negative pressure wound therapy, hyperbaric oxygen (HBO) therapy, and so forth.

If audits result in many claim denials and repayments, Medicare continues to conduct wound/ulcer management-related audits in the hopes that those services will only be provided when medically necessary and that the documentation will meet all coverage requirements. To show readers how these claim denials and repayments can be easily prevented, this column provides a review of recent HBO therapy audits and guidance documents that the payers provide to help wound/ulcer management professionals keep their payments. Please note that the audit results are not unique to HBO therapy; similar audit results have been reported for most of the other wound/ulcer management services.

HBO THERAPY POSTPAYMENT AUDIT

Palmetto GBA recently reported1 the results of a postpayment audit of Healthcare Common Procedure Coding System code G0277, Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval. The audit was conducted from January through March 2021 for hospital-owned outpatient provider-based departments in North Carolina, South Carolina, Virginia, and West Virginia. This author was disappointed to learn that greater than 50% (50.53%) of claims were either completely or partially denied. That translated into repayments of 42.67% of charge. The reasons for the repayments were disheartening:

* No documentation of medical necessity

* Services performed not documented

* Dependent services/items denied because qualifying service was medically denied

* Dependent services denied because qualifying service was technically denied

* The recommended protocol was not ordered and/or followed

* Billing errors

* More units billed than were ordered

Palmetto GBA stated that these repayments could be prevented if providers:

* Document thoroughly to support orders, services rendered, and medical necessity for the qualifying service on the date billed.

* Verify that all of the coverage requirements are met and documented

* Legibly sign all documentation necessary to support orders and medical necessity

* Use the most appropriate International Classification of Diseases, 10th revision, Clinical Modification codes to identify the beneficiary's medical diagnosis

* Verify that initial certification and recertifications are in the medical record

* Verify that the physician's orders align with all the units billed

* Only bill for services/items documented in the medical record. During an audit, submit all documentation related to the services billed and ensure that it is for the correct date of service, beneficiary, and specific service.

* Do not bill for services that are not covered

* Check all bills for accuracy prior to submitting to Medicare

As you can see, none of these expectations are new. In fact, every HBO therapy medical record should include all the above information.

HBO THERAPY AUDIT INITIATIVES

First Coast Service Options (FCSO) recently (October 2020) completed an audit of physicians who perform HBO therapy supervision 99183; they even created a checklist2 to aid physicians in submitting their documentation for the audit. This checklist was intended to be used in addition to the documentation requirements published in extant guidelines and can be found here: https://medicare.fcso.com/Med_doc_checklists/0413363.pdf. As you read this excellent checklist, you will see that FCSO focuses on: legible patient identification and legible signature, justification of diagnoses code(s), thorough description of procedure performed and products used, initial assessment to substantiate the need for HBO, physician progress notes, re-evaluation every 30 days, physician-to-physician communication, the results of required diagnostic tests, standard wound care documentation, patient response to treatment, availability of a trained emergency response team and ICU services, and so forth. Even if FCSO is not the Medicare contractor that processes your claims, this checklist is worth reviewing and incorporating into your own documentation practices.

Despite this explicit checklist, the FCSO audit report3 shows that greater than 50% of the submitted claims required repayment and that the major reason for the repayments was that the documentation did not support medical necessity of the services billed. NOTE: FCSO supplied an identical HBO therapy documentation checklist to the hospital-owned outpatient provider-based departments, who are currently undergoing a similar audit of G0277.

HBO THERAPY DOCUMENTATION REQUIREMENTS

Noridian Healthcare Solutions also published a checklist4 of the documentation that should be submitted during HBO therapy audits. This checklist can be found here: https://med.noridianmedicare.com/web/jea/topics/documentation-requirements/hyper. As you review this checklist, you will see that it also focuses on the order for the service, documentation to support medical necessity, progress notes, treatment plan, procedure logs, documentation for diabetic lower extremity wounds, description of service provided, use of the Advance Beneficiary Notice of Noncoverage, and signature and electronic signature process. Even if Noridian Healthcare Solutions is not the Medicare contractor that processes your claims, reading this succinct checklist will be well worth your time.

SUMMARY

This author is aware that proper documentation takes time, but thorough and complete work should help you avoid repayments and wasting valuable administrative hours filing appeals. When you are selected for an audit, assemble all of the documentation requested. Before the documentation is submitted, the medical professional(s) who managed the case should review the entire packet to be sure that all the pertinent documentation is included in a logical order. Most important, do not give the auditors a reason to deny your claims and request a repayment. We can change this repayment situation if we personally resolve to read all the guidelines available to us and use that information to improve our documentation.

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