Auditing Your Wound Care Documentation

Auditing your documentation should be a best practice initiative. Knowing the principles of medical record information provides the basis for performing an internal audit of that medical record. There are specific strategies to consider when performing a wound care audit.

First, review your fiscal intermediary's website for the language that supports wound care services and medical necessity requirements. Next, interview staff to ensure a clear understanding of the documentation processes and workflows that define the medical record in your department. Create and/or review the policies and procedures that support the department's work, and make sure that you have a policy in place that supports your facilities, evaluation, and management practices. Meet with your compliance officer to review trends within your department. And verify each patient's visit is supported by a physician's order. Also verify that that procedure documented meets medical necessity and supports the physician's order as well.

You also need to review the most frequently documented procedures such as your debridements or the application of cellular and/or tissue based products or negative pressure wound therapy as examples, and make sure you have the proper documentation elements to support the procedure as well as the proper codes for billing.

So this dovetails into really the next guiding principle, which is reviewing your charge master as well as your ICD 10 codes and making sure that those updates are made annually. So as you reconcile charges prior to billing, make sure that you review the documentation for the visit or the procedure to ensure it supports the work performed. Given changes in the NCD and LCD landscape, it's extremely important for you to review the number of procedures completed within a given timeframe for each patient. Also, make sure that you work with your medical records department to define what is timeliness of documentation and what does it mean to close a record?

Lastly, follow the bill and make sure that you understand those services performed from the beginning of the documentation process, through the billing process, and ask about denials. You need to understand the denial management process and make changes to your documentation or processes as necessary to alleviate those denials in the future.

While the list that we just talked about is not an exhaustive list, it's a lot to manage. So remember to reach out for assistance, if you need help to align your wound care specialty EHR with your organization's workflows and best practices, and just remember assistance is just a call away.