Focusing on Wound Care Documentation and Audits

There are many important reasons for auditing documentation, including determining its accuracy, assessing the completeness of a medical record, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine whether it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, and poor compliance with policies and procedures and/or payer regulations may not be identified.

Each clinician must understand the rules and regulations guiding the wound care department’s documentation and billing processes. The rules within the wound care department are generated from your Fiscal Intermediary, Carriers, and Medicare Administrative Contractors; National Coverage Determination and respective Local Coverage Determinations; the Centers for Medicare & Medicaid Services, The Joint Commission, and the American Medical Association; and so on. With so many rules and regulations governing your work, it is important to have an audit process in place to ensure your documentation supports them.

Proactive monitoring and auditing are designed to test and confirm compliance with legal requirements. These implementation and monitoring strategies include:

• defining risk areas and establishing the need for self-audit;
• considering your departmental resources for practicable auditing;
• determining the subject, method, and frequency of audits;
• reviewing medical and financial records that support claims for reimbursement;
• preparing the internal audit report;
• presenting findings to applicable parties;
• developing corrective action plan; and
• continuing ongoing monitoring.

Steps specifically outlining Internal Auditing strategies include:

• establishing and identifying the need for an internal audit;
• defining the specific issues of the audit;
• determining an appropriate sample size;
• establishing an audit schedule;
• preparing a concise audit report;
• presenting audit results to applicable personnel;
• developing an action plan; and
• performing ongoing monitoring.

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To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.

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