The most critical function of the medical record’s multiple purposes is to plan and provide continuity of care for a patient’s medical treatment. However, in many instances, we as healthcare providers forget that the medical record offers additional provisions including the following:
- information for financial reimbursement to hospitals, healthcare providers, skilled nursing facilities, and patients;
- legal documentation in cases of injury or other legal proceedings;
- information to support quality assurance and peer review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and
- critical information for accreditation processes.
The underpinning of the documentation must support rules and regulations based on your Medicare carrier and other insurers. The importance of understanding and self-auditing the rules and regulations governing your place of service is paramount. For example, Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process with opportunities for public participation. In some cases, CMS’s own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).
The Medicare Coverage Database (MCD) contains all NCDs and LCDs, local articles, and proposed NCD decisions. The database also includes several other types of National Coverage policy-related documents, such as National Coverage Analyses, Coding Analyses for Labs, MEDCAC proceedings, and Medicare coverage guidance documents.
Local coverage determinations are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states:
For purposes of this section, the term “local coverage determination” means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).
Let’s take a look at one LCD and how the utilization guidelines within the LCD establish parameters for typical or expected use of specific services in the outpatient wound care department:
Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.
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Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.