Podiatrists have observed a significant increase in audits, particularly centered on skin grafts and wound care. This heightened focus extends to both Medicare and private insurance companies. The rise in scrutiny can be attributed to podiatry’s expanded role in treating lower extremity wounds.
Understanding how audits are initiated, your rights during the process, and what you can do proactively will save you time, money, and stress.
The Audit Process
Insurance companies and Medicare typically request patient charts as part of pre-payment or post payment audits. It is crucial to comply with records requests and maintain professional conduct throughout the process. In the case of an unscheduled office visit, politely inform the investigator that your legal counsel will contact them to facilitate a secure record transfer. Do not grant investigators unfettered access to your office, employees, or electronic records without oversight.
When preparing records, never change anything in the office notes as it could be considered an alteration, which is fraud. Consult with legal counsel and a certified professional coder to determine if an attestation, supplementation, or certification may be necessary.
After the documentation is produced, you may wait months for a formal response, which may carry with it an overpayment demand. In the case of an alleged overpayment, be mindful of deadlines and work closely with counsel to ensure you follow the appropriate due process afforded to you.
Essential Documentation for Skin Grafts and Wound Care
Practices are chosen for audits if they are considered outliers. However, many times a practice may be an outlier for practical reasons. As providers have no say over how a payor determines their “outlier” status, to minimize the risk of an overpayment, practitioners need to ensure their documentation shields them from unfavorable findings.
For podiatrists and other providers engaging in wound care, to ensure your medical records support your use of skin grafts for wound care, you must ensure that you clearly document the following:
- Wound/skin graft size: Include precise measurements (e.g., 1mm x 3mm) or utilize diagrams/photographs with annotations.
- Wound depth and purulence.
- Wound color and odor (if present).
- Wound vascularity.
- Wound type (traumatic, pressure, infected).
- Prior conservative treatment attempts and their effectiveness.
- Improvement in wound size/depth with treatment (photographs are valuable).
- Basis for diagnosis.
- Diagnostic test performed and the impact of the diagnostic test results on treatment decisions (e.g., antibiotic adjustments).
- Detailed treatment plan explanation.
While this is not an exhaustive list of documentation requirements, it highlights many of the areas targeted by payors that are frequently under documented. Healthcare providers focus on the well-being of patients and understandably do not have the time to keep up to date on the latest coding and documentation guidelines and revisions to existing policies. Healthcare is one of the most highly regulated fields in the country, and it takes experienced professionals in the area to understand the intricacies and frequent changes.
To protect your practice, consider yearly self-audits of your most frequently used codes, with particular focus on high reimbursement procedures like skin grafts.
Conclusion
While self-auditing and implementing preventive measures are crucial, audits are inevitable. The proactive engagement of experienced healthcare attorneys and their teams is the most effective strategy to navigate audits successfully and minimize financial repercussions.
