Medicare Documentation Requirements:
By Angela Breslin, BSN, R.N
Simply stated, Medicare documentation is the key to a quality driven, results achieving, compliant and successful business. This applies to DME providers, physicians, home health agencies, long term care facilities, or any Medicare approved supplier. Most Medicare wound care claims that are denied are denied due to issues related to Medicare documentation errors.
Medicare states that the Medicare wound care documentation, “should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not be medically necessary.”
Additionally, at a high level, Medicare wound care documentation should meet all of the following expectations:
All Medicare documentation should be complete, legible, signed and dated
Medicare documentation is the recording of pertinent facts of and observations about an individual’s health history, including past and present illness, test results, treatment and outcomes.
The Medicare documentation of each patient encounter should include: the date, the reason for the encounter, appropriate history and physical exam, review of lab results, x-ray results, other ancillary services (where appropriate) assessment, and plan of treatment
If your billing codes are time based, then the Medicare documentation must clearly and accurately notate how much time was spent with the Medicare beneficiary.
If your billing for E/M services, you need to be sure that your Medicare documentation includes History of Present illness (HPI), Review of Symptoms (ROS), and Past Medical, Family, and Social History (PFSH)
Your Medicare documentation should clearly and accurately include the proper ICD-10’s that are required for treatment, testing, and payment
Your modifiers, if appropriate, should reflect what story the Medicare documentation tells
Medical Records Documentation Requirements: Surgical Dressings and Wound Care Supplies
1. Dispensing Order, if applicable- Verbal Order
2. Doctors Written order- DWO
3. In order to meet the Medicare documentation requirements, the wound must have been:
a. Caused by a surgical procedure; or
4. The Medical Records MUST state the following:
a. Type of surgical dressing; AND
b. Size of the surgical dressing; AND
1. Including length, width, and depth
c. The number/amount to be used at one time; AND,
d. The frequency of change; AND
e. The expected duration of need; AND
f. Is the surgical dressing being used as a primary or secondary dressing; AND
g. The numbers of wounds; AND
h. Evaluation must be AT LEAST monthly except for the following:
1. Patient is in a nursing home or long-term care facility- weekly evaluation
2. The wound is heavily draining or has infections- at least a weekly evaluation
i. The type and location of each wound
j. The amount of drainage for each wound
It is important to note that all of the above wound care medical record requirements MUST be documented in the beneficiaries actual medical records file and not simply on a supplier provided form. Far too many suppliers have been misled that simply checking a box on a form will meet the Medicare documentation requirements or be compliant with Medicare documentation requirements. It should be noted, and understood, that if the DWO is provided by the supplier, it is not considered a part of the medical records requirements for Medicare wound care and surgical supplies.
In order to be compliant with Medicare documentation requirements, the Medical Records Documentation Requirements noted in this article MUST be in the medical records and be signed and dated by the health care professional who is treating the beneficiary.
According to recent Medicare TPE audit results, click here for the actual article, the following are the top Medicare TPE audit denial reasons regarding Blood Glucose Monitors: The overall denial rate was 82%
Medical documentation was not received in response to the ADR letter
Medical record documentation was not received
The DWO was incomplete or missing requirement elements
Being compliant with Medicare wound care medical documentation requires is paramount to achieving operational and financial excellence. If you receive a Medicare audit notification letter regarding a TPE audit, RAC audit, or UPIC audit, you must be diligent, complete, and timely in your response. If you have any questions whatsoever feel free to contact Boost Advisory Group for a free consultation. Boost Advisory Group provides a 100% satisfaction guarantee regarding Medicare audit response services and Medicare documentation compliance.
About the author:
Angela M. Breslin is a Registered Nurse (BSN, RN) with some 20 years of clinical experience in a hospital setting. Angela is an expert in Medicare, Medicare, Medicaid, third party payor audits response services, appeals submissions, Medicare audits, and medical LCD compliance. Angela has effectively responded to and won audit response and payer appeals across many product s and services, including but not limited to, urological supplies, wound care and surgical supplies, ostomy supplies, diabetes testing supplies, CGM, insulin pump therapy, diabetic shoes, psychiatry, orthoses, breast pump supplies, and emergency services.
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