Responding To a Wound Care Audit

The first step for a provider to survive a UPIC, ZPIC or OIG audit is to ensure you are properly maintaining your records and following both national and local coverage determinations.

The reimbursement rate of the growing field of biologic or synthetic skin substitutes is extremely high, which is why CMS places all wound care providers using these products at high-risk. Knowing you are on the high-risk list makes it extremely important to follow the proper processes:

1. 1. Ensure medical necessity – Medical necessity is often subjective; however, necessity can be demonstrated and supported by appropriate records. When auditors review for medical necessity, they are looking for certain objective findings that tend to substantiate the necessity for elevating wound care to the use of biologics and synthetic skin substitutes.
   2. Failure of Conservative treatment – Prior to using biologics or skin substitutes the provider must document the failure of conservative treatment. This generally means the medical record must document the standard of care for general wound management has been followed and failed. Regardless of whether you previously treated the patient and administered the standard wound care treatment to failure or you are taking over patient management, the failure of traditional approaches must be documented. The medical necessity for the use of more aggressive treatment using biologics or skin substitutes is essential and often lacking.
   3. Adequately describe the wound – As the application of conservative treatment fails the provider should begin measuring the wound and taking pictures regularly. Measuring and taking pictures in addition to detailed written descriptions of the wound establishes a couple of key elements.
      1. 1. First, the wound is sufficiently serious to warrant the application of aggressive therapy such as biologics or synthetic skin substitutes, or other aggressive therapies.
         2. Second, the wound is responding to the treatment. CMS will not continue paying for aggressive treatment with biologics or synthetic skin substitutes unless the wound demonstrates progressive healing.
   4. Frequency of application – One of the factors considered by CMS auditors is the frequency of dressing changes and use of biologics. There is a built-in bias here. Distributors prefer the frequent application of biologics or synthetic skin substitutes, and CMS prefers less frequent changes. Medical necessity lies somewhere in the middle. Whatever you do, make sure you can justify and document the necessity for dressing changes whatever the frequency.
   5. Use of E/M Codes – Dressing changes can usually be completed by a trained ancillary provider and do not require a medical provider. Sometimes the patient has underlying medical conditions that do require a medical provider’s presence, treatment, and management. When this is the case, providers should ensure the records properly document the underlying or co-morbid condition that requires treatment and justifies the use of an E/M code.
   6. Types of wounds Medicare Expects to Cover:
      1. Surgical wounds that must be left open to heal by secondary intention
      2. Infected open wounds induced by trauma or surgery
      3. Wounds with biofilm (biologics or synthetic skin substitutes)
      4. Wounds associated with complicating autoimmune, metabolic, and vascular or pressure factors
      5. Open or closed wounds complicated by necrotic tissue and/or eschar.