OF WOUNDS SENIOR AUDITOR CAROLINAS HEALTHCARE SYSTEM. AHIA 32 nd Annual Conference August 25-28, 2013 Chicago, Illinois

Transcription

1 1 THE WACKY WORLD OF WOUNDS ERIN RYDELL SENIOR AUDITOR CAROLINAS HEALTHCARE SYSTEM AHIA 32 nd Annual Conference August 25-28, 2013 Chicago, Illinois

2 Carolinas HealthCare System 2 Carolinas HealthCare System (CHS) is the largest healthcare system in the Carolinas, and the second largest non-profit public system in the nation. CHS provides a lifetime medical home to patients through a network of more than 600 care locations including hospitals, freestanding emergency departments, physician practices, surgical and rehabilitation centers, home health agencies, nursing homes and other facilities. CHS Corporate Mission To create and operate a comprehensive system to provide health care and related services, including education and research opportunities, for the benefit of the people we serve.

3 Objectives 3 Gain a general understanding of wound care center and hyperbaric operations Explain the contractual relationship benefits and risks associated with having a 3 rd party manage the Wound Center Describe the key elements of clinical wound care medical record documentation Provide examples of key CAAT analytical tests using charge code pairings

4 What Is The Big Deal About Wound Care? 4 One of the fastest growing lines of business in healthcare driven by the aging population, rise in chronic diseases, and technological advancements. It is a profitable line of business for many healthcare facilities. Payor mix is predominately Medicare and Medicaid. OIG and RAC have performed audit reviews. Wound Care services are provided in multiple healthcare settings: Inpatient, Outpatient, Home Health, Long Term Care, Rehabilitation Facilities, Burn Centers

5 Perspective on Wound Care 5 In the United States, chronic wounds affect around 7 million patients. Approximately US$25 billion is spent annually on treatment of chronic wounds. The burden is growing rapidly due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The need for post-surgical wound care is sharply on the rise. Over 1,600 outpatient wound centers are in operation in the U.S., not including all the wound care rendered by clinicians in their offices, by inpatient acute care hospitals, long term facilities and nursing homes. More than ½ of these are managed by outpatient wound centers.

6 Perspective on Wound Care 6 Over 23 million people or 7.8% of the U. S. population suffer from diabetes. While 17.9 million have been diagnosed, 5.7 million are unaware that they have the disease. Up to 25% of individuals with diabetes will develop a foot ulcer during their lifetime. Adjusting for health-care inflation in 2007, foot ulcers cost between $7,439 and $20,622 per episode Average time to heal is weeks. Some wounds are palliative as they are not going to heal. Over 90% of the wounds treated in a wound center heal. The global wound care market is forecasted to rise to $21 billion in 2015, from $16.8 billion in 2012.

7 What does that mean? 7 VOLUME COST OVERSIGHT

8 What risks should we audit? 8 Proper billing of wound care procedures performed; understanding of services that cannot be billed on the same date of service. Proper billing of bioengineered skin substitutes. Presence of properly executed contracts for ownership of the Wound Center and Hyperbaric equipment. Volume of wound care denials. Existence of proper medical record documentation of wound care provided. Evidence of proper maintenance of hyperbaric equipment.

9 Understanding the Risks 9 Requires knowledge of wound care concepts Involves analysis of charge data Includes verification of medical record documentation requirements Takes into account typical front end control processes like scheduling, registration, payment processing, etc.

10 Wound Care Concepts 10 Debridement removal of devitalized tissue and foreign matter from a wound. Enzymatic (chemical) debridement Mechanical debridement Sharp debridement

11 Wound Care Concepts 11 Dressing the material applied to a wound for the protection of the wound and absorbance of drainage Alginate dressing Film dressing Foam dressing Gauze dressing Moist saline gauze Wet-to-dry to saline gauze Hydrocolloid Hydrogel dressing Pastes/Powders dressing

12 Wound Care Concepts 12 Layers of skin Epidermis Dermis Subcutaneous layer Deep Fascia Muscle layer

13 Bioengineered Skin Substitutes 13 Definition: An assorted group of substances that aid in the temporary or permanent closure of many types of wounds. The materials used to produce these products may be derived d from human or animal tissue. Types of Skin Substitutes: Apligraf, Dermagraft, Oasis, MatriStem Key Considerations: Must indicate medical necessity for their use Must document amount used and wasted know your Local Coverage Determinations.

14 14 Dressings and Supplies Unna boot, compression wraps, and total contact casting (29580, 29581, 29445) Negative pressure wound therapy (97605/97606) Uses special dressings and wound vacuum technology Routine supplies such as gauze, alginate, and foam are considered to be included in the procedure.

15 Key Audit Program Areas Handout # Contract Review 2. Registration/Scheduling and Cash Management 3. Information Privacy and Security 4. Photographs 5. Charge capture of procedures and supplies 6. Charge data analysis 7. Medical Record Testing 8. Hyperbaric Oxygen Therapy

16 1. Contract Review Handout #2 16 Understand how responsibility is delegated between parties. Identify all payment arrangements and determine compliance with contract terms. Gain an understanding of the monthly invoice calculations and the supporting data compiled.

17 Contract Review What We Found 17 No buyout provisions existed. No provision for exclusivity. Wound Company invoices to Hospital A were not compliant with contract Compensation and Payment Terms. Discrepancies were identified in the number of HBO treatments and wound care encounters billed to Hospital A.

18 4. Photographs 18 What is the wound center s approach to photography? Determine if the patient consent form adequately addresses photograph privacy. Determine how wound photographs are maintained i and labeled. l

19 Photographs What We Found 19 The frequency of Wound Center photographs h were not sufficient to adequately support wound progression and medical necessity for the frequency of debridement codes billed. For 12% of accounts reviewed, no photographs were present. Wound photographs h were saved to diskettes used by the digital camera. Once the photographs were downloaded from the diskettes, the used diskettes were stacked at the nurse s workstation. Each diskette was used until the storage space was full. The completed diskettes were not discarded or stored securely in accordance with HIPAA standards.

20 6. Charge Data Analysis Handout #3 20 Perform charge data analysis on final billed accounts Usually series accounts so review multiple dates of service for the same account

21 Charge Data Analysis What We Found in Missed Charges 21 Matrix Analysis Description No. of Gross Charges Ref No. Accounts OC04 Apligraf Used and Discarded 2 $3,120 MC x series additional w/o 2 $1,410 initial MC additional w/o initialiti 1 $387 OT05 HBO units incorrect 6 $8,396 Total Missed Charges $13,313313

22 Charge Data Analysis What We Found in Over Charges 22 Matrix Analysis Description No. of Gross Charges Ref No. Accounts OC08 Total Contact Cast & debridement on same 2 $1,214 date of service OT03 Review of top 10 charges 1 account had 10 1 $7,719 addl debridement's charged OC10 Chemical cauterization & debridement on same 4 $1,101 date of service MC01 Debridement 1104x each addl w/o initial 6 $3,933 OC03 Multi-layer compression wrap & debridement 2 $480 on same date of service OC07 Negative pressure wound therapy & 1 $320 debridement on same date of service OC01 Multiple E&Ms charged 2 $789 Total Over Charges $15,556

23 7. Medical Record Testing 23 Exact location of each wound treated t must be documented. Physician order required for all services Daily treatment notes should include: Progress notes Changes in condition, improvements, etc. Wound size and details (photos, etc.) Procedure details Signed, dated and timed.

24 7. Medical Record Testing cont. 24 Progress notes for Debridement Documentation require the following be specified: Location Anatomic location Appearance Surface dimension and depth Presence/absence/extent of granulation tissue, eschar, slough, fibrin Presence/absence/extent / of obvious signs of infection i Presence/absence/extent of necrotic, devitalized or non-viable tissue Stage or grade where indicated (press ulcers, diabetic ulcers) Pre-debridement measurements

25 7. Medical Record Testing cont. 25 Anesthesia If not used, document why (neuropathy, paraplegia) Instrument Scalpel, scissor, curette Type of tissue removed Devitalized tissue (non-selective debridement w/o anesthesia) (97602) Partial thickness (epidermis only superficial wound) (97597/97598) Full thickness (epidermis and dermis) (97597/97598) Subcutaneous (11042, 11045) Muscle (includes tendon, ligament) (11043, 11046) Bone *not common in clinic setting (11044, 11047)

26 7. Medical Record Testing cont. 26 Character of the wound after debridement Type of epithelialization Post debridement measurements Bleeding and its control Dressing (type, frequency of dressing changes noted) Patient tolerance to the procedure

27 Medical Record Testing What We 27 Found Lack of photos to aide in supporting medical necessity. Negative Pressure Wound Therapy Instruments and the method by which they were used did not appear to satisfy the definition of a sharp instrument. Debridement's billed did not include key required elements: character of the wound, instrument used, tissue material removed, and level of tissue removed. Dictations that did not agree with the wound site referenced in the Wound Assessment Record. Physician orders that were different or incomplete when compared to the actual products/supplies used per the Wound Assessment Record.

28 28 Documentation Example: Wound location, size, appearance and condition

29 Example with questionable measurements 29 L x W = sq cm

30 Example: Surgical Debridement performed without instruments and type of tissue removed specified 30 Wound #9 is a Diabetic Ulcer located on the Left, Plantar Foot. There was a Skin/Sub Tissue Excisional debridement performed after achieving pain control using Insensate. A time out was conducted prior to the start of the procedure. A minimal amount of bleeding was controlled with Pressure. The procedure was tolerated well with a pain level of Insensate throughout and a pain level of Insensate following the procedure. Wound #3 is a Diabetic Ulcer located on the Right Lateral Lower Leg. There was a Skin/Subcutaneous Tissue/Muscle Excisional debridement performed after achieving pain control using Local % Inj. A time out was conducted prior to the start of the procedure. A moderate amount of bleeding was controlled with pressure. The procedure was tolerated well with a pain level of 4 throughout and a pain level of 2 following procedure. Post Debridement Measurements: 2 cm length x 2.2 cm width x 1.1 cm depth Wound #3 is a Diabetic Ulcer located on the Right, Lateral Lower Leg. There was a Skin/Sub Tissue Excisional debridement performed after achieving pain control using N/A. A time out was conducted prior to the start of the procedure. A minimal amount of bleeding was controlled with Pressure. The procedure was tolerated well with a pin level of 2 throughout and a pain level of 0 following the procedure. General Notes: post debridement measurements revealed a 1-2 cm cavity.

31 8. Hyperbaric Oxygen Therapy (HBO) 31 Definition: A modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Referred to as HBO or HBOT Examples of Common Covered Conditions: Acute carbon monoxide intoxication Loss of Limbs Preparation and preservation of compromised skin grafts Diabetic wounds Post radiation therapy treatment Considered an adjunctive therapy only after there are no measureable signs of healing; must be used in addition to standard wound care.

32 8. Hyperbaric Oxygen Therapy(HBO) 32 Beneficial effects of HBO Improves cellular energy and metabolism Antibacterial t i effect Regenerating wound tissue effect Equipment Maintenance HBO protocol Treatments are daily Each treatment t t lasts about 2 hours Safety precautions are priority Physician supervision Blood Glucose and TCOM charges

33 Documentation Example: Hyperbaric Oxygen Therapy 33

34 Hyperbaric Oxygen Therapy(HBO) 34 What We Found Hyperbaric Oxygen Therapy (HBO) has strict specifications for linen to include the ingredient content of the linen and the way it is laundered. The Wound Center is routinely receiving regular hospital linens when they should receive back the laundered HBO approved linens. Varying approaches to the utilization of TCOMs Varying approaches to the utilization of TCOMs and other supporting vascular studies

35 35 Questions? Contact Information:

36 Save the Date September 21-24, rd Annual Conference Austin, Texas 36