Toll Free 888-357-3226

Office of Inspector General (OIG) Highlights for Organizations to Assess Wound Care Coding Practices

May 02, 2017


The Office of Inspector General (OIG) protects the integrity of Department of Health and Human Services. It carries out regular audits to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout HHS. Through its numerous audits conducted way back from 1995 to date OIG has highlighted and brought to open questionable reimbursements and over payments being made due to errors in Wound Care coding practices.

The high cost of wound care is a major contributor to the hemorrhaging of Medicare funds. In 2012, the U.S. Wound Registry (USWR) published data on the costs over time in outpatient wound care. That data included an analysis of 5,240 outpatients living with wounds who, over a five-year period, accrued a total "cost to the system" of $29,249,500 — in outpatient charges only. If we assume that 6.5 million people in the U.S. live with chronic ulcers, then extrapolating these data would yield a cost of at least (approximately) $25 billion on the outpatient side alone.
(Ref: Today's Wound Clinic, April 17, 2017)

What is wound Care? There are different kinds of wound care procedures. Some are performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. Whereas, some wound care deals with debridement, which is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. Depending on which of these procedures are employed, accordingly the CPT codes are used by health professional medical billers and coders. In case when extensive wound sterilization is needed these procedures can also be billed.

Wrongly Coded:
OIG audit findings in 2007 highlighted that 64 percent of surgical debridement services in 2004 did not meet Medicare program requirements, resulting in approximately $64 million in improper payments. 39 percent of surgical debridement services were billed with a code or modifier that did not accurately reflect the service provided. These wrongly coded services resulted in improper payments to the tune of $19 million approximately.

Billing Claims:
In 2013, an OIG audit of a hospital found a very high number of wrongly coded claims for physician services. The Hospital billed the claims using a non-facility place-of-service code for services that were in fact performed in its wound care facility. It also found that the incorrect billing was due to billing software error resulting in $5 million in improper payment. Moreover, improper payments may result from clerical errors, misinterpretations of rules, or poor record keeping

Prior Authorization:
Today, hyperbaric oxygen therapy (HBOT) in Wound care use is growing at a rapid pace and is seen as the No. 1 target for auditing purposes. Moreover, the criteria for "appropriate conservative care" if not met prior to the initiation of HBOT, can lead to claim denials. So if you fall into one of the 3 states which are now in a Medicare prior authorization program whereby the medical records of patients have to be reviewed prior to the initiation of non-emergent HBOT to ensure payment, then you need to ensure you cover all criteria requested.

Regular Audits:
Such errors prompt the OIG in recommending organizations to monitor and periodically audit their billing systems to avoid overpayments and their subsequent refunds. OIG also emphasizes that CMS (Centers for Medicare and Medicaid Services) should either develop a National Coverage Determination or instruct carriers to develop more uniform policy guidance for appropriately coding various wound care billing services performed and situations where modifiers should be used. Carriers should also proactively review common coding errors and perform data analysis to track providers who have aberrant billing patterns.

A truly patient-centered appointments system will allow patients to choose when and where they are seen. Using the patient's preferred method of contact for e.g. telephone, e-mail, text message in an appointments system characterized by 'contact and book' rather than 'book and contact' would seem ideal.

Carrier/Payer's requirement:
Wound care procedures reimbursements constitute a significant portion of a hospitals'/medical practitioners' income. Consequently, its medical coding poses a great challenge when wound treatment as well as evaluation and management, that are part of wound care, need to be coded correctly as per the Carriers' requirements. Coding practices should also be careful to follow the per-session/per-wound surface area and bundling of procedures diligently.

Patients with chronic Urologic conditions have different needs. Rarely will face-to-face consultations with an urologist provide optimum care. Support groups, telephone consultations, or remote monitoring of blood results might more effectively meet the patient's needs.

Sometimes the codes used are open to interpretations where the payments can go way high in case wrong codes are used. Therefore, it's vital to use code that covers the duration and area (skin/tissue/muscle) of the procedure to avoid up-coding or false claims.

A stringent documentation goes a long way in helping avoid claim denials and in claim appeals. Also helps when audits come up. Practitioners of Wound care should ensure that the medical record(s) of the patient(s) are verified and patient is eligible and meets the coverage indications. The medical record should have the "why "services are medically necessary. Lack of co-ordination between the documentation provided by the nurse as that provided by the doctor could lead to problems when claiming reimbursement

Following the above best coding practices, Wound care organizations can help avoid audits and help the Office of Inspector General (OIG) in reducing waste, abuse and fraud and promote efficiency and economy.


Category : Outsource Medical Billing