Corporate Compliance

We would like to conduct an audit of our urgent care and wound care centers. Where should we begin?

Compliance Monitor, April 20, 2007

Q: We would like to conduct an audit of our urgent care and wound care centers. Where should we begin?

A: As you know, wound care is one of the OIG's favorite topics, having been on its Work Plan for several years. If you are reviewing wound care cases, pay particular attention to the documentation in the record to support medical necessity for the service provided.

Review the local coverage determination (LCD) for the fiscal intermediary (FI)/carrier of your state.

Click here to find LCD information, such as documentation requirements and frequency of service.

Identify those instances where a coder appends modifier -25 to an E/M code on the same day as a separately billable procedure. Determine whether a separate E/M service truly was provided over and above what is expected for any procedure.

I think you will find that the E/M is not typically warranted on the same day as a procedure. Refer to your facility's E/M guidelines regarding wound care and determine the E/M distribution.

As for the urgent care review, focus on medical necessity problems surrounding services provided, the proper capturing of all diagnoses, and assessment of the validity and reliability of the E/M criteria.

A recent review of E/M assignment at a hospital-based urgent care center revealed that staff assigned very few low-level E/M codes. As a result, the facility's E/M criteria needed some revisions.

Also, validate the documentation to support procedures, particularly wound closures.

The above question was adapted from HCPro's APC Answer Letter, April 2007. For more information click here.

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