Each year, the Centers for Medicare & Medicaid Services (CMS) conducts medical reviews (audits) of Medicare Part A/B, Medicaid, and DMEPOS claims in an effort to help lower improper payment rates and protect the Medicare Trust Fund. For CY 2024, CMS has scheduled medical review activities for wound care-related services, which include E/M visits, wound/ulcer debridements, and more. In fact, one Medicare Administrative Contractor (MAC) is auditing all covered Hyperbaric Oxygen Therapy (HBOT) indications. The focus of these reviews is to determine whether claims follow coverage, coding, payment, and billing requirements. Medical reviews are conducted by various entities, such as Recovery Audit Contractors (RACs), a Supplemental Medical Review Contractor (SMRC), Unified Program Integrity Contractors (UPICs), and by the MACs themselves through the Targeted Probe and Educate (TPE) program. If you are not conducting self-audits for any of these services, consider using C+ Consulting, a firm with over 30 years of experience in the outpatient wound management industry, for your audit needs. We work closely with our clients to conduct medical record audits and help prepare documentation packets for submission in response to ADRs (Additional Documentation Requests). This assistance includes more than just a review of the denied dates of service, as it is necessary to determine if supporting documentation exists for services provided preceding, during, and post the denied dates. In addition, our presence on calls with the different contractors helps to clarify which documentation is missing as well as the rationale for the denials, which helps when gathering additional documentation for re-review. See our "Services" page for detailed information on how we can assist you with internal audits, whether your practice is currently being audited or not.

Successfully passing an audit depends almost entirely on the documentation submitted in response to an Additional Documentation Request (ADR).  Assuming the documentation meets all coverage requirements, it must be comprehensive and incorporate information that supports the service(s) provided as well as any further treatment(s), such as another round of Hyperbaric Oxygen Therapy (HBOT), additional skin substitute applications, etc.  Most importantly, medical necessity must be clearly stated and evidence of medical decision making (MDM) present in the medical record - - just because the provider states that the ulcer is a Wagner grade III doesn’t make it so, without supporting lab or radiology reports.  Providers and/or Facilities who fail to document and bill or code claims properly may be required to pay back some or all of the payments they received and possibly face additional fines, among other sanctions. If you are in the process of responding to an ADR or have received denials due to documentation you provided to an audit contractor, visit our “Services” page to see how C+ Consulting can assist you with compliance audits.

Good business decisions begin with recurring medical record and claim reviews that encompass all aspects of a compliant revenue cycle management process. This practice often translates into more accurate claim outcomes, which in turn reduces loss of revenue and risk for non-compliance with Medicare coverage requirements. In addition, with payment changes to both on- and off-campus outpatient departments, ensuring maximum revenue capture is essential. C+ Consulting conducts onsite (and remote) semi-annual Revenue Cycle Assessments (RCA) which include a retrospective review of the complete revenue cycle management process (via chart reviews, personnel interviews and other means) utilized for services provided in the Wound Management Center. Results are reviewed with Center and Facility personnel and additional training provided, as needed.

Errors in medical billing are inevitable and more common than we may want to admit; in fact, a 2023 article in a GITNUX newsletter found billing errors to be a substantial issue in the US healthcare system, costing an estimated $935 million weekly. Studies indicate that around 80% of medical bills have errors, with the majority due to hospital coding mistakes (63%), many of which included outdated CPT/HCPCS and diagnosis codes. Billing for wound care and hyperbaric services is challenging enough, especially with the many changes that have occurred over the past decade. For example, longstanding biopsy codes 11100/11101 were replaced by more specific codes (11102-11107) in 2019. CY 2021 and 2023 introduced drastic changes to E/M billing and documentation practices - - the first in more than 20 years! Having a current chargemaster is key to avoiding such errors. C+ Consulting is positioned to provide annual updates to your Wound Management Center's chargemaster, billing tools and policies for billing practices.

The nonexistence of a management company's fees might be an immediate boost to the Center's bottom line, but the loss of operational support can at times be a challenge. Billing policies, tools, guidelines, education and training functions typically provided by managment companies are now gone leaving your staff struggling to fill the gaps left by their absence. C+ Consulting provides ongoing support in all of these areas with a focus on tools and education that meet current regulatory requirements. Additionally, we provide continued electronic assistance and updates of "industry news" so that you are aware of changes which might have an impact on the future of your Wound Management Center operations.

C+ Consulting offers comprehensive and cost-effective solutions to these questions and more! In addition, take advantage of our complimentary resources such as quarterly newsletters, business tools and more!