How to Fail a Medicare Audit Without Even Trying – a Cautionary Tale from the WPS Region

In a previous blog post on this site, Dr. Helen Gelly described the OIG evaluation in the WPS J5 region (Iowa, Kansa, Missouri, Nebraska, and all legacy hospitals) in which the OIG found an error rate of 85% among hyperbaric oxygen therapy claims. The OIG recommended that WPS notify all the hospitals in the region that they needed to “self-audit” and return over-payments. It’s possible that the “look-back” period could be SIX YEARS. WPS did send letters out to hospitals demanding they self-audit but didn’t provide any guidance about how to do this. We now know that at least one hospital is in the process of paying back money for HBOT services. We haven’t been able to get any details about the audit tool, but we have managed to find out a few basic things. The big news item is that many of the hyperbaric oxygen therapy note were not signed.

We have known what sort of things that the OIG might be looking for since they published a report on HBOT 18 years ago. I was the President of the UHMS during the first OIG review of HBOT in 1998 which was published in 2000.

Here are the OIG’s Top 4 Compliance Issues for HBOT:

  1. Billing Medicare for a non-covered condition
  2. Failing to perform/document the appropriate tests or treatment before instituting HBOT (inadequate documentation of medical necessity)
  3. Giving patients more hyperbaric treatments than medically necessary
  4. Not having a physician in attendance during the hyperbaric treatment

If you are the government and your goal is getting money back in the coffers that you think might have been paid out “improperly,” reviewing records to establish whether a treatment was “medically necessary,” is way too time consuming. However, if the auditor can make the case that the physician was not in attendance or that the correct procedures weren’t followed, it is very hard for the facility to refute.

In her guest blog below, Dr. Helen Gelly provides the list of basic documentation pitfalls that could result in payback of Medicare dollars for HBOT. One of them is that the HBOT treatment note needs to be signed.

That made me curious regarding the percentage of unsigned HBOT treatment notes. I’ll tell you in a future post, but first I’m curious what you think it is. I queried data on the National Hyperbaric Oxygen Therapy Registry hosted by the USWR. What do you think is the national average for the percentage of HBOT treatment notes that remain unsigned more than 72 hours after the treatment?


Guest Blog from Helen Gelly:

Documentation is the name of the game. We all chuckle when someone reminds us that if it isn’t documented it wasn’t done, but many times we think that does not apply to us. Wisconsin Physician Services (WPS) has been sending letters to all of the hospitals that provided hyperbaric services in 2013-2014, requesting that they self-audit their charts, report their error rate, and then return the incorrectly paid claims. With a 6-year look back period, that could translate into some serious money.

Documentation has become the linchpin in this process, since no one can really remember that far back. Since we cannot change the records, we need to learn from our past. Time to review what is required to document a hyperbaric treatment.

  1. An order for the treatment that day.
    • You can reference the standing order, but 99183 assumes that you have deemed the patient fit and appropriate for the treatment that day.
    • Order for blood sugars if appropriate and why they are necessary
  2. The diagnosis for which HBOT is being provided must be on the chart
  3. The note must state that the patient is being treated in a “hard sided chamber using 100% oxygen”
  4. Details of door to door time, with air breaks, rate of descent and ascent (in real time, not rounded to the nearest 00 or 05 minutes) with the correct number of segments attributed to the treatment
  5. Documentation by the hyperbaric tech/nurse that the physician/NPP was immediately available
  6. Documentation by the hyperbaric physician/NPP that you were immediately available
  7. Signing the chart by all parties after the treatment is over, and within a reasonable time frame
    • Clinical staff should sign the chart off after the treatment is over on the same day as the treatment
    • Physician staff would ideally sign the charts the same day, but definitely not more than 48 hours later
  8. If there is an abnormal event (high blood sugar, trouble clearing, blood pressure changes) these need to be addressed in the physician notes. For example, you have low blood sugars, requiring dietary supplementation, the physician needs to document the order for repetitive blood sugar testing, and then plans for addressing this issue going forward.

In an informal survey of reasons why hospitals have had to send money back, unsigned charts, incorrect segments, and a medical unnecessary indication, loom as major contributors. The easiest of these to fix is our daily treatment documentation. Not getting that right is how to fail an audit without really trying.