Here’s a guest blog from Michael Crouch, following up on Martha Kelso’s post about audit requirements. I hope the information from these industry experts will help practitioners prepare themselves better for the audits that are bound to happen.

If you have been audited and want to tell us about what you learned, feel free to contact me (no HIPAA protected information, please!).

–Caroline

Dear Dr. Fife –

I read with great interest the recent guest blog by Martha Kelso and wanted to provide some feedback since I have been actively involved in a similar audit.  Martha mentioned that her recent request for records included 39 items, including invoices, for a 2025 audit.  My experience comes from a 2024 audit (which we are currently appealing) and thought you might like to see how they have ramped up their record requirements.  Keep in mind that Martha’s UPIC auditor is different from the one I am dealing with, which may or may not account for the difference in the list below.  However, I agree that the list of auditor’s requirements in 2025 is very different from those in 2024!

I should also add that we failed the 2024 UPIC audit despite excellent documentation and were referred to the relevant MAC (which I will not identify since we are still appealing).  We went through the 1st appeal level with the MAC and our documentation passed with flying colors.  However, we failed anyway due to the particular “skin substitutes” (CTP/CAMP) that were used. The MAC determined that the products were not “approved” for use as a skin substitute but were merely a dressing.  Ironically, one of the products denied was on the “approved list” of skin substitutes in the pending LCDs!  Thus, we are moving on to appeal level 2!

The list of records required for the 2024 audit only numbered 26 (compared to Martha’s 39) but in our case, the auditor also demanded product invoices as well as shipping orders and product inventory.  Below is a list of the documentation required by the UPIC with my comments added in red:

1. Form CMS-1500, all that apply (or electronic equivalent)
2. Signature attestation of all personnel providing services
3. List of all personnel billing services under the provider’s NPI – also a list of their credentialing, training, licensure, etc.
4. Office notes, including all patient questionnaires (we included patient education brochures explaining the product’s use, etc.)
5. History & Physical, with diagnoses
6. Consultation reports (important to include ulcer/wound baseline status, including measurements, and history of previous wound care in the initial intake report)
7. Discharge summary (we included patient’s last application date and final wound resolution)
8. Nurse’ notes (the provider is a sole practitioner and does not have a nursing staff, which is information we provided in our cover letters)
9. Treatment plan
10. Procedure reports, if applicable
11. Operative reports, if applicable
12. Emergency Room records, if applicable
13. Physician orders and progress notes, if applicable
14. Laboratory reports, if applicable
15. Radiology reports, if applicable
16. Pathology reports, if applicable
17. Nursing home notes, if applicable
18. Medication record, if applicable
19. Anesthesia records (including pre- and post-anesthesia)
20. If billing with the GW modifier include the Hospice Election Statement Addendum
21. Any additional documentation that demonstrates the medical necessity of the services provided
22. Prior Authorization documents, if applicable
23. Advanced Beneficiary Notice (ABN) of non-covered services, if applicable
24. A list of all abbreviations and/or acronyms used, including definitions
25. Please provide copies of purchase invoices and shipping order to include the sizes and amount of each skin substitute ordered and delivered
26. Product inventory

Important considerations:

1. The audit included 12 patient records and 30 dates of service, which had to be sent as individual packets. (Remember this means printing the chart and sending it by Fed Ex which is expensive.)
2. We included cover letters with each of the 30 packets and included some of the information indicated in red above as well as rationale that each ulcer/wound met the LCD criteria which applied at the time of service.
3. The provider had an average application number of 5 applications for the 12 accounts and none of them exceeded 10 applications.
4. Some of the UPIC denial reasons bordered on desperation and a misinterpretation of the applicable LCD, for example:

“UPIC Denial Reason: Treatment of any chronic skin wound lasting more than twelve (12) weeks is considered not reasonable and necessary. Records appeared to indicate that treatment of the chronic sacral stage 4 pressure ulcer wound had far exceeded twelve (12) weeks.”

Supporting Evidence: Even though care was initiated on 09/29/2022 by this provider, the first skin substitute graft application did not occur until 03/16/2023 and continued through 05/02/2023, which does not exceed 12 weeks.  In addition, we believe that the UPIC has misinterpreted this LCD requirement – – the 12-week period begins once the first application occurs, not the entire care period of the wound.  The treatment period in the LCD screenshot below refers to the use of skin substitute graft applications, which cannot exceed 12-weeks.  Medicare has paid for wound care in chronic ulcers for periods sometimes lasting years and that should not be confused with the requirements of a policy on the application of an advanced treatment modality, such as skin substitute grafts.

Additional Evidence:

The “future” MAC LCD on skin substitute applications, which becomes effective on 02/12/2025*, even makes a point to clarify this requirement (see screenshot below) – – note the use of “skin replacement therapy” to clarify that the 12-week (now 16) period only refers to the time of graft application, not the entire care of the wound:

* This information was sent to the MAC prior to the delay of the date stated

Mike

Michael Crouch is a Certified Professional Coder (CPC) and Medical Auditor (CPMA) with more than 30 years’ experience in the Wound Management and Hyperbaric Medicine industry. Mr. Crouch has authored numerous articles and several textbook chapters. He is the founder and CEO of C+ Consulting, LLC, a consulting firm which specializes in providing revenue cycle and audit support for outpatient wound management programs.

Michael J. Crouch, CPC, CPMA, CHT-ADMIN

Caroline Fife, M.D.

Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.