Called to the Principal’s Office: My Experience With a TPE Audit

One day, as medical director of three wound centers—two with hyperbaric services in a five-hospital system—I was called to the wound care administrator’s office. I heard the three things that I never wish to hear going into a meeting:

1.    “Please come to my office and close the door.”

2.    “I would like to give you a heads-up.”

3.    “You are being audited by Medicare for a targeted probe and educate.”

So, on this occasion this meeting was triple whammy. As I exited the meeting, and walked back to my office, I recalled a similar feeling I had as a child when I was called to the principal’s office (no recollection why) in elementary school.  

I returned to my office. I sat by my computer and searched and reviewed anything and everything, including the Centers for Medicare Services (CMS) website for information on targeted probe and educate (TPE). As I did so, my anxiety level increased. In an effort to calm myself, I took a very deep breath, and closed my eyes. After a deep exhalation, I realized I was actually prepared for this audit.

In my first month in my new position as medical director, the wound program manager and I attended a national wound healing meeting. In one of the lectures, we listened attentively to a presentation given by Helen Gelly, MD, on CMS and the TPE process. Upon return to our home organization, we developed a proactive strategic plan. This included a current evaluation of our state of documentation, coding, billing, and compliance. We then noted our deficiencies in our current state. We then reviewed in detail the necessary requirements/elements for an audit with not only CMS, but any third party. We noted any deficiencies in our current documentation in our electronic medical records (EMR).

It was then that I realized many of these requirements were already included in our wound care–specific EMR but were not being utilized by the providers. We worked with our wound care–specific EMR vendor to tailor-build custom hard stops. After educating the entire wound/hyperbaric staff, we then developed audit tools. We also developed documentation checklists that were reviewed by both the medical director and the safety director.

So, despite my anxiety of being audited, we were prepared. After the initial request for 40 charts to be reviewed by CMS, there were a number of additional requests to the hospital audit team for additional documentation. Okay, so the audit is now complete. Just like in my past memories of school, the audit team delivered a report card. Two things were ultimately reported. First, I met the criteria for a successful TPE audit in 39 out of 40 charts. Second, the 40th chart was noted be out of compliance in its documentation of the diagnosis. The case was then referred to CMS for an overpayment audit.

It was a case of delayed effect of radiation in a gentleman who had pelvic radiation and significant debilitating symptoms including multiple gastrointestinal bleeding episodes requiring multiple blood transfusions. He had multiple hospitalizations including ICU admissions. He had poor quality of life indicators with severe impact on his activities of daily living. As a result of this one chart in a TPE audit, Medicare was now looking at 70 patient encounters for hyperbaric oxygen therapy (HBOT) for delayed effect of radiation. The expectation from Medicare was that we received an overpayment of the 70 HBOT treatments for the diagnosis of soft tissue radionecrosis of the bowel. Per Medicare’s definition, soft tissue radionecrosis of bowel does not exist.

As the hospital organization was disputing this claim by Medicare, I submitted any and all literature, national organization guidelines, and references regarding the clinical indication and treatment utilizing HBOT for delayed effect of radiation. Despite this effort and the additional documentation, our dispute was rejected.  We then requested a peer-to-peer review with Medicare. They agreed to have this meeting.  

How the Meeting Went Down

The meeting was on and I felt like I was back in the principal’s office with a parent. Sitting by my side was a team representing the hospital: Compliance, Billing, Coding, Nursing and Leadership.
 
Medicare: So, it seems the issue per Medicare on this treatment of this patient is: Medicare does not believe that soft tissue radio necrosis of the bowel exists. The bowel is not a soft tissue so this is viewed as experimental and not payable by Medicare. Therefore, you received an overpayment for 70 HBO treatments.
 
Me: I have reviewed the medical records, which you have before you. This includes the billing, coding documents, history and physical, 70 treatment notes for hyperbaric treatment and utilization and review. I have also reviewed submitted labs, and any and all nursing notes. My question to the Medicare panel: Do you see any reference in any documentation or coding or billing to suggest a diagnosis of soft tissue radio necrosis?  
 
Medicare: No.  

Me: Do you see a clearly defined documentation of diagnosis of the delayed effect with all of the Medicare requirements?

Medicare: Yes.

Me: Do you see any documentation of soft tissue radio necrosis of the small bowel?

Medicare: No.

Me: Do you see my clearly documented “meets medical necessity” in the medical record?

Medicare: Yes.

Me: Do you see clearly defined weekly improvement of quality of life indicators for this patient with a defined endpoint of treatment?  

Medicare: Yes.

At the conclusion of this meeting the Medicare team noted that we were 100% compliant in Documentation, Coding and Compliance. Most importantly, there was no evidence of any overpayment, fraud or abuse.

We won!

Of course, any audit can be stressful but it should not be traumatic. The best defense is a good offense. Proactive advanced preparation and planning will be your best defense against any audit from a third party. Having a wound care specific electronic medical record that includes and updates the necessary requirements and language for compliance with documentation, coding and billing should be part of that strategic plan.

Dr. Charash is owner and principal in Dive Medicine and Hyperbaric Consultants. His consulting firm offers insight into efficiency, effectiveness and quality of care for all things Wound Care and Hyperbaric. He is a consultant to Intellicure.

Dive Medicine and Hyperbaric Consultants
DMCdivemed@gmail.com
Web: Divemedicineandhyperbaricconsultants.com

Click here to download a PDF of this article.