Have You Revised Your EHR Screens/Templates and Charging System?

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At the 2021 SAWC Fall a team (medical director, program director, and clinical nurse manager) from a hospital owned outpatient wound/ulcer management provider-based department (PBD) asked many questions after my main session reimbursement presentation and during my interactive reimbursement session post-conference.

When I returned to my office the next week, this same team called me and requested teleconsultation services as soon as possible.

As a reimbursement consultant, I always expect the unexpected. However, my findings during the teleconsultation were totally unexpected. Therefore, this month’s Consultation Corner shares this preventable situation, so it does not happen to you!

Scenario

During my introductory teleconference with the chief financial officer of the hospital, he explained that the PBD’s volume of business has doubled in the last year (even during the COVID-19 public health emergency) and that the PBD’s supply costs have risen dramatically, but their revenue was about the same as the previous year. The vice president, who is responsible for the PBD, reported that the patients’ evaluations of the PBD, the physicians, and their care were excellent. My assignment was to see if I could uncover if the PBD and physicians/nurse practitioners may be billing incorrectly.

Facts to Consider

•    Electronic health record screens and templates should allow wound/ulcer management stakeholders to appropriately document all the services provided and the work performed at every patient encounter and to reflect all the documentation requirements of their Medicare Administrative Contractor’s (MAC) local coverage determinations (LCDs).

•    Charge sheets and Charge Description Masters (CDM) should be updated before new services and procedures are performed and before new separately billable products are purchased.

Consultation

First, I had to determine if any protocols, procedures, or products changed over the past year. Therefore, I began by conducting a virtual interview with the physicians and nurse practitioners who work in the PBD. I learned that a total of 5 additional wound certified physicians and nurse practitioners were added to the staff in January of last year.  

Prior to the arrival of these new professionals, the typical procedures performed in the PBD were selective debridements, surgical debridements of subcutaneous tissue, applications of multi-layer compression bandage systems, and applications of low-cost cellular and/or tissue-based products (CTPs) for skin wounds. After their arrival, the patients’ initial assessment visits were longer  because the physicians/nurse practitioners did everything possible to identify the underlying cause(s) for each patient’s non-healing wound/ulcer. Therefore, they added several new diagnostic services, such as non-contact real-time fluorescence wound imaging and non-contact near-infrared spectroscopy, as well as biopsies, to their assessment protocols. They also expanded their procedures to include enzymatic debridements, surgical debridements of muscle, applications of total contact casts, and applications of high-cost CTPs. These new services were not out of the ordinary for a wound/ulcer management Center of Excellence.

Next, I conducted a virtual interview with the program director, who reported that the new diagnostic services and additional procedures required the PBD to acquire new equipment and supplies. In addition, the new physicians/nurse practitioners ordered more advanced dressings than the PBD previously purchased. These new expenses appeared to align with the new level of care that the new physicians/nurse practitioners reported.

Then I conducted a virtual interview with the coders and billers and asked them to share any changes they had noticed in the PBD and physician/nurse practitioner documentation or coding in the past year. To my surprise, they reported that the coding and documentation had not changed much over the past 3 years. That was definitely not the answer that I was expecting!

Therefore, I had another conversation with the PBD program director and medical director. I requested to see deidentified printed copies of the physicians’ and nurse practitioners’ documentation for a representative sample of patient encounters and the matching claims that were submitted to Medicare. I also asked for a copy of their charge sheets and the PBD’s Charge Description Master (CDM). Upon reviewing these documents, I was absolutely stunned by the following documentation and charge sheet/CDM observations:

Documentation Observations

•    When the physicians and nurse practitioners performed initial evaluation and management (E/M) services that exceeded the time allocated to 99205 or 99215, they did not report prolonged visit codes.
•    The documentation did not discuss the diagnostic services that were performed.
•    The documentation for all the debridement performed was either selective or subcutaneous, even though the photographs showed muscle debridement.
•    The documentation for the compression was always for multi-layer compression bandage systems, even though photographs showed that total contact casts were applied
•    The documentation for application of CTPs was always for low-cost products, even when  the brand  names and lot number information described high-cost products.
•    The documentation rarely aligned with the LCD requirements of their MAC.

After reviewing the documentation, I had another virtual meeting with the physicians/nurse practitioners and explained that I was confused because I never saw any of the new diagnostic services or additional procedures that they said they performed. In addition, I observed that their documentation did not align with the MAC’s LCDs. They reported that the health system would not allow them to update their electronic health record screens (EHR) and templates. Therefore, they were forced to select the items from the EHR screens that were closest to the work they performed.

Of course, I asked them who said they could not update their EHR screens and templates. I then spoke with that EHR decision-maker and was told that the cost to change the screens and templates was expensive, and that he did not have much money in his budget for those changes. Therefore, he only allows EHR changes every 3 years!

Charge Sheet and CDM Observations

Neither the charge sheets nor the CDM listed the codes for any of the new diagnostics or procedures that the physicians/nurse practitioners performed all year. When I asked the PBD and professionals why the codes were not listed, they said their health system only permitted charge sheet and CDM updates in December of every year. Because the new professionals began working in January, much of their work for the entire year was not on the charge sheets and CDM. Therefore, the PBD invested in diagnostic equipment, but never billed for the services. The PBD purchased the enzymatic debridement ointment, but never billed for the procedure. Any time muscle was surgically debrided, the PBD and professionals billed the procedure as subcutaneous debridement. Any time total contact casts were applied, the PBD and professionals billed the procedure as application of multi-layer compression bandages. And you guessed it—any time high-cost CTPs were purchased and applied, the PBD billed the packaged procedure code for low-cost CTPs. In addition, the physicians/nurse practitioners did not bill for the many prolonged E/M services they provided for initial patient encounters.

Under normal circumstances, when coders and billers review the documentation of patient encounters, they would notice these missed revenue opportunities. Because the EHR screens and templates were not updated to allow appropriate documentation for the new diagnostics and procedures, the submitted charges aligned with the documentation. Therefore, the coders and billers had no way to know that the PBD and the professionals were not accurately documenting and coding for their work.

When the team met to learn about my findings, the chief financial officer and vice president were surprised to learn that their health system’s self-imposed policies caused a significant amount of lost revenue to both the PBD and the physicians/nurse practitioners who work in the PBD. In fact, the lost revenue could have paid to update their EHR screens and templates many times over! Both the chief financial officer and the vice president thanked me for uncovering their health system’s shortcomings, and most important, they apologized to the PBD director, physicians, and nurse practitioners for thinking they were the cause of the revenue shortfall.

Summary

As you read about this consultation, you may have been thinking that you are lucky because your health system does not have such strict EHR and CDM update policies. However, you should not assume that your system is working perfectly. In fact, I often consult with wound/ulcer management PBDs and professionals who do not regularly update their EHRs to reflect new work performed and new documentation requirements of LCDs. In addition, many of them do not like to go through the charge sheet and CDM update process and end up losing revenue.

Therefore, as the new year begins, this consultant recommends that you make a new year’s resolution to update all components of your revenue cycle before you perform any new work and as soon as new coverage requirements are released in LCDs.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net.

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