How to Respond to an Audit

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In an edited transcript of an interview from SAWC, this physician offers information on what you need to respond to an audit, the importance of documentation, trends in audits, and how to avoid common pitfalls.

What are the most important things you need to respond to an audit?

The most important aspect is that you actually live and die by your documentation and it is very, very important to understand what essential components you need to document for the procedure or the product that you're planning on using or doing.
 
One example is a wound care product that requires evaluation of a vascular status. You need to document that and it needs to be available in the record should those records be required for an audit. The most common error that happens is that when you are evaluating wounds, before and after every debridement there need to be measurements. There also needs to be a photograph, and in that photograph you actually need to have a ruler or some kind of measuring device because the Centers for Medicare and Medicaid Services (CMS) are no longer accepting photos that don't have a way for them to actually see whatthe size. You can make it look larger or smaller depending on how close you are to the wound. You also have to make sure you understand all the elements of the procedure you're doing and document those steps in the procedure and why you're choosing to do what you're choosing.
 
It really requires attention to detail, and usually in our busy clinical practice it's sometimes hard to keep track of the details.

What is the importance of documentation?

Documentation is key. It is important that your documentation is not just a copy, paste, and forward reconstruction of a past visit. You actually have to have something that makes it a more unique document that visit has some uniqueness to it—it's not just a template one after another, which is one of the pitfalls of using electronic medical records.

What are some common pitfalls with responses to audits?

When you look at the CMS audit outbriefs, the most common pitfall is that people ignore the documentation request, which is really an unforced error. If you get the request for documentation or for a chart audit, you need to take it seriously. The problem in a hospital outpatient department (HOPD) is that many of these requests are seen as going directly to medical records, and medical records doesn't know what is required. Typically, the medical Records Separtment will just send one day and they won't send the initial consultation. They won't send the laboratory values that show that you've looked at nutritional assessment. They won't send the vascular assessment because they're responding to what they're being asked for, which is that particular date of service.
 
So if you're in an HOPD, there has to be a process in place where when one of these requests come in, it actually goes to the department, to the program manager or to the medical director to be addressed. In an office setting, that's a little less of a problem.
 
The other problem is that with the electronic medical record there is a disconnect between what you are seeing on your screen as you're documenting and what gets printed out at the end and so it's really imperative that you establish a self-auditing system and actually kill some trees and print the medical record because that is what's going to get sent to CMS or to any of the other organizations that are doing these audits. You have to make sure what is printed is actually reflecting the care you gave and that you didn't say something stupid inadvertently that will torpedo the review.

What trends are you seeing in audits?

Audits are becoming more comprehensive. They're learning and they're actually reading product inserts and so if you're applying a product and you are not documenting that you followed the instructions that are given in the product insert, that's a reason for denial.
 
They're also looking at, for example, with cellular- and tissue-based products, they're looking at making sure you are picking a product that is an appropriate size and that you're documenting what you use and what you waste. Even though there is some variability in the documentation requirements between hospital outpatient department and an office-based practice, it is still important that you document that within the clinical record.
 
The other thing is that audits are becoming more sophisticated or more aware of the areas where we tend to be a little more lackadaisical in our documentation and so CMS is starting to hone in on these areas. These documentation requirements change not only with the governmental insurance plans but also with commercial plans. It really behooves you to do a review of your major carriers every 6 months.
 
If they have a medical policy for hyperbaric oxygen or for wound debridement or for skin substitutes they need to be accessed and reviewed biannually. You need to know what they are because the subtle changes are where they're going to catch you up. They now have put new rules down, and you need to follow those new rules. Ignorance is not an excuse.
 
Helen B. Gelly, MD, FUHM, FACCWS, UHM/ABPM, is the President and founder of Regenerative and Hyperbaric Medicine, Marietta, GA. Dr. Gelly is emeritus medical director of the Hyperbaric Physicians of Georgia, Atlanta.