Why Won’t the DME Provide Dressings for My Patient?

Maybe Because Of My Documentation

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I am signed up for all sorts of “eblasts” from the Centers for Medicare and Medicaid Services (CMS). A few days ago, I got one about the results of Medicare CERT audits.
 
CERT stands for Comprehensive Error Rate Testing. CERT auditors compare a sampling of bills for Medicare fee-for-service (FFS) payments against medical records for the patient. The audit looks at whether there is sufficient documentation to back up the claim against Medicare.
 
In 2021, the CMS estimated that, based on data from the CERT audits, 6.26% of Medicare funding was incorrectly paid out, totaling $25.03 billion. The vast majority of those incorrect payments (64.1%) were marked as incorrect because the chart had insufficient documentation. Another 13.6% were flagged as medically unnecessary, 10.6% were labeled as incorrectly paid out due to improper coding, 4.8% had no supporting documentation at all and 6.9% were flagged as incorrectly paid for some other reason. CMS publishes the estimated improper payments in its annual report.
 
I decided that I’d just skim the 2021 report and see if anything jumped out at me. I was surprised to see surgical dressings on the list. Collagen dressings had an overpayment rate of 66.4% and alginate dressings of 70.8%. Here’s the scariest part—only 40 or 50 charts were reviewed to determine the overpayment rate on those two surgical dressings, but the results were extrapolated to indicate that over $37 million had been paid out improperly for collagen dressings and $25 million had been paid out improperly for alginate dressings. Remember, that does not mean that the patients didn’t need those dressings. It only means that the documentation in the chart didn’t meet the Medicare requirements for those products.  
 
How exactly do these documentation problems arise? Here are a few examples:

• Mrs. Jones was seen today for her stage 3 pressure ulcer, which was almost 100% granulated. She had previously been treated with an antimicrobial dressing but the care team decided that it was the perfect time to start a collagen, so this was ordered from the durable medical equipment (DME). However, at today’s visit, the patient requested that a foam with a film dressing be placed over the wound because she was going home to take a shower. Because the clinic note and the treatment plan did not specifically state that the plan was to use a collagen, and because a different category of dressing was documented as being placed today, if the DME provided a collagen, an audit it will be considered an improper payment.
• Mr. Smith has 2 large venous leg ulcers (VLUs) that drain copiously. He is being treated with an alginate covered by an absorbent secondary dressing. He had had to change his dressing just before coming to clinic because it was saturated, so at his visit, the clinical team documented his drainage as minimal. An alginate and absorbent secondary dressing were ordered from the DME, but because the nurse did not record the drainage as being moderate to large, if audited, these absorbent dressings will be considered improperly paid.
• Mr. Doe was seen for his very painful arterial ulceration. Due to pain and ischemia, sharp debridement of necrotic material is not an option. He has been tolerating enzymatic debridement and the amount of necrotic material is decreasing. The clinical note states that no debridement has been performed even though autolytic debridement has been used. If audited, the DME will have provided dressings improperly to this patient because the record does not state that the wound underwent autolytic debridement.
• Mrs. Doe has several large wounds and is dependent on the dressings supplied by the DME to care for her wounds at home. The clinical staff do an excellent job of care but are often behind at signing off the chart. The DME received the orders for all the supplies and called the clinic to request that the most recent notes be faxed to them. The final documents cannot be generated until the clinical staff members sign off, so the order is delayed until the chart is signed and a copy of the notes sent to the DME.

To understand this issue in detail, read Kathleen Schaum’s Business Briefs in this issue of TWC. The DMEs have been audited nearly to death. Most are simply not providing dressings unless the clinical documentation is in order and until they have a copy of it. This is costing both the DMEs and practitioners many hours of work. The DMEs call to get records faxed and the doctors and nurses get frustrated trying to provide the documentation that is needed. It’s a frustrating game with the patient caught in the middle. A patient emailed me that the new wound center she was going to did not know that documenting autolytic debridement would qualify her wound for surgical dressings from a DME and she was now not able to get the dressings she needed. She knew the documentation requirements better than the wound center.

Who is at risk for paying back that money? Not the physicians or hospitals, but the DME companies. However, the paybacks are based on the documentation provided by clinicians. The next time a DME company calls and asks for more information from the chart or explains that there is a problem with what you recorded, keep in mind that if clinicians are not meticulous about the documentation, it’s the DMEs who will pay back money because of it, and your patients will not be able to get the dressings they need.

Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.