Services · Documentation audits
Find documentation gaps before an auditor does.
We review a sample of your wound care charts against the Medicare rules that apply to them and give you a clear findings report — what's missing, why it matters, and how to fix the template.
What we check
Every element Medicare asks your charts to show.
- A qualifying wound is documented: caused by or treated by surgery, or after debridement
- The initial evaluation records wound type; location, number and size; primary or secondary dressing; drainage; dressing type; amount used at one time; and change frequency
- Re-evaluations happen monthly — weekly for nursing-facility patients and heavily draining or infected wounds — with length × width and depth
- A new order every 3 months for each dressing, and whenever a dressing is added or a quantity goes up
- Written orders carry the six required elements: beneficiary name or MBI, item description, quantity, order date, practitioner name or NPI, and signature
- Quantities and change frequency line up with the LCD's utilization guidelines
- Skin substitute application notes against your MAC's current policy
Medicare details checked against CMS sources on October 6, 2026. Not billing, coding or legal advice.
What you get
Findings report
Results by chart and by documentation element, with the rule behind each finding.
Template fixes
Specific changes to your wound evaluation and order templates to close the gaps.
Staff walkthrough
A session with your providers and staff on what the findings mean in day-to-day charting.
How it starts
Four steps, in writing.
- 1
Scope
Agree the chart sample, time period and rules in scope.
- 2
Secure access
A business associate agreement is signed and a secure channel is set up.
- 3
Review
Charts are reviewed element by element against the published rules.
- 4
Report and walkthrough
You get the findings report and a session with your team.
Questions
Documentation audits: common questions
Does an audit guarantee we won't see denials?
No. An audit finds documentation gaps against published rules so you can fix them; payers still decide each claim.
Do you need access to patient charts?
Yes, so audits run only under a signed business associate agreement through a secure channel — never through this website or email.
Do we have to buy supplies from PCSS to get an audit?
No. Audits are contracted separately, and buying supplies is never a condition of using them.
Contact PCSS
Scope an audit in one call.
Contact PCSS for help with your account, billing services or documentation audits.
Help: (803) 422-2710Request an audit scope
Tell us about your practice — no patient information, please. We'll set up a short call and send a written scope.