Cathy Thomas Hess, BSN, RN, CWOCN, is Vice President and Chief Clinical Officer, Net Health. Ms Hess presides over Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Cathy Thomas Hess, BSN, RN, CWOCN, via e-mail: email@example.com.
In the previous column, Wound Care Documentation, Compliance, and Revenue Checklist, we looked at an updated clinical checklist to assist you with the new payment parameters within the 2014 OPPS Final Rule. This checklist included the following:
✓ Work with your coding and billing department to educate your team on the Final Rule and payment changes (Medicare and non-Medicare payers).
✓ Review your local coverage determination for updated changes.
✓ Update your Charge Description Master to reflect the new code changes.
✓ Review and update your Policies and Procedures to reflect stated changes.
✓ Develop a Transition Memorandum to denote the change in coding and billing practices as of January 1, 2014.
To achieve accurate documentation and payment for wound care, you must invest time to create best practices for your processes and workflows. Remember, the goal for your department is to be fiscally responsible and to maintain a viable business. This starts with effective and efficient revenue cycle management practice and policies.
Revenue cycle processes include patient registration, compliant billing, query management, and denial management for a fiscally successful department. These processes are governed by policy. Policies specify the circumstances under which payers cover specific services. In addition, most payers have implemented medical necessity guidelines for wound care services. It is important to work with our revenue cycle management team to define process and policies, specific to your facility, and bridge compliance in your department. The checklist below provides the key components of the revenue cycle that drive the wound care department’s fiscal strength.
Revenue Cycle Components Checklist
✓ Schedule the initial and follow-up visits
✓ Reason for visit
• Review the physician order for complete diagnosis information
○ What is the primary reason for the visit?
○ Do comorbidities exist?
✓ Patient Demographics
• Verify first and last name spelling
• Confirm patient address, city, state, and zip code
• Confirm patient telephone number
✓ Patient Insurance Information
• Request complete information, primary, secondary, and/or tertiary.
• Be careful to identify the one insured. Do not make assumptions that the main insured person is the patient.
• Is this a Medicare Secondary Payer?
• Is this a Managed Care Payer?
○ Is the wound care department contracted?
○ Will the service be paid at a nonpar rate?
○ Does the payer authorize wound care in the plan?
▪ Is your wound care department an authorized payer center?
○ Will the patient be sanctioned penalties for using the wound care center?
✓ Verify the coverage before the patient visit
• Determine coverage for the diagnoses on the physician order.
• Implement the Medicare Advance Beneficiary Notice if medical necessity or coverage fails
• Determine whether the payer has coverage limitations
• Identify whether utilization parameters will be a concern
• Obtain precertification and/or preauthorization numbers
✓ Front-end collections
• Prepare the patient for copay, coinsurance, or deductible based on the findings before the visit
• Plan collecting the patient obligation at the point of service
(© Hess CT, 2013)