Process and Workflow Drivers
In order to achieve accurate documentation and payment for wound care, you must invest time to create best practices for your processes and workflows. Process is the thread that pulls documentation and payment together. Workflow analyzes your department’s key processes and determines the proper steps to eliminate redundancies by identifying gaps in your practice, all in an effort to provide optimization (Figure 1).
Revenue Cycle Management and Medical Necessity Drivers
Revenue cycle processes include patient registration, compliant billing, and denial management for a fiscally successful department. These processes are governed by policy. Policies specify the circumstances under which payers cover specific services. Furthermore, most payers have implemented medical necessity guidelines for wound care services.
Chargemaster and Billing Drivers
The wound care department’s charge description master represents chargeable services and will include CPT-4 and Healthcare Common Procedure Coding System (HCPCS) Level II codes1 that define the services conducted and/or used during the visit.
The CPT-4 HCPCS Level II2 with modifiers will describe the procedures used, and International Classification of Diseases, Ninth Revision represents diagnosis codes. All services and supporting diagnosis(es) need to be reported timely and completely. Review the billing software edits to manage National Correct Coding Initiative and Medically Unlikely Edit and payer-specific billing compliance.
Documentation components comprising the medical record provide the platform for medical necessity and continuity of care. Remember, the goal for your documentation details is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis.
Audit and Compliance Drivers
Proactive monitoring and auditing are essential to test and confirm compliance with legal requirements. The auditing function is the check and balance for your documentation.
1. HCPCS Level II codes are maintained by the US Centers for Medicare & Medicaid Services.http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo/
. Last accessed September 3, 2013.
2. Current Procedural Terminology (CPT). Chicago, IL: American Medical Association; 2013. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page
. Last accessed August 26, 2013.