Wound Care Documentation, Compliance, and Revenue Checklist : Advances in Skin & Wound Care

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Wound Care Documentation, Compliance, and Revenue Checklist

Hess, Cathy Thomas BSN, RN, CWOCN

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Advances in Skin & Wound Care 27(3):p 144, March 2014. | DOI: 10.1097/01.ASW.0000444190.29613.63
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In the previous column, 2014 OPPS Final Rule Drives Critical Documentation Elements, we discussed the release of the Centers for Medicare & Medicaid Services (CMS) 2014 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates. We also began to review the essential documentation elements necessary to support the work performed in the wound care department, focusing our efforts on medical necessity. The information provided can easily be positioned as a checklist for your team to follow.

Many checklists can be created and used as written guides to help your team meet key steps in compliance. In wound care, clinical and operational rules help maintain compliance with standards, and checklists can provide an audit tool to ensure that requirements have been followed. Using a clinical checklist can help to better organize the clinician’s time.

Given the new payment parameters within 2014 OPPS Final Rule, the clinician’s checklist might look like this:

  • 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.

Another initiative followed closely at this time is the progression of Meaningful Use. At a high level and as detailed in the Health Information Technology for Economic and Clinical Health Act, the government’s research concluded that using an electronic health record (EHR) would serve to improve patient care, increase patient safety, and simplify compliance in the US healthcare system, as well as reduce costs in the long term, minimize errors, and increase productivity and administrative efficiency. As the government has rolled out its plan, hospitals need to have their EHRs in place, be able to send “meaningful” data to the CMS, and measure the actual impact on patient care. Armed with the knowledge of initiatives and focusing on the wound care department, using this sample checklist may assist providers to achieve clinical and financial goals:

Develop evidence-based prevention and intervention wound care pathways.

Use technology to reduce length of stay, number of dressing changes, number of professional visits, time to heal, and total cost of care.

Design a skin and wound care formulary based on clinically proven efficacy and cost-effectiveness, availability, ease of use, function, and direct cost.

Identify all International Classification of Diseases, Ninth Revision, Clinical Modification, Current Procedural Terminology, Healthcare Common Procedure Coding System, Pass-Through, New-Technology, and local codes that represent the diagnosis, evaluation and management service, procedures, and products that need to be included on payer claim forms.

Integrate a photodocumentation process with your electronic medical record.

Utilize outcomes to improve efficiency in your department.

Educate and validate competency of all levels of staff, including physicians, in how to assess, aggressively manage, and appropriately document skin and wound care.

Design a supply management system that controls product utilization internally or externally, to control costs and waste.

Obtain cost reductions based on volume purchases, due to standardization of products.

Implement a delivery system that prevents delays in management and oversupplying products.

Develop a multidisciplinary plan of care with clearly defined endpoints.

Assess wounds accurately, and document them completely.

Accurately select the primary diagnosis, and map to medical necessity.

Order wound management modalities based on assessment, an outcome-oriented care plan, the skill of patient and caregiver, and payer guidelines.

Be sure physician orders include all required components and document medical necessity for modalities ordered.

Provide patient and caregiver education regarding efficient use of appropriate dressings, drugs, and medical equipment.

Reach achievable clinical and financial outcomes and patient satisfaction in the least amount of time, using the least amount of labor and material resources.

Establish a method of transferring documentation about origin of wound, surgery date (if applicable), type of debridement (if applicable), original stage of wound, wound assessment, diagnoses, and physician orders.

Initiate timely referral to the next logical level of care.

Prepare a discharge summary that includes information required by the next provider to manage care and supplies in a cost-efficient manner.


Hess CT. Clinical Guide: Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.

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