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Compliant Workflow Design: Engage, Define, Review, and Refine

Hess, Cathy, Thomas, BSN, RN, CWCN

Advances in Skin & Wound Care: May 2018 - Volume 31 - Issue 5 - p 240
doi: 10.1097/01.ASW.0000532241.93855.05
Departments: Practice Points

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via e-mail: chess@nethealth.com.

Workflow design is a key step in your department’s clinical and operational efficiencies. Workflows enhance healthcare quality and safety, patient throughput, and care coordination. These steps occur from the moment the patient contacts the department through patient discharge. Workflows need to be defined, reviewed, and refined as roles in the department change, medical record requirements change, regulatory requirements become mandatory, and denials are discovered. Although the list provided in this column is not exhaustive, it highlights questions to consider for process improvement.

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Patient Registration Workflow

Revenue cycle processes are governed by policies that specify which payers cover specific services. Further, most payers have implemented medical necessity guidelines for wound care services. Questions to consider for workflow design include:

  • What is the primary reason for the visit? Do comorbidities exist? Have you reviewed the physician order for complete diagnosis information?
  • What are the patient demographics and insurance information?
  • What is the payer type? 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 department an authorized payer center? Will the patient be sanctioned for using the center?
  • Has coverage been verified prior to 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 and if utilization parameters will be a concern. Obtain precertification/preauthorization numbers.
  • What is your front-end collections process? Prepare the patient for copay, coinsurance, or deductible based on the findings prior to the visit.
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Staff and Provider Workflows Mapping to Visit Types

Documentation components comprising the medical record support medical necessity and continuity of care. Remember, the goal for your documentation details is to provide the highest possible degree of clinical specificity. Consider:

  • What types of visits are seen in your department and how are they mapped to the schedule?
  • How are you constructing your documentation workflows to support the visit? How are you verifying the documentation requirements necessary to complete the visit (ie, hospital policies, National or Local Coverage Determination policies)?
  • What are the signature requirements for the documentation? How are staff and providers trained on documentation requirements?
  • How are you reconciling the documentation to ensure the visit is complete for coding, billing, and medical records review?
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ICD-10 and Charge Master Description for Billing Workflow

The wound care department’s charge description master (CDM) includes Current Procedural Terminology (CPT)-4 and Healthcare Common Procedure Coding System Level II codes1 that define the services provided during the visit. The CPT-4 and HCPCS Level II codes with modifiers describe the procedures used, and the International Classification of Diseases, 10th Revision (ICD-10) codes2 represent diagnoses. All services and supporting diagnoses need to be reported promptly and completely. Review billing software edits to manage National Correct Coding Initiative and Medically Unlikely Edit and payer-specific billing compliance. Consider:

  • Who is responsible for updates to the CPT-4 and ICD-10 codes and your CDM? How often are they updated?
  • What is the process to add a procedure and modifiers to the CDM, and are they represented on the CDM?
  • Are workflows properly constructed to support documentation compliance for the ICD-10 codes and procedure?
  • What is your facility and provider method for billing?
  • What are the billing and denial processes?
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Medical Record Workflow

Understanding your medical records documentation requirements is key for registration, coding, billing, documentation compliance, and medical record closure. Questions you may ask include:

  • What information is collected on the initial visit and subsequent visits? Does this information support the registration, coding, billing, and medical record processes?
  • What documentation is provided to the patient at discharge?
  • How does signature sequencing affect the medical record closure process and documentation compliance?
  • What is the time frame for “timely record closure”?
  • What is the reconciliation process to close the medical record?
  • How often is documentation audited and what is the process?
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References

1. Centers for Medicare & Medicaid Services. HCPCS—General Information. 2018. www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/medhcpcsgeninfo. Last accessed March 26, 2018.
2. CPT (Current Procedural Terminology). Chicago, IL: American Medical Association; 2013. www.ama-assn.org/practice-management/cpt-current-procedural-terminology. Last accessed March 26, 2018.
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