Avoiding errors in wound care billing service

September 20, 2016

Avoiding errors in wound care billing service

As in any medical field, billing and coding is an important component in 'wound care' services too. With the competition rising, it is becoming extremely imperative for wound care practitioners to receive accurate and timely payments for their services. In order to have their revenues in place and concentrate on patient care, a plethora of inefficiencies need to be eliminated as these create a dent in profits (due to errors and inefficient billing and coding).

The chief reason for wound care billing inadequacies has been found to be a lack of required documentation (90%), giving rise to payer denials. Other errors that cause denials leading to diminished payments are incorrect use of modifier 25, wound dimensions not being taken and documented correctly, deficient knowledge in selective/non-selective debridement, separate coding of wound dressing and the evaluation and management service, and/or coding for the multiple layers of debridement rather than the deepest layer. Wound care practitioners also need to capitalize on other services that they render such as wound care supplies and dressings. As payer guidelines and reimbursement plans constantly change, apt measures must be taken to not be bothered by reduced reimbursements. It is known that the basic diagnosis related group (DRG) payment amounts will reduce by: 1.75% decrease in 2016 and 2% decrease in 2017 categorizing a significant decrease in wound care reimbursements in acute care settings. Also, beginning FY 2015, hospitals- acquired wounds will see lower reimbursements. Hence, to maximize reimbursements, a couple of processes that can be undertaken to avoid errors in wound care billing service are:

  1. Put an efficient workflow in place by organizing a revenue component checklist.
  2. Aptly follow the compliances related to documentation, billing and coding as per the CMS. All elements and signatures must be complete in the documentation. Documentation and charts must include laboratory outcomes and nutritional considerations. Physicians too must be aware of the apt diagnosis and documentation required for accurate billing and coding. This will also prevent RAC audits.
  3. It is known that errors in wound care billing and coding services rate at a 12% where topmost denials are codes 11040 (partial skin debridement) and 11042 (skin and tissue debridement). Hence, each stage of all wounds must be measured and documented appropriately for apposite reimbursements.
  4. Tested strategies such as payer specific regulations and guidelines must be kept in mind while billing and coding. Charge masters must be set up by the center.
  5. Along with billers and coders, the physicians too must be aware of denials taking place and the measures must be taken to ensure they are not repeated in future. Once this is done, it leads to an almost low to no denial rate increasing compensation. Also, billers and coders must be regularly trained and possess a strong and large knowledge base, along with trainings in latest payer rules and government regulations. This also aids in questions being answered about revenues pertinently. The current local coverage determinations and wound care information must be posted for the billing and coding staff to regularly view and update them.
  6. For Medicare reimbursements, ensure that all wound care related products and services are coded as per the standard coding system of HCPCS, and their levels; where level I codes are used for services and level II codes are used for products and supplies (in long-term care settings or acute care settings in hospitals).
  7. It is advisable to photograph wounds along with using wound assessment tools to trace the healing; and if there are no wounds at the time of admission, pressure-redistribution products must be used to prevent a 'never' event.
  8. An exceptional auditing team must be in place which can identify the potential problems with billing and coding, preventing further audits and aid in requesting for repayments. An audit report can be sent daily listing all the missing details in the documentation, thereby making it as compliant as possible.
  9. An extremely important task for the staff at the wound care desk is to verify and authorize all insurance details before the patient visits the hospital and not depend on the patient to submit details. Re-verification must also occur on a regular basis (monthly if possible as insurance coverage's regularly change).

An excellent team of physicians, and billers and coders will ensure the prevention of readmissions; wound development after admission and aid in maximizing reimbursements from all payers. This will also serve in healing the patients in the most cost-effective manner.


Category : Best Billing and Coding Practices