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Ways to Optimize Workflow for Wound Care for Faster Reimbursement

March 01, 2016

Ways to Optimize Workflow for Wound Care for Faster Reimbursement

Inaccuracies & inefficiencies in diagnosing, treating and documenting cases at the point of care, and unavailable and lack of accessible patient information and documentation are known to result in financial losses for physicians and hospitals, primarily because of payer denials. Based on the U.S. government accountability office the aggregate application denial rate across the U.S. is stated to be 19 percentage which results in financial losses to the Revenue Cycle Management (RCM) process.

Three Major Components of a revenue cycle are:

  1. Operational Systems
  2. Clinical expertise
  3. Documentation System

Processes are part of workflows. For an efficient outcome, clinical and documentation practices are required to be optimized. Getting the right mix between operational workflows and efficient clinical practices, together with the solid documentation system, is the only way to optimize for patient wound care treatment. Below are a few processes to set an effective and efficient workflow to help faster reimbursement in wound care practice.

Preparing a Revenue Component Checklist to set an effective workflow:

  • Automating the scheduling of Patient visits and their follow ups is essential.
  • Reason for Visit &/or Review of Physicians diagnosis.
  • Patient Demographics – eligibility & Verification of patient's information and Insurance information should be checked. Payer medical necessity verification is a must before service can be rendered prior to the service.
  • Check Wound care parameters: Various parameters with respect to wound care and payer payment should be checked.

Medical billing and coding compliance:

The wound care department's charge description master needs to be reviewed and checked against coding and billing chargeable services. The billing software edits need to be reviewed to manage National Correct Coding Initiative, Medically Unlikely Edits, and payer specific billing compliance.

Medical necessity and Document Compliance:

Proper and meticulous documentation translates into higher returns in the revenue cycle. It is the medical documentation that will be used to dispute and potentially overturn any denial claim. A known fact: 90 percent of wound care denial claims are due to lack of proper documentation.

The primary goal of documentation is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis. When assessing the patient with a skin or wound condition, the details of the documentation should reflect a complete chronology and review of the patient to help the clinician and practitioner provide complete medical diagnosis reflecting the wound's status across the healing continuum. Providing an accurate description of the wound's characteristics is critical during each visit. The tools employed, procedures performed, reasons why certain supplies and tests were ordered need to be well documented to justify every action taken to justify the claim when auditing is called for in case of denial of claim. Medicare review of surgical debridement services showed that 29% has insufficient or no documentation and 39 percent were billed in a manner that did not accurately reflect the services provided.

Hence, an effective Revenue cycle processes thus includes well planned patient registration, compliant billing, and denial management, which should compliment an efficient documentation process for a fiscally successful wound care department.


Category : Revenue Cycle Management