1. Hess, Cathy Thomas BSN, RN, CWCN

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Designing, opening, managing, and maintaining an outpatient wound care department take time, dedication, and ongoing focus. Managing volume and supporting your clinical, operational, and financial outcomes are key areas for success. Utilizing a comprehensive, interoperable specialty electronic health record (EHR) with smart workflow synchronization is key to driving compliance with the ever-changing rules, regulations, and findings performed within your department.


Documentation that supports regulations needs to be mapped within the specialty EHR itself. Specific wound care elements and medical necessity requirements are essential for compliant patient records. Clinical and operational wound care triggers, outlier management, and coding and billing requirements are also necessary to drive your facility's standards, enhance outcomes, and optimize reimbursement.


The most critical step to a successful specialty EHR implementation is conducting a workflow analysis. This analysis maps current clinical processes and data flows, identifies gaps with industry best practices, and produces recommendations for improvement through collaboration with clinical team members. It is paramount that the clinic's workflow is implemented correctly and the software is customized to suit your facility's expectations of staff and providers. These steps will also drive a higher adoption rate of the EHR.


We are reminded of the importance of accurate workflows and documentation through the recent findings from the Office of the Inspector General.1 Read the findings and recommendations below and ask yourself: Does the documentation in my EHR support the full scope of wound care performed? If not, why? Do I need to update my workflows or processes to capture additional information to meet medical necessity? Does my EHR solution allow more details about wound care documentation and services? A specialty wound care EHR is an important step in the compliance process.


"For this review, we focused on one Medicare administrative contractor, Wisconsin Physicians Service Government Health Administrators (WPS), because of the high volume of paid outpatient claims that contained hyperbaric oxygen (HBO) therapy services.


Our objective was to determine whether WPS paid providers in 2013 and 2014 for HBO therapy services that complied with Medicare requirements.


Our review covered 44,940 outpatient claims totaling $59.5 million for Jurisdiction 5 that contained HBO therapy services provided to Medicare beneficiaries during calendar years 2013 through 2014. We selected a stratified random sample of 120 outpatient claims. Our medical review contractor subsequently reviewed the medical records for compliance with Medicare requirements.


WPS paid 73 providers for HBO therapy services that did not comply with Medicare requirements. Of the 120 sampled outpatient claims totaling $438,210, WPS made payments for HBO therapy in accordance with Medicare requirements for 18 claims. However, WPS made payments for HBO therapy that did not comply with Medicare requirements for 102 claims, resulting in overpayments totaling $300,789. WPS made payments for HBO therapy that did not always comply with Medicare requirements because it had limited policies and procedures in place to ensure that it made correct payments. Based on our sample results, we estimate that WPS overpaid providers in Jurisdiction 5 $42.6 million during the audit period for HBO therapy that did not comply with Medicare requirements.


We made several recommendations to WPS, including that it (1) recover the appropriate portion of the $300,789 in identified Medicare overpayments; (2) notify the providers responsible for the 44,820 nonsampled claims, with potential overpayments estimated at $42.3 million, so that those providers can investigate and return any identified overpayments; (3) identify and recover any improper payments for HBO therapy made after the audit period; and (4) strengthen its policies and procedures for making payments for HBO therapy, which would result in millions in future cost savings.


In written comments on our draft report, WPS generally agreed with our recommendations. WPS stated that it has taken corrective actions to address issues with the overuse of HBO therapy. In 2015, WPS initiated CMS's Non-Emergent Hyperbaric Oxygen Therapy Prior Authorization demonstration program in Michigan. WPS also stated that it conducted further data analysis to identify providers and diagnosis codes at risk for overutilization and offered education to providers about the proper use of HBO therapy."


A medically necessary service must prove to be reasonable and necessary to diagnose or treat a patient's medical condition. Therefore, documenting medical necessity must be at the top of your mind during each patient encounter. Now ask: Does my EHR solution capture the granularity of information necessary for documentation compliance in my specialty department?




1. Office of Inspector General. Wisconsin Physicians Service paid providers for hyperbaric oxygen therapy services that did not comply with Medicare requirements. Last accessed February 21, 2018. [Context Link]