1. Hess, Cathy Thomas BSN, RN, CWCN

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Welcome to 2019! Launching into a new year brings an opportunity to review the work plan created and implemented by you and your team. The underpinning for the work plan must reside in the data collected within the medical record. The medical record demonstrates the clinician's ability to plan, coordinate, and evaluate patient care. Proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation. This information can easily function as a checklist for your team to follow, driving the path for clinical, operational, regulatory, and economic/financial compliance.


Checklists can be created and used as written guides to help your team meet key steps in compliance. In wound care, clinical, operational, regulatory, and economic/financial 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.


Consider the following clinical and operational checklist:


* Use an interoperable, specialty wound care electronic health record.


* Create and streamline smart, strategic workflows for staff and providers.


* Integrate evidence-based medicine and wound care pathways.


* Manage the department through a comprehensive reporting engine providing clinical, operational, financial, and marketing reports.


* Update patient-specific education.


* Review and update the product formulary and technologies.


* Know hospital accreditation standards and support within department and documentation workflows.


* Implement Clinical Decision Support Alerts.


* Review and update your department's clinical and operational policies and procedures, including signature requirements for your documentation process.


* Review and update job descriptions.


* Ensure staff credentials and competencies and skill sets are up to date.


* Review budget for staff education.


* Reevaluate the use of technology and supplies to ensure appropriate use for your patient population.


* Coordinate discussions with clinical providers to ensure appropriate understanding of surgical wound care services and documentation requirements.


* Manage patient outliers and update plans of care.


* Review and update payer matrix.


* Map authorizations and verification of benefits, advance beneficiary notice, and copay processes.


* Ensure the "reason for referral" is clearly documented.


* Understand insurance verification and medical necessity by payer process.


* Review the annual Office of Inspector General work plan to improve operations, clinical documentation, and charging and coding practices.


* Implement and review the wound care department's charge description master, Current Procedural Terminology 4,* and Healthcare Common Procedure Coding System level II with modifiers (if appropriate).


* Meet with select departments to review updates for preregistration, coding, billing, medical records, and denial management.


* Implement interfaces to capture and send codified data, which decreases duplicative work and improves patient safety.


* Mentor staff.


* Participate in the 2019 Quality Payment Program1



- Some prominent Year 3 policies adopted in this final rule include expanding the definition of Merit-based Incentive Payment System (MIPS)-eligible clinicians to include new clinician types (physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals), adding a third element to the low-volume threshold determination, and giving eligible clinicians who meet one or two elements of the low-volume threshold the choice to participate in MIPS (referred to as the opt-in policy). The Centers for Medicare & Medicaid Services (CMS) is also adding new episode-based measures to the Cost performance category, restructuring the Promoting Interoperability (formerly Advancing Care Information) performance category, and creating an option to use facility-based Quality and Cost performance measures for certain facility-based clinicians. The CMS is continuing to reduce burden and offer flexibilities to help clinicians successfully participate by adopting the following policies:


[white circle] Overhauling the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record interoperability and patient access while aligning with the Medicare Promoting Interoperability Program requirements for hospitals


[white circle] Moving clinicians to a single, smaller set of objectives and measures with scoring based on measure performance for the Promoting Interoperability performance category


[white circle] Allowing the use of a combination of collection types for the Quality performance category


[white circle] Retaining and increasing some bonus points


[white circle] For the Cost or Quality performance categories, providing the option to use facility-based scoring for facility-based clinicians, who are planning to participate in MIPS as a group. This option does not require data submission. The CMS expects to release a facility-based scoring preview in the first quarter of 2019.



- The CMS is also committed to continue helping small practices in Year 3 by


[white circle] increasing the small practice bonus to six points, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus;


[white circle] continuing to award small practices three points for submitted quality measures that do not meet the data completeness requirements;


[white circle] allowing small practices to continue submitting quality data for covered professional services through the Medicare Part B claims submission type for the Quality performance category;


[white circle] providing an application-based reweighting option for the Promoting Interoperability performance category for clinicians in small practices;


[white circle] continuing to provide small practices with the option to participate in MIPS as a virtual group; and


[white circle] offering no-cost, customized support to small and rural practices through the Small, Underserved, and Rural Support technical assistance initiative.



- Last, notice the use of new language that more accurately reflects how clinicians and vendors interact with MIPS (ie, Collection types, Submitter types, etc). These terms are defined within the referenced final rule fact sheet.


Consider the following regulatory and economic/financial checklist:


* Schedule time for denial management reviews, and reevaluate facility process based on findings.


* Determine the denial management process.


* Review the Recovery Audit Contractor trends and develop a plan to proactively minimize your risk for loss.


* Inquire whether scribing is allowed within your department.


* Review the process for physician ordering to support nurse visitation.


* Review the National Coverage Determination and Local Coverage Determination policies on an ongoing basis.


* Check the fiscal intermediary's website for any specific guidance of Local Coverage Determination for wound care and hyperbaric oxygen therapy services.


* Review managed care and payer agreements and limitations.


* Watch for overuse of products and/or services.


* Obtain cost reductions based on volume purchases and standardization of products.


* Review and update the Clinical Level of Care form for facility charges to ensure methodology reflects clinic flow.


* Review distribution of charges across the five levels of service; does this represent a "bell curve"?


* Discuss medical necessity requirements with staff for proper documentation requirements.


* Review payer-specific billing compliance.


* Confirm revenue cycle processes that include patient registration, compliant billing, and denial management.


* Ensure clinical documentation, diagnosis, and codes reported meet medical necessity.


* Review medical necessity guidelines that can be payer-specific.


* Determine which team member is responsible for application of modifier(s) based on documentation and coding practices.


* Ensure coding and billing personnel are familiar with the wound care process.


* Encourage educational updates for clinical, coding, and billing personnel.


* Develop and implement internal and external auditing processes to minimize compliance risks.


* Test and confirm compliance with legal requirements.



This checklist is not meant to be exhaustive. It remains your responsibility to review your processes to determine which checklist items are appropriate for your practice. Cheers to you and your staff for a wonderful year of wound caring in 2019!




1. Centers for Medicare & Medicaid Services Quality Payment Program. Quality Payment Program Year 3: Final Rule Overview. Last accessed November 26, 2018. [Context Link]