1. Hess, Cathy Thomas BSN, RN, CWCN

Article Content

Proper workflows are at the heart of a successful wound care business. Whether you are in the outpatient wound care setting or working as a traveling physician, designing clinical and operational workflows requires close review and customization of current clinical and documentation practices for an efficient outcome. Current practices include the operational processes for registration, coding, billing, medical records, and denial management, as well as cognitive workflow by clinicians. Each of these workflows should map to the documentation elements within your electronic health record. Producing the right combination of operational oversight and clinical experience with the underpinning of a solid documentation system will produce efficient business practices and optimal patient flow and care.


Understanding Your Regulations

Each clinical staff member must understand the rules and regulations that guide wound care documentation and billing processes. The rules within the wound care department are generated from your fiscal intermediary, carriers, Medicare Administrative Contractors, National Coverage Determination, respective Local Coverage Decisions (LCDs), the Centers for Medicare & Medicaid Services, The Joint Commission, American Medical Association, Merit-based Incentive Payment System (MIPS), and so on. With so many rules and regulations governing your work and documentation, it is important to have processes in place to ensure your workflows and documentation support the rules.


Understanding Your MIPS Workflow

Let's take a look at mapping MIPS into your workflow, focusing on the MIPS clinical quality measures ( This calendar year, participants collect measure data for the 12-month performance period (January 1 to December 31, 2019). The amount of data that must be submitted depends on the collection (measure) type.


For electronic Clinical Quality Measures, MIPS Clinical Quality Measures (formerly "Registry Measures"), Qualified Clinical Data Registry Measures, and Medicare Part B claims measures (only available to small practices):


* Participants should submit collected data for at least six measures or a complete specialty measure set; and


* One of these measures should be an outcome measure. If you have no applicable outcome measure, you can submit another high-priority measure instead.


* In addition, for groups of 16 or more clinicians who meet the minimum of 200 cases, the administrative claims-based all-cause readmission measure will be scored as a seventh measure automatically.



An individual or group can submit any combination of measures across these collection types to fulfill the requirement to submit six measures.


To incorporate the Quality Measures in your workflow, you will need to review each measure to fully understand its impact within your workflow. This includes how the measures are designed by


* collection type,


* measure type,


* description of the measure,


* instructions for the measure,


* measure submission type,


* denominator description and exclusions,


* numerator description, and


* rationale for the measure.



Understanding how each measure is designed will allow you to properly configure your documentation workflow and collect the necessary information to successfully meet the intent of the measure. It may be helpful to build a MIPS reconciliation workflow to ensure that you account for the proper documentation during an encounter. As part of your workflow, you should build in steps to check your quality reports to ensure you are meeting the documentation requirements for each measure.


Managing Your Workflow

Managing workflow is like threading a needle, and MIPS documentation is one important aspect of the regulations to meet. It is also important to stay abreast of the National Coverage Determination and your specific LCDs for the latest information and for coverage guidance by the specific Medicare Administrative Contractor that processes the Medicare claims in your jurisdiction. Information about Medical Necessity can generally be found under the LCD section entitled "Coverage Indications, Limitations, and/or Medical Necessity." This section defines coverage criteria based on a determination of whether an item is reasonable and necessary. Be familiar with the managed care payer agreements and limitations too.


Remembering to document medical necessity should be at the top of your mind at each patient encounter. Each service must prove to be reasonable and necessary to diagnose or treat a patient's medical condition. Further, the diagnosis code(s) and service(s) rendered reported (on the claim) justify (to a payer) why a service was performed. The diagnosis reported can be the determining factor in supporting the medical necessity of the procedure.


Knowing the principles of medical record information provides the basis for performing an internal audit of the medical record. Specific strategies to consider when performing a wound care audit may include the following:


* reviewing the Fiscal Intermediary's website for the language that supports wound care services and medical necessity requirements;


* interviewing the staff to ensure a clear understanding of the documentation process and workflow that define the medical record;


* creating and/or reviewing the policies and procedures that support the department's work;


* meeting with your Compliance Officer to review trends within your department;


* ensuring each patient's visit is supported by a physician's order;


* reviewing the most frequently documented procedures such as debridements or the application of cellular- and/or tissue-based products;


* reviewing updates to the International Classification of Diseases, 10th Revision, and Current Procedural Terminology codes annually;


* reviewing the Chargemaster annually;


* reviewing the documentation for the procedure to ensure it supports the work performed;


* verifying that the procedure documented meets medical necessity and supports the physician's order;


* reviewing the number of procedures completed within a given time frame for each patient audited;


* working with Medical Records to define "timeliness of documentation" and closing a record;


* following the billing process for services performed from the beginning of the documentation process and asking about any denials; and


* understanding the denial management process and ensuring the department is a part of this process.



Last, auditing your documentation should be a best practice initiative. Through the audit, you may need to adjust your workflows.