1. Hess, Cathy Thomas BSN, RN, CWCN

Article Content

I have the good fortune to work with wound care departments and providers all over the US. When I meet with these departments, I am working with them to understand their Clinical, Operational, Regulatory, and Economic/financial (CORE) processes,* which is imperative for compliance with hospital or facility standards. Once the collective process is understood, the next step is to review six specific areas directly impacting return on investment: people and workflows, the product formulary, procedures, payment, process, and documentation. Understanding how these specific areas influence your work is critical. This knowledge allows you to work smarter, not harder.


People and Workflows

Each wound care team member who provides services-from the front desk coordinator to coding, billing, medical records, and denial management teams-must understand how his/her department meets the CORE processes and ensures compliance with the hospital or facility standards. The key for staff efficiency is understanding patient throughput and the clinical documentation requirements for the medical record. Setting up your specialty wound care electronic medical record (SWC EMR) with smart, specific workflows will save the clinical team time in the documentation process as well as map the compliance standards necessary for your facility to follow.


At the end of the day, the documentation captured for the visit performed is the source of truth for the encounter, which must support medical necessity and serve coding and billing. Review your current processes, documentation components, and data flows, identifying gaps in best practices and guiding recommendations for improvement in the clinical and operational workflow.


Product Formulary

Reviewing your product formulary to meet the needs of your patients is critical for patient satisfaction and clinical and economic outcomes. Building your formulary into your SWC EMR allows you to capture charges otherwise lost or being captured by hand. Once you have done this, you should align the product's Healthcare Common Procedure Coding System codes within your Charge Description Master. When clinical and financial outcome data are documented in the SWC EMR, the data can be used to advance critical pathways, improve product formularies, validate contract fees with payers, improve patient and clinician satisfaction, and comply with federal mandates.



Insurance payers expect clean, compliant claims. All services and supporting diagnosis/diagnoses need to be reported promptly and accurately. Using an SWC EMR that employs a procedure code automation tool to reconcile codes based on provider documentation and supports the charges and codes submitted allows you to work smarter, not harder. These features directly impact your department's billing and bottom-line revenue.



As you detail your workflow to map preregistration to coding to billing to medical records and understand the denial management process, it is important to review your National and Local Coverage Determinations to ensure compliance. Even more important is for your department to understand how the billing department implements software edits to manage proper coding and review the Medically Unlikely Edits and payer-specific billing compliance. The value in these processes is priceless.



With every process come defined, targeted actions and goals. All of the actions taken need to be clearly defined through your healthcare systems processes. By aligning your processes, you will define the requirements necessary for your organization's CORE compliance, provide consistent and compliant documentation, and automate a superbill to show the work performed for the visit.



The last step is documentation. Remember that the goal of documentation is to provide the highest possible degree of clinical specificity to reflect the work performed. Documentation must capture medical necessity, compliance, and continuity of care. Choosing an SWC EMR that supports documentation elements necessary for quality and compliance standards is key.


It is important to remember that diligent documentation details data and determines dollars for your facility. Documentation data reveal trends across wound and patient types and clinical practices and operations. The data also allow comparison of clinical, operational, and financial outcomes. To interpret the report effectively, you must understand the report requirements, as well as the data inclusion and exclusion requirements.


Consider introducing the following EMR enhancements to improve efficiencies and workflows and work smarter:


* a scheduling module to coordinate patient visits and productivity,


* patient and provider portals to engage in the quality metrics,


* secure email exchanges for coordination of care,


* smart EMR features to meet the needs of clinicians and patients,


* clinical decision and practice management tools to alert the user to medication errors and adverse drug interactions and track diagnostic study results and patient follow-up,


* interfaces to pull data in and out of the system for clinical and operational compliance and audit mechanisms,


* compliance with accreditation and certification standards, and


* audit trail to report work performed for outcomes and benchmarking.



The healthcare industry continues to evolve and become more accustomed to the EMR guiding process. Examining and updating your clinical workflows, documentation standards, product formulary, and processes are the keys to a healthy return on investment.


* CORE is a proprietary process developed by the author. [Context Link]