1. Hess, Cathy Thomas BSN, RN, CWCN

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It has been quite a busy year! Although this column is not intended to exhaustively cover all rules and regulations, let's look back at what we learned this year about the Quality Payment Program (QPP) and other documentation approaches to plan ahead using smart strategies. And remember, it is your responsibility to understand the rules and regulations that govern your business while mapping the coding and coverage guidelines into your practice as appropriate.


QPP and Your Workflow

The CMS is required by law to implement a quality payment incentive program that rewards value and outcomes via the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models. Clinicians are included in MIPS if they are an eligible clinician type and meet the low-volume threshold. Beginning in payment year 2019, the low-volume threshold encompassed allowed charges, the number of beneficiaries who receive services, and the number of services provided. Clinicians must participate in MIPS (unless otherwise exempt) if, in the determination period, they bill more than $90,000 for Part B-covered professional services, see more than 200 Part B patients, and provide 200 or more covered professional services to Part B patients.


The Eligible Clinician Type list that must report this year has expanded to include physical therapists, occupational therapists, clinical psychologists, qualified speech-language pathologists, qualified audiologists, and registered dietitians or nutrition professionals. To determine participation status, use the QPP Participation Status Tool and ensure you review your eligibility data at multiple points throughout the year to help you plan your program participation. Remember, if you are eligible and do not score at least 30 points, you can lose up to 7% of your Medicare fee reimbursement to your 2021 payments.


Next, ensure you understand the configuration of your workflow and verify you have incorporated all documentation requirements. Check your MIPS documentation progress often to verify documentation requirements are being met. Last, remember that change in process always brings an opportunity to review and refine documentation workflow(s) in general. Note: The submission window for reporting payment year 2019 opens January 2, 2020, and closes March 31, 2020.


Regulations, Medical Necessity, and Audits

Each clinical staff member must understand the rules and regulations that guide the wound care department's documentation and billing processes. With so many rules and regulations governing your business, it is important to have processes and workflows in place to ensure your documentation supports them. For example, beginning October 1, 2019, the International Classification of Diseases, 10th Revision has been expanded to include codes for deep-tissue pressure injury and are to be used from October 1, 2019, through September 30, 2020.1


Other code changes exist that may affect the documentation and payment in your place of business. Bookmark the appropriate sites for each organization listed above for your reference and update your documentation tools and workflows as appropriate.


Equally important are the National and Local Coverage Determinations. Review the latest coverage guidance from the specific Medicare Administrative Contractor that processes the Medicare claims in your jurisdiction; know that Local Coverage Determinations typically impose frequency limitations. Also remember to be familiar with the managed care payer agreements and limitations.


Remembering to document medical necessity should be paramount for each encounter. The service must prove to be reasonable and necessary to diagnose or treat a patient's medical condition. Further, the diagnosis code(s) reported (on the claim) with the service rendered is to justify (to a payer) "why" a service was performed. The diagnosis reported can be the determining factor in supporting or not supporting the medical necessity of the procedure.


Last, auditing your documentation should be a best practice initiative. 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 are listed in the November 2019 Practice Points article.


Review the regulations governing your place of business often, document diligently, and update workflows as appropriate. Wishing you a happy, healthy, productive, and successful 2020!




1. National Center for Health Statistics. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). 2019. Last accessed October 24, 2019. [Context Link]