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Grow Your Rehab Therapy Practice Using Paid Ads and Search Engine Marketing

When done right, paid advertising and search engine marketing are amazing tools to reach new patients and grow your business. By applying several basic tactics, you can start using powerful digital advertising platforms like Google and Facebook to target specific audiences and help ensure a steady flow of business for your practice. Click to View […]

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Five Key Stressors Hospice Professionals Face, with Guidance for Support

Hospice professionals help others face death and loss, while juggling interdisciplinary communications, quality compliance regulations and ever-evolving technologies. You are continually there for families and their dear ones who are passing away. But what about you? Get the eBook In caregiving professions, it is easy to get swept up in the needs of others and forget […]

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Net Health’s CIO discusses diversity and how it can build a stronger organization

Diversity in the workplace is an on-going issue but it’s an issue with solutions. To build diversity, it takes forward-thinking initiatives, a reexamination of the hiring philosophy, and the support of the company’s decision-makers.  One such supporter of diversity in the workplace is Net Health’s CIO, Jason “JJ” James.  Recent social movements like Black Lives […]

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Tough Questions | Real Answers: Net Health’s Fireside Chat about Race

Net Health did something different recently. Nearly two hundred employees and their families gathered around their computer screens to take part in a landmark event in our company’s history – we called it a “Fireside Chat about Race”.  The purpose of this event was to have a truly open conversation about the controversial but relevant […]

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Industry News Auditing Your Wound Care Documentation

Auditing Your Wound Care Documentation

June 1, 2018 by LimeCuda

When it comes to performing an internal audit of your wound care documentation, there are specific strategies to consider. Each of the strategies that help you prepare can ease the audit process and create a more efficient procedure.

Hear from Cathy Thomas Hess, BSN, RN, CWCN on what steps to take to ensure that your internal wound care audit can be completed smoothly and efficiently.

Net Health's 360 Services and professional coaching can enable your facility to perform internal audits seamlessly.

 

View Video Transcript

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 that medical record. There are specific strategies to consider when performing a wound care audit.

First, review your fiscal intermediary's website for the language that supports wound care services and medical necessity requirements. Next, interview staff to ensure a clear understanding of the documentation processes and workflows that define the medical record in your department. Create and/or review the policies and procedures that support the department's work, and make sure that you have a policy in place that supports your facilities, evaluation, and management practices. Meet with your compliance officer to review trends within your department. And verify each patient's visit is supported by a physician's order. Also verify that that procedure documented meets medical necessity and supports the physician's order as well.

You also need to review the most frequently documented procedures such as your debridements or the application of cellular and/or tissue based products or negative pressure wound therapy as examples, and make sure you have the proper documentation elements to support the procedure as well as the proper codes for billing.

So this dovetails into really the next guiding principle, which is reviewing your charge master as well as your ICD 10 codes and making sure that those updates are made annually. So as you reconcile charges prior to billing, make sure that you review the documentation for the visit or the procedure to ensure it supports the work performed. Given changes in the NCD and LCD landscape, it's extremely important for you to review the number of procedures completed within a given timeframe for each patient. Also, make sure that you work with your medical records department to define what is timeliness of documentation and what does it mean to close a record?

Lastly, follow the bill and make sure that you understand those services performed from the beginning of the documentation process, through the billing process, and ask about denials. You need to understand the denial management process and make changes to your documentation or processes as necessary to alleviate those denials in the future.

While the list that we just talked about is not an exhaustive list, it's a lot to manage. So remember to reach out for assistance, if you need help to align your wound care specialty EHR with your organization's workflows and best practices, and just remember assistance is just a call away.


Cathy is Chief Clinical Officer for WoundExpert® and Vice President at Net Health, and in addition to being the MIPS Clinical Consultant for WoundExpert. She gained over 30 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. Cathy is the author of Clinical Guide to Skin and Wound Care (also translated into Italian and Portuguese) – Eighth Edition published in September of 2018.

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