Specialty electronic medical records (EMRs) have revolutionized the way data are collected, collated, and delivered at the press of a button. But are you sure that the information that you are documenting within your specialty EMR is truly reflective of your Clinical, Operational, Regulatory, and Economic (CORE)* processes? Understanding how the final documentation is compiled is […]

In 2019, wound/ulcer management providers and professionals experienced many reimbursement changes. Because confusion still exists about many of these issues, this author recommends taking the self-test below.  After you complete the test, download the answers to see how you did. Give yourself 4 points for every correct answer. Hopefully, everyone will score 100 points! If […]

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 […]

The most critical function of the medical record’s multiple purposes is to plan and provide continuity of care for a patient’s medical treatment. However, in many instances, we as healthcare providers forget that the medical record offers additional provisions including the following: information for financial reimbursement to hospitals, healthcare providers, skilled nursing facilities, and patients; […]

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 […]

There are many important reasons for auditing documentation, including determining its accuracy, assessing the completeness of a medical record, and discovering lost revenues. When auditing a medical record, the documentation is examined to determine whether it adequately substantiates the services billed and identifies medical necessity for the services rendered. If this process is not conducted […]

While you are fully focused on managing your Merit-based Incentive Payment System (MIPS) documentation for your 2019 reporting, the Centers for Medicare & Medicaid Services has updated a number of important resource documents within the full resource library at the Quality Payment Program website. One of these resources is the MIPS Promoting Interoperability Prevention of […]

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, […]

Performing a comprehensive patient assessment is an essential first step toward healing a chronic skin condition or wound. After the clinician has assessed the patient, identified any underlying conditions affecting healing, performed a complete assessment of the patient’s nutrition status, performed the proper tests to provide an accurate diagnosis of the underlying problem, assessed the […]

After taking the time to diligently document and report your Merit-based Incentive Payment System (MIPS) measures and activities, it is important to review your Performance Feedback Report detailing the category scores for your MIPS data submission. The scores provide you with payment adjustment information (excluding voluntary submitters) and details about measures and activities. Clinicians participating […]