A Comprehensive Guide toWound Care Documentation and Audits

A Comprehensive Guide toWound Care Documentation and Audits

There are many important reasons for auditing wound care 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…

Promoting Interoperability 2019: Sharing Electronic Health Record Information

Promoting Interoperability 2019: Sharing Electronic Health Record Information

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…

Managing Your Wound Care Workflow to Meet Regulations

Managing Your Wound Care Workflow to Meet Regulations

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,…

Comprehensive Patient and Wound Assessments

Comprehensive Patient and Wound Assessments

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…

Understanding Your Merit-based Incentive Payment System Performance Feedback Report

Understanding Your Merit-based Incentive Payment System Performance Feedback Report

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…

Merit-based Incentive Payment System 2019: Promoting Interoperability Details and Measures

Merit-based Incentive Payment System 2019: Promoting Interoperability Details and Measures

In the February 2019 Practice Points column, Merit-based Incentive Payment System 2019 Changes, we reviewed the final changes to the 2019 Quality Payment Program Final Rule1 under the Medicare Access and CHIP Reauthorization Act of 2015 released by the Centers for Medicare & Medicaid Services (CMS). In this column, we will focus on the Promoting…

Misdiagnosis of Wounds

Misdiagnosis of Wounds

Wound healing is a complex process that uses specific cellular and biochemical actions to achieve wound closure. These processes (homeostasis, inflammation, proliferation, and maturation) occur over defined periods of time. They are often taken for granted as the wound innately granulates, contracts, and epithelializes under optimal conditions. A wound begs the clinician’s attention when the…

Merit-based Incentive Payment System: 2019 Changes

Merit-based Incentive Payment System: 2019 Changes

Terminology Changes The CMS has created new MIPS terminology that more accurately reflects how clinicians and vendors interact with the QPP, namely MIPS. The new MIPS terms include Collection Type, Submitter Type, and Submission Type. Collection type: a set of quality measures with comparable specifications and data completeness criteria including, as applicable, electronic clinical quality…

2019 Checklist: Organizing Your Wound Care Department for the New Year

2019 Checklist: Organizing Your Wound Care Department for the New Year

Welcome to 2019! Launching into a new year brings an opportunity to review the work plan created and implemented by you and your team. The underpinning for the work plan must reside in the data collected within the medical record. The medical record demonstrates the clinician’s ability to plan, coordinate, and evaluate patient care. Proper…