Launching into a new year brings opportunity to review the work plan created and implemented by you and your team. The underpinning for the work plan resides in the data collected within the medical record. The medical record serves as the instrument for demonstrating the clinician’s ability to plan, coordinate, and evaluate patient care. Proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation.
Checklists can be created and used as written guides to help your team meet key steps in compliance. In wound care, clinical, operational, regulatory, and economic/financial rules help maintain compliance with standards, and checklists can provide an audit tool to ensure that requirements have been followed. Using a clinical checklist can help to better organize the clinician’s time. Consider the following clinical and operational checklist:
- Utilize an interoperable, specialty wound care electronic health record and streamline strategic workflows.
- Update patient-specific education.
- Review and update the product formulary and technologies.
- Know hospital accreditation standards and support within department and documentation workflows.
- Manage the department through a comprehensive engine providing clinical, operational, financial, and marketing reports.
- Implement Clinical Decision Support Alerts.
- Participate in the Quality Payment Program.
- Review and update signature requirements for your documentation process.
- Review and update job descriptions.
- Ensure staff credentials and skill sets are up to date.
- Reevaluate the use of technology and supplies to ensure appropriate use for your patient population.
- Ensure clinical provider understanding of surgical wound care services and documentation requirements.
- Manage patient outliers and update plans of care.
- Review and update payer matrix.
- Map authorizations and verification of benefits, advance beneficiary notice, and copay processes.
- Ensure the “reason for referral” is clearly documented, and follow the documentation process.
- Understand the insurance verification and medical necessity by payer process.
- Review the annual Office of Inspector General work plan.
- Implement and review the wound care department’s charge description master, Current Procedural Terminology 4 (CPT*-4), and Healthcare Common Procedure Coding System Level II with modifiers (if appropriate).
- Meet with select departments to review updates for preregistration, coding, billing, medical records, and denial management.
- Implement interfaces to capture and send codified data, which decreases duplicative work and improves patient safety.
Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.
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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.