Beyond Workflow: Why ThinkFlow is Newest Wound Care Documentation Strategy

ThinkFlow combines workflow and CORE methodology to ensure a smarter approach for key wound care processes and tasks

By:  Cathy Thomas Hess
BSN, RN, CWCN, Vice President, Chief Clinical Officer, Net Health Wound Care

Documenting the steps taken during wound care used to be viewed as – while not the most exciting task on your to do list – one that was relatively straightforward. You performed a task; you recorded it in the patient record. But as with all things related to healthcare, even simple tasks are becoming more complex, and crucial.

Based on years of talking with wound care providers striving to ensure proper wound documentation, I formulated some proprietary strategies that are open to anyone to adopt or adapt. One such strategy integrates a methodology I developed years ago known as CORE—Clinical, Operational, Regulatory, and Economic.

It involves mapping out the guidelines and policies governing prevalent wound care procedures and therapies, then aligning them with standard documentation processes. CORE serves as the driving force behind a fresh strategy I’ve been working on called ThinkFlow, created to combine workflow and CORE to ensure a smarter approach for key wound care processes and tasks like documentation. (Here’s a checklist with a lot more details on CORE.)

ThinkFlow and the CMS clawback initiative

Let’s look deeper at ThinkFlow and how it can help impact a key challenge facing wound care providers today. As you’ve likely heard and read, the Centers for Medicare and Medicaid Services (CMS) is now trying to clawback billions of dollars they view as overpayments to hospitals and insurers.

There are reasons for the effort. While the overall accuracy rate of payments is high, the current inaccuracy rate of 7.38% still equals billions of dollars annually. For example, the Fiscal year 2023 Medicare Fee-for-Service (FFS) report estimated that the improper payment rate was $31.2 billion. CMS reports that there are multiple reasons for overpayment, including:

• Improper documentation with items such as missing orders or inadequate documentation to support an order = 62.8%
• Missing documentation to support medical necessity= 15%
• Incorrect coding=11.6%
• Missing attestations to support unsigned orders and records =3.7%

The Office of Inspector General (OIG) is conducting provider audits to find overpayments. These audits have many wound care providers concerned because they recognize that simple oversights and human error could lead to serious fines and other penalties.

As a first step, wound care organizations need to understand what the OIG is doing, why, and most importantly, the impact it will have on their organization. Step 2 is to implement the processes and technology that will mitigate risk.

Here’s where your current workflow and ThinkFlow enter the picture and meld with CORE. Together, they take into consideration the basic steps of clinical wound care, linking the alphabet soup of acronyms we know all too well – Local Coverage Determinations (LCD), National Coverage Determinations (NCD), and/or Policy Articles (PA) within the Medicare Administrative Contractor (MAC) – to then follow for clinical, operational, regulatory and economic direction.

In short, workflow analyzes your practice’s key processes and illustrates the proper steps to eliminate redundancies by identifying gaps in your practice, all to provide program optimization. Thinkflow depicts the intentional actions within a workflow that pull documentation and payment together. CORE are the processes you implement to ensure the steps you are taking accurately capture the clinical documentation of your work driving measurable clinical outcomes and payment.

Find out more about CORE and ThinkFlow at SAWC in Orlando on May 14 – 18. Posters are available for viewing Thursday, May 16 and Friday, May 17 from 7:30 a.m. to 5:30 p.m. Join us for the Poster Reception, Thursday, May 16, 2024, from 7:30 PM – 8:30 PM.

Applying ThinkFlow to documentation

Documentation is critical to avoid audits and support services billed. However, incomplete documentation is one of the critical factors leading to errors. That’s why today’s wound care providers spend hours each month on administrative tasks to ensure accuracy.  And despite all the time and effort, there are often still mistakes.

Wound care providers often tell me, “Hey, I did everything right; I coded, documented, and did everything I was supposed to, and still, I got dinged.” When we reviewed what happened, we found that critical rules were overlooked while the basic steps were followed. I often see this when a provider does not follow the guidance provided in the LCD, NCD, or PA within the patient’s MAC region location. (Here’s a video on documentation from CMS with more information.)

Steps to take

Let’s take those scenarios and see what would happen if you applied ThinkFlow and the principles of CORE.

CORE	Thinkflow
Clinical	Maps to quality and payment standards (E/M) and medical records compliance | Diligent documentation defines dollars for your practice
Operational	Maps to product formulary, Charge Description Master (CDM), Wound product Healthcare Common Procedure Coding System (HCPCS) codes used during treatment and Physician Orders, accurate accounting for the Superbill
Regulatory	Maps documentation to procedure code population in the Superbill based on code definitions and NCCI edits, optimizes accuracy of procedure code calculations | Maps to the procedure modifiers for coding and billing review
Economic	Maps to department efficiencies from patient registration, coding, billing, medical records, denial management, to support documentation.  Maps to CDM | Maps to Superbill| Point of care charge entry interfaces to hospital billing system

To get even more from ThinkFlow, ask the questions that will get you the answers you need to minimize the potential for audits while also optimizing your performance and program outcomes. Some to ask include:

• What codes most frequently get denied? Are there patterns or trends for your denials? For example, do you get a lot of denials for skin substitutes or debridement?
• What are the common reasons why billing is denied? Is it insufficient documentation?
• Are you making simple errors of oversight, such as missing a signed physician’s order for treatment or incomplete or missing treatment records?
• Do you know the red flags for auditors? Auditors will most likely review these areas related to documentation, including whether you are following utilization guidelines, what’s required to justify medical necessity, and whether you are using correct modifiers.

How does ThinkFlow address these areas?
Simple: The person coding has to KNOW and determine the best CPT code based on Medical Decision Making (MDM) vs. Time to ensure compliance and profitability. The latter refers to the duration it takes for a healthcare organization or provider to accurately submit claims, adhere to CMS guidelines, and ensure that the billing process is not only compliant with regulations but also financially viable for the organization.

Additional questions to ask within your ThinkFlow to help ensure more accurate documentation

• Are you being specific? Insufficient details in the documentation can lead to coding errors. Healthcare providers should provide clear and detailed information about the wound, location, size, depth, and associated conditions or complications.
• Are your codes correct? Changes in coding guidelines and updates to code sets can lead to errors if healthcare providers are unaware of the latest changes.
• Is this the proper terminology? Inconsistent or ambiguous terminology in medical records can make it difficult for coders to assign the appropriate codes accurately.Did I bundle it? Incorrectly breaking down or combining codes for wound care procedures can lead to errors in billing and coding.
• How is the integrity of my documentation? Errors can occur when documentation is altered or amended after the fact, leading to inaccuracies in coding.

Think about ThinkFlow

The most crucial step in your ThinkFlow process is educating and supporting your wound care providers. Ensure they understand why documentation and coding processes are so important and providers are aware of the OIG’s clawback program and its potential impact on their organization and jobs.

While most may have some understanding, it’s a complex issue, and wound care providers are often busy with little time to explore the big-picture issues affecting their industry. Education and training are, therefore, critical.

Share with them the value of ThinkFlow and CORE – help them understand how it can make their workday less stressful, more seamless, and more focused on patient care. Encourage mentors within your department to become experts in the areas that may be problematic for your program and to share their expertise with colleagues.

Wound care remains a rewarding profession. Those of us who work daily in the industry have awesome stories to share about patients who have made remarkable progress, caring colleagues who go above and beyond, and more. However, it is also challenging to keep up with rules and ensure steps are taken to avoid OIG audits and other penalties.

We can do it! We can use technology like specialty EHRs, AI-powered digital imaging, and other solutions to help ensure accurate and consistent wound measurements, improve patient care, increase patient safety, minimize errors, and increase productivity and administrative efficiency.  We can emphasize ThinkFlow in our workflow documentation processes and incorporate the CORE principles to ensure we always focus on those areas most likely to lead to errors and audits.

Process innovations like this will help us minimize risk, optimize reimbursement, and, most importantly, improve the quality of care and patient outcomes.