As we usher in 2022 with optimism and hope, the timing of the new year acts as a reset button for our personal and professional lives. It’s a time to reflect on what we achieved, celebrate the wins, and benchmark new goals.
To be good stewards in our business, the reflection is cast when we begin to look back at the clinical, operational, regulatory, and economic/financial (CORE)1 work plan created and implemented by your team through workflow dependencies. Workflows are a key step in your clinical and operational efficiencies. Workflows enhance health care quality and safety, patient throughput, and care coordination.
These steps occur from the moment the patient is referred through patient discharge. Workflows need to be defined, reviewed, and refined as roles change, medical record requirements change, regulatory requirements become mandatory, and denials are discovered.
As you reflect on the areas of your business, ask the following questions:
- What is the why behind your workflow?
- How are your workflows constructed and what are the dependencies?
- When do you update your workflows?
- What features have you implemented this year to update your workflows?
Consider the following CORE checklist as you review your work plan. Cheers to you and your staff for a wonderful year of wound caring in 2022!
- Know hospital accreditation standards and support within department and documentation workflows.
- Review and streamline smart, strategic workflows for staff and providers.
- Integrate predictive analytics to gain insights and improve accuracy.
- Integrate digital imaging to measure, analyze, and document wounds.
- Integrate and update evidence-based medicine and wound care pathways.
- Integrate new COVID-19 policies and stay abreast of best practice guidelines to help ensure optimal care for wound patients.
- Update patient-specific education based on the patient population served.
- Review and update the product formulary and technologies.
- Implement clinical decision support alerts.
- Implement telemedicine workflows and functionality.
- Manage patient outliers and update plans of care.
- Coordinate discussions with clinical providers to ensure appropriate understanding of surgical wound care services and documentation requirements.
- Inquire whether scribing is allowed within your department.
- Review the process for physician ordering to support post-visit care.
- Use a comprehensive reporting engine providing clinical, operational, financial, and marketing reports.
- Review and update your department’s clinical and operational policies and procedures, including signature requirements for your documentation process.
- Review and update job descriptions.
- Ensure staff credentials, competencies, and skill sets are up to date.
- Review the budget for staff education.
- Reevaluate the use of technology and supplies to ensure appropriate use for your patient population.
- Review and update the payer matrix.
- Map authorizations and verification of benefits, advance beneficiary notices, and copay processes.
- Ensure the “reason for referral” is clearly documented.
- Understand insurance verification and medical necessity by payer process.
- Review the annual Office of Inspector General work plan to improve operations, clinical documentation, and charging and coding practices.
- Implement and review the wound care department’s charge description master, Current Procedural Terminology (CPT) 4, and Healthcare Common Procedure Coding System level II with modifiers (if appropriate).2
- 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.
- Participate in the 2022 Quality Payment Program3
- Mentor staff.
Regulatory and Economic/Financial Checklist
- Review the National coverage determinations (NCDs) and Local Coverage Determinations (LCDS) and Articles4 on an ongoing basis.
- Check the fiscal intermediary’s website for specific guidance with wound care and hyperbaric oxygen therapy services.
- Review managed care and payer agreements and limitations.
- Review and update the Clinical Level of Care tool for facility visit charges to ensure methodology reflects clinic flow.
- Discuss medical necessity requirements with staff for proper documentation requirements.
- Review medical necessity guidelines that can be payer-specific.
- Review payer-specific billing compliance.
- Confirm revenue cycle processes that include patient registration, compliant billing, and denial management.
- Ensure clinical documentation, diagnosis, and codes reported meet medical necessity.
- Determine which team member is responsible for application of modifier(s) based on documentation and coding practices.
- Ensure coding and billing personnel are familiar with the wound care process.
- Encourage educational updates for clinical, coding, and billing personnel.
- Develop and implement internal and external auditing processes to minimize compliance risks.
- Test and confirm compliance with legal requirements.
- Determine the denial management process.
- Schedule time for denial management reviews and reevaluate facility process based on findings.
- Review the Recovery Audit Contractor trends and develop a plan to proactively minimize your risk for loss.
NOTE: This checklist is not meant to be exhaustive. It remains your responsibility to review your CORE processes to determine which checklist items are appropriate for your practice. (For the original version of this checklist, click here.)
Wound Care Checklist
Measures Matter: How to Obtain Optimal Dimensions for Any Wound
1CORE, a proprietary process developed by Cathy Thomas Hess, VP, Chief Clinical Officer for Wound Care, Net Health, Pittsburgh, Pennsylvania.
2CPT is a registered trademark of the American Medical Association. All rights reserved.
3Centers for Medicare and Medicaid Services. Quality Payment Program. https://qpp.cms.gov/
4Centers for Medicare and Medicaid Services. Medicare Coverage Determination Process. https://www.cms.gov/Medicare/Coverage/DeterminationProcess