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Outpatient Therapy

Grow Your Rehab Therapy Practice Using Paid Ads and Search Engine Marketing

When done right, paid advertising and search engine marketing are amazing tools to reach new patients and grow your business. By applying several basic tactics, you can start using powerful digital advertising platforms like Google and Facebook to target specific audiences and help ensure a steady flow of business for your practice. Click to View […]

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Hospice

Five Key Stressors Hospice Professionals Face, with Guidance for Support

Hospice professionals help others face death and loss, while juggling interdisciplinary communications, quality compliance regulations and ever-evolving technologies. You are continually there for families and their dear ones who are passing away. But what about you? Get the eBook In caregiving professions, it is easy to get swept up in the needs of others and forget […]

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Net Health’s CIO discusses diversity and how it can build a stronger organization

Diversity in the workplace is an on-going issue but it’s an issue with solutions. To build diversity, it takes forward-thinking initiatives, a reexamination of the hiring philosophy, and the support of the company’s decision-makers.  One such supporter of diversity in the workplace is Net Health’s CIO, Jason “JJ” James.  Recent social movements like Black Lives […]

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Tough Questions | Real Answers: Net Health’s Fireside Chat about Race

Net Health did something different recently. Nearly two hundred employees and their families gathered around their computer screens to take part in a landmark event in our company’s history – we called it a “Fireside Chat about Race”.  The purpose of this event was to have a truly open conversation about the controversial but relevant […]

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Industry News Wound Care Documentation and Audits
Wound Care

Wound Care Documentation and Audits

September 10, 2019 by Cathy Hess , BSN, RN, CWCN, VP, Chief Clinical Officer for Wound Care

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 not conducted on an ongoing basis, incorrect or inappropriate documentation and coding practices, potential risks to the organization, and poor compliance with policies and procedures and/or payer regulations may not be identified.

Each clinician must understand the rules and regulations guiding the wound care department’s documentation and billing processes. The rules within the wound care department are generated from your Fiscal Intermediary, Carriers, and Medicare Administrative Contractors; National Coverage Determination and respective Local Coverage Determinations; the Centers for Medicare & Medicaid Services, The Joint Commission, and the American Medical Association; and so on. With so many rules and regulations governing your work, it is important to have an audit process in place to ensure your documentation supports them.

Proactive monitoring and auditing are designed to test and confirm compliance with legal requirements. These implementation and monitoring strategies include:

  • defining risk areas and establishing the need for self-audit;
  • considering your departmental resources for practicable auditing;
  • determining the subject, method, and frequency of audits;
  • reviewing medical and financial records that support claims for reimbursement;
  • preparing the internal audit report;
  • presenting findings to applicable parties;
  • developing corrective action plan; and
  • continuing ongoing monitoring.

Steps specifically outlining Internal Auditing strategies include:

  • establishing and identifying the need for an internal audit;
  • defining the specific issues of the audit;
  • determining an appropriate sample size;
  • establishing an audit schedule;
  • preparing a concise audit report;
  • presenting audit results to applicable personnel;
  • developing an action plan; and
  • performing ongoing monitoring.

To read the full article in “Advances in Skin & Wound Care” by Cathy Thomas Hess, click here.

Read previous articles in “Advances in Skin & Wound Care” by Cathy Thomas Hess in the link.

Download a brochure and learn how Net Health 360 professional services programs conquer the most complex problems in specialized lines of work.


Cathy Hess, wound care documentation expert and Chief Clinical Officer for Net Health WoundExpert 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.

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Filed Under: Industry News, Wound Care

About the Author

Cathy Hess , BSN, RN, CWCN

VP, Chief Clinical Officer for Wound Care

Cathy oversees clinical and professional services for Net Health. Cathy gained over 25 years of expertise in various acute care, long-term care, sub-acute care facilities, home-health agencies, and outpatient wound care department settings. She is the author of The Clinical Wound Manager™ Manual Series, Clinical Guide to Skin and Wound Care – Seventh Edition (also translated into Italian and Portuguese).


See all posts by Cathy Hess , BSN, RN, CWCN

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