I have the good fortune to work with wound care departments and providers all over the US. When I meet with these departments, I am working with them to understand their Clinical, Operational, Regulatory, and Economic/financial (CORE) processes, which is imperative for compliance with hospital or facility standards. Once the collective process is understood, the next step is to review six specific areas directly impacting return on investment: people and workflows, the product formulary, procedures, payment, process, and documentation. Understanding how these specific areas influence your work is critical. This knowledge allows you to work smarter, not harder.
People and Workflows
Each wound care team member who provides services—from the front desk coordinator to coding, billing, medical records, and denial management teams—must understand how his/her department meets the CORE processes and ensures compliance with the hospital or facility standards. The key for staff efficiency is understanding patient throughput and the clinical documentation requirements for the medical record. Setting up your specialty wound care electronic medical record (SWC EMR) with smart, specific workflows will save the clinical team time in the documentation process as well as map the compliance standards necessary for your facility to follow.
At the end of the day, the documentation captured for the visit performed is the source of truth for the encounter, which must support medical necessity and serve coding and billing. Review your current processes, documentation components, and data flows, identifying gaps in best practices and guiding recommendations for improvement in the clinical and operational workflow.
Reviewing your product formulary to meet the needs of your patients is critical for patient satisfaction and clinical and economic outcomes. Building your formulary into your SWC EMR allows you to capture charges otherwise lost or being captured by hand. Once you have done this, you should align the product’s Healthcare Common Procedure Coding System codes within your Charge Description Master. When clinical and financial outcome data are documented in the SWC EMR, the data can be used to advance critical pathways, improve product formularies, validate contract fees with payers, improve patient and clinician satisfaction, and comply with federal mandates.
Insurance payers expect clean, compliant claims. All services and supporting diagnosis/diagnoses need to be reported promptly and accurately. Using an SWC EMR that employs a procedure code automation tool to reconcile codes based on provider documentation and supports the charges and codes submitted allows you to work smarter, not harder. These features directly impact your department’s billing and bottom-line revenue.
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.