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.
Consider the following regulatory and economic/financial checklist:
* 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.
* Inquire whether scribing is allowed within your department.
* Review the process for physician ordering to support nurse visitation.
* Review the National and Local Coverage Determination policies on an ongoing basis.
* Check the fiscal intermediary's website for any specific Local Coverage Determination for wound care and hyperbaric oxygen therapy services.
* Review managed care and payer agreements and limitations.
* Obtain cost reductions based on volume purchases and standardization of products.
* Review and update the Clinical Level of Care form for facility charges to ensure methodology reflects clinic flow.
* Review distribution of charges across the 5 levels of service; does this represent a "bell curve"?
* Review payer-specific billing compliance.
* Confirm revenue cycle processes that include patient registration, compliant billing, and denial management.
* Ensure clinical documentation, diagnosis, and CPT-4 codes reported meet medical necessity.
* Determine which team member is responsible for applying modifier(s) based on documentation and coding practices.
* Ensure coding and billing personnel are very familiar with the wound care process and promote education.
* Develop and implement internal and external auditing processes to minimize compliance risks.
* Test and confirm compliance with legal requirements.
This checklist is not meant to be exhaustive. It remains your responsibility to review your processes to determine the checklist items appropriate for your practice.