Ensure you have good documentation
There is a lot of complexity involved in wound care process. As we look at patients coming in the outpatient hospital setting, to really be successful, it takes a lot of work from a lot of individuals in your organization to make it all come out clean in the end and you get a paid claim for your services. Read these expert and sure-fire strategies provided by our speaker in a healthcare conference for more.
So having integrated systems, integrated communication between these departments is critical. You may have a central scheduling registration process. They may come to one particular area or you could be one of those situations where the actual wound care area will register the patient. Either way, you need to follow and get all the demographics and information we need.
They’ll come to the treatment department or office for their visit. They’ll check in of course. And what will happen is you probably have the chart prepared and ready and you'll have a charge sheet or encounter form that’s going to be used for the day to indicate what services were provided. Going by the CMS rules, you'll also validate that you have your MD order, there’ll be daily charting on the medical record. It could be dictated or written depending if you have an electronic record or not.
And then the charging process of course through a hospital environment, we’re going to have a charge description master through that software program and like an Excel spreadsheet sometimes, you will have listed the services that you will be providing through the wound care department. And will include information from materials management, supplies. It could have pharmaceuticals on there, very important from your finance perspective because that has your fee or your charge that you're charging for those services.
Using your encounter form to charge those services or write them down and then key them into the computer, that puts the fee or charge into the system to go on to the claim. But we also have to have the true coding part. We can't charge certain services without making sure that they follow the coding guidelines. We can't charge for services without making sure we have good documentation to support them. So that coding process needs to be evoked at that time. And you need to make sure your outpatient wound care areas have your health information management coding staff as part of your outpatient process for a successful wound care.
As per a healthcare conference conducted by our expert, once the coding is completed, then it will be electronically submitted to the billing department. There may be some denial management. And that should be brought back to the wound care area and the coding staff if there is denial management. So if there are any patient financial services or business office staff on today’s call, that will be an area that we need to see if we've got good communication.
If there are any compliance concerns, maybe there are audits by compliance. That would be where they would come in next and we would have a process. And then you can add additional steps in the process to make sure your wound care service line is successful, just a simple model to help you look at the process and work flow.
The work flow can be outlined in a flow sheet if you want to do that within your department or you can sit and have a meeting about what's going to happen and how it happens just to validate you’re doing everything we should do correctly.
And following your paper flow, if you have a paper record, looking at how it goes through each of those steps and each of those individuals. And making sure you perform an audit occasionally to validate each of these steps and processes are working well.
In some outpatient departments, they may have a process where they have electric records that help them with the wound care documentation. But the healthcare coding staff still needs to have availability to the electronic record or the paper record. And they can certainly service as your educators and auditors as well if you want to establish internal process or do not have an internal coding compliance auditing staff.
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