When thinking about the goals of documentation, consider the following: • Any word has a singular meaning. • Words placed in a particular order and sequence along with punctuation create a sentence. • Sentences denote thoughts. • In healthcare, our thoughts and actions performed for patients are documented to justify the work achieved.
Legal Medical Record Drivers
One of the most critical functions of the medical record’s multiple purposes is to plan and provide continuity of care for a patient’s medical treatment. The documentation in the medical record does provide for this function, but in many instances healthcare providers forget that the additional function of the medical record includes: • Providing information for the financial reimbursement to hospitals, healthcare providers, skilled-nursing facilities, and patients; • Providing legal documentation in cases of injury or other legal proceedings; • Providing information for quality assurance and peer-review committees, state licensing agencies, and state regulatory agencies when assessing the quality of care provided; and • Providing the critical information in an accreditation process such as the Joint Commission, Centers for Medicare & Medicaid Services (CMS), Undersea and Hyperbaric Medical Society, etc. As the medical community moves forward to become compliant with federal laws, the most common documentation tool used to collect the patient information is an electronic medical record (EMR), the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.1 The clinician must remember that data collected in the medical record serves as the instrument for demonstrating the clinician’s ability to plan, coordinate, and evaluate patient care. Therefore, developing a workflow for documentation is an essential prerequisite for a facility to evaluate the clinical efficiency and cost-effectiveness of its staff. Proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation. Once established, the documentation system should become the framework of clinical practice for all members of the wound care team.
Process and Workflow Drivers
Clinical decision making for skin and wound management is dependent upon the types of patients we manage in our care settings, the skillsets of the clinicians making the decisions for those patients, the products we have available within our facilities to improve skin and wound care, and documentation platform to capture our work. Essentially, the chain of events that should occur to move the skin and wound care forward is through defined process management and workflow (Figure 1). “Process” is defined by Merriam Webster as “a series of actions or operations conducing to an end.” And, with every process, are defined, targeted goals. All actions taken in skin and wound management need to be clearly defined through skin- and wound-caring processes. Workflow includes the structure or work system features and processes that support care.2 Designing clinical and operational workflow requires review and customization of current clinical and documentation practices for an efficient outcome. Current practices include the operational processes for registration, coding, and billing as well as the cognitive workflow by clinicians. Producing the right mix of operational oversight and clinical experience grounded with a solid documentation system will produce efficient business practices and optimal patient flow and care.
Revenue Management & Medical Necessity
Revenue cycle processes that include patient registration, compliant billing, and denial management compliment the documentation process for a fiscally successful department. These processes are governed by policy and Medicare is required by the Social Security Act to ensure payment is made only for those medical services that are reasonable and necessary. Policies specify the circumstances under which Medicare covers specific services. Further, most payers have implemented medical necessity guidelines for wound care services. CMS has defined medical necessity as: “No Medicare payment shall be made for items or services that are not reasonable and/or necessary for the diagnosis or treatment of illness or injury to improve the function of the malformed body member.” In short, the clinical documentation, diagnosis, and Current Procedural Terminology (CPT-4)3 codes reported must meet medical necessity or the claim will not be paid. Medical necessity guidelines can be payer specific, but most often payers follow those guidelines published by CMS’ national coverage determinations or Local Coverage Determinations (LCDs). It is also prudent to be familiar with the managed care payer agreements and limitations. From the time patients are called to schedule services, the documentation process begins. Patient demographic and payer information is gathered and medical necessity and coverage are confirmed and entered into the documentation system. Let’s consider the following components of the revenue cycle that drive the wound care department’s fiscal strength: Revenue Cycle Component Checklist4 A) Schedule Initial and Follow-up Visits B) Reason for visit: 1. Review physician order for complete diagnosis information 2. What is the primary reason for the visit? 3. Do comorbidities exist? C) Patient Demographics: 1. Verify first and last name spelling. 2. Confirm patient address. 3. Confirm patient telephone number. D) Patient Insurance Information: 1. Request complete information: primary, secondary and/or tertiary. 2. Be careful to identify the insured. Do not make assumptions that the main insured is the patient. 3. Is this a Medicare secondary payer? 4. Is this a Managed Care Payer? a. Is the wound care department contracted? b. Will the service be paid at a non-par rate? c. Does the payer authorize wound care in the plan? — Is your wound care department an authorized payer center? d. Will the patient be sanctioned penalties for using the wound care center? E) Verify the Coverage Prior to Patient’s Visit: 1. Determine coverage for the diagnosis(es) on the physician order. 2. Implement the Medicare Advance Beneficiary Notice if medical necessity or coverage fails. 3. Determine if the payer has coverage limitations. 4. Identify if utilization parameters will be a concern. 5. Obtain Precertification and/or Preauthorization numbers. F) Front-end Collections 1. Prepare the patient for co-pay, co-insurance, or deductible based on the findings prior to the visit. 2. Plan collecting the patient obligation at the point of service.
Charge & Billing Drivers
The wound care department’s charge description master represents chargeable services and will include CPT-4 and Healthcare Common Procedure Coding System (HCPCS) Level II codes5 that define the services conducted and/or used during the visit. Insurance payers expect clean, compliant claims. CPT-4, HCPCS Level II with modifiers will describe the procedures and skin substitutes used and ICD-9 represents diagnosis codes. All services and supporting diagnosis(es) need to be reported timely and completely. Review the billing software edits to manage National Correct Coding Initiative, Medically Unlikely Edits, and payer specific billing compliance.
Medical Necessity & Denial Management Drivers
As indicated in the initial step of the revenue cycle management process, payer medical necessity verification should be completed prior to the service. There will be times when it is “thought” that the service would be considered medically necessary based on the inquiry confirmation, but a denial may result. Every effort must be made to insure complete and compliant documentation. It is the medical documentation that will be used to dispute and potentially overturn the denial.
Documentation components comprising the medical record provide the platform for medical necessity and continuity of care. Skin and wound care documentation can combine a variety of information-gathering tools reflecting the wound’s status across the healing continuum. Remember, the goal of documentation is to provide the highest possible degree of clinical specificity to ensure accurate interventions and diagnosis. Diligent documentation determines dollars. When assessing the patient with a skin or wound condition, the details of the documentation should reflect the following data points as appropriate: Chief Complaint The chief complaint is the first step toward complete documentation for the skin and wound care patient. The chief complaint bridges the reason for the patient’s visit to the detailed history and physical captured by the practitioner, capturing the medical necessity for the visit. The clinician should document the specific reason the patient is visiting the practitioner. This statement should be clearly written, describing the reason for the patient’s visit, in the patient’s own words. History of Present Illness (HPI) An HPI provides necessary subjective information for the practitioner to review in conjunction with a review of symptoms, physical examination, risk assessment and screening tools, and skin and wound assessments. The HPI should include a complete chronological account of the presenting problem to date. The majority of this information is subjective based on interviewing the patient. If there is more than one chronic condition discussed (ie, lower leg pain, headaches), make sure to document this in the HPI. This will assist in justifying the needed orders. Past Medical, Family, and Social History There are many chronic illnesses or diseases, medications, allergies, diets, or activities of daily living that can lead to poor wound healing. A review of the patient’s past medical, family, and social history should be captured. This thorough documentation will provide complete information needed for the clinician to link any and all disorders to the patient with the chronic wound. Review of Systems Defined by CPT-4 as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced,” a symptom review is a general discussion related to the patient’s complaints or problems identified during the visit that provides necessary subjective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; physical assessment; and wound/skin/ostomy assessment. Physical Examination A focused examination pertinent to the skin condition, ostomy, or wound healing history, the physical examination is based on the patient’s history and the nature of the presenting problems and provides necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; and wound/ostomy/skin assessment. Documentation of the affected system(s) is mandatory in this section. Risk Assessment Risk assessments are used as predictors to ensure systematic evaluation of individual risk factors and exist for areas of the skin at risk, such as pressure ulcers and diabetic foot ulcers. Nutritional risk-assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutritional risk. Manual risk-assessment tools are part of the prevention of many disease states. Other factors (ie, laboratory values, radiologic studies, vascular studies) should be taken into consideration when evaluating a patient at risk. Risk assessment provides necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; physical examination; and wound/ostomy/skin assessment. Manual Screening Tools Manual screening tools are objective findings that assist the clinician in determining an accurate diagnosis. Screening results provide necessary objective information for the practitioner to review in conjunction with the history of present illness; past medical, family, and social history; review of systems; physical examination; and wound/ostomy/skin assessment. Wound/Skin Assessment Wound care documentation can combine a variety of information reflecting the wound’s status across the healing continuum. Providing an accurate description of the wound’s characteristics is critical during each patient visit. These objective findings assist the clinician in mapping the care during the wound-management process. The values obtained include etiology, qualitative information, and quantitative information. Establishing the etiology or cause of the wound or skin condition will help identify the correct classification and management process. Underlying medical conditions such as poor nutrition, diabetes, and/or neuropathy may explain why the wound is healing slowly. These underlying conditions need to be treated concurrently. Finally, treatment history is significant because the clinician may learn which management modalities have been tried and have been either successful or failures. Qualitative information should capture the anatomical location; classification of tissue-layer destruction; edema; or swelling of tissues, wound exudate, odor, pain, periwound skin description, type of tissue exposed, wound bed description and wound color, and wound margin condition. Quantitative information may include ankle and calf circumference, photograph of the wound, surface area of wound, wound depth, and undermining. Procedures Performed Components of the procedure performed include, but are not limited to, consent for the procedure, physical examination completed and updated in the last seven days, time-out parameters, name of physician and/or clinician performing the procedure, pre-operative diagnosis, procedure description, anesthesia used, noted complications, post-operative diagnosis, and the procedure performed (eg, techniques and tissues removed). Review LCDs as they relate to the specific procedure performed. There are important details to document within your procedure note to make you fully compliant with your documentation. Ordering Supplies and Tests The physician/non-physician provider (NPP) must supply an order for all of the care the patient receives related to the treatment. In many cases, it is important that the physician/NPP document the reason for the order to justify one’s actions. Patient Education Patient education and compliance are the cornerstones to successful wound and skin care. The educational needs of the patient should be evaluated on an individual basis beginning with the non-judgmental assessment of the patient’s current knowledge base relevant to the plan of care determined. An educated clinician should direct the educational activities. Validating the impact of the education by measuring retention of the material is paramount for a successful plan. Plan of Care/Discharge Instructions Designing, developing, and executing a clinical plan of care that is straightforward and comprehensive is paramount. Discharge summaries should be provided to patients in writing. The summaries can include diagnosis, summary of tests or procedures performed, medications prescribed during the visit, potential side effects of any tests or medications, and follow-up instructions.
Audit and Compliance Drivers
There are many important reasons for auditing documentation, including assessment of medical record completeness, determining the accuracy of documentation to ensure medical necessity, and discovering lost revenues (Figure 2).6 Proactive monitoring and auditing are essential to test and confirm compliance with legal requirements. The auditing function is the check and balance for your documentation. When auditing a medical record, documentation is examined to determine if 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, compliance with the organization’s policies and procedures, and compliance with payer regulations may not be identified. Keeping one’s finger on the pulse of clinical and regulatory changes for documentation requirements can be a daunting task. However, this is one task that everyone needs to stay abreast of for the benefit of wound care business and patients. Cathy Thomas Hess is vice president and chief clinical officer at Net Health, Pittsburgh, PA. She may be reached at email@example.com. Gail A Burke, CPAM, partner with the Manchester Group, Hoboken, NJ, contributed to this article. References for this article can be found online at www.todayswoundclinic.com.
1. The national alliance for health information technology report to the office of the national coordinator for health information technology on defining key health information technology terms, April 2008. Georgetown Law Library. Accessed online: http://cdm16064.contentdm.oclc.org/cdm/singleitem/collection/p266901coll4/id/2086/rec/10 2. Clinical decision support systems: State of the art. Agency for Healthcare Research and Quality. Accessed online: http://healthit.ahrq.gov/images/jun09cdsreview/09_0069_ef.html 3. Current procedural terminology CPT 2013. American Medical Association. 4. Hess, CT. Wound care policies and procedures. 2013. (Excerpted with permission.) 5. HCPCS Level II codes are maintained by the US Centers for Medicare and Medicaid Services (CMS). 6. Hess, CT. Clinical guide to skin and wound care (7th ed). Lippincott Williams & Wilkins, Philadelphia, PA. 2012.