CHAPTER 2 Billing, reimbursement, and setting up a clinic
1. Describe how wound clinics may differ with regard to their management, location, and services offered.
2. List key components of a wound clinic.
3. List documentation that must be in the medical record to meet Medicare and billing requirements.
4. Distinguish among the different Medicare and insurance programs, including how they relate to billing for clinic services.
Creating the business plan
The first step in creating a new clinic is to establish a business plan (Box 2-1). The goal of a business plan is to provide a step-by-step guide to follow when creating a new program or project. A well-constructed business plan is an important tool to use when obtaining administrative support because the plan will enumerate the benefits of the service and summarize existing internal and external competitors. The business plan should include a pro forma or projected operating budget for the next 5 years. Getting started requires consideration of several topics that should be covered in the business plan: local health care environment, referral sources, customers, competitors, regulators, and revenue sources. The business plan must emphasize the product or service being proposed as well as the marketing plan. A key element of the business plan is often referred to as the unique service advantage, which is what this business will do that no other business currently does, or how this new business will do it better than the competition does.
BOX 2-1 Components of a Business Plan
IV. Product/Service Descriptions
VI. Critical Success Factors/Key Assumptions
The benefits of a wound care clinic to a hospital or organization are numerous (Box 2-2) and should be outlined in the business plan. A completed sample business plan is available through the Wound Ostomy and Continence Nurses Society’s Professional Practice Manual (Wound Ostomy and Continence Nurses Society, 2005).
Clinic management
Although wound clinics offer similar services, they differ in their management arrangements and structure. Management can be overseen externally by a managed contract or proprietor or they may be self-directed (internal), similar to a physician office. Table 2-1 lists advantages of both types of management. Available resources are a key consideration in determining the type of management needed. Resources include guidelines for care, policies, and forms, materials for staff and patient education, and quality improvement processes. Another essential consideration is access to the staff with expertise in developing these resources. External management often has these resources ready for use. However, such an arrangement could conservatively commit more than half of the wound center revenue to the management contract. Decision-makers should be aware of the type and extent of support that the management company can provide before choosing that company as a partner.
TABLE 2-1 Advantages of External versus Internal Clinic Management
| External (Outside) Management | Internal (Self-directed) Management |
| Policy and documentation forms already developed | Able to create policy and forms that flow with current hospital tools already in place |
| Education and resources available via managed company | Establish and seek education via both national and local conferences based on clinic focus |
| Able to compare productivity and outcome numbers with other management facility to gauge quality outcomes | Quality care program based on internal data or nationally available data |
| Established evidence-based pathway provided | Create clinic pathway to fit patient population and current hospital protocols using available evidence-based resources |
| Decisions and goals made at the corporate level and can be implemented with corporate support | Decisions and goals made at local level with flexibility to respond based on internal assessment and preferences |
| Audits by oversight to determine compliance, alert to national changes | Verify changes to payment rate, make local coverage determinations at least quarterly, make policy/form changes as prompted from data to fit local changes |
| Database system to assist with reports and documentation | If database desired, may choose from many available for reports and documentation; this option may offer benchmarking with other sites for outcome comparisons |
| Potential for faster startup/growth due to already created tool and knowledge | Potential to add services other than wound care if clinic desires (e.g., nail care, ostomy clinic, lymphedema, continence clinic) |
| Staffing needs determined by job descriptions | Less outgoing expense, increased clinic revenue potential |
Clinic structure
Structurally, the physical space of a wound clinic can be attached to a hospital (a hospital-based clinic or hospital outpatient clinic) or freestanding (clinic without any physical attachment to a hospital). The hospital-based clinic is a portion of a hospital that provides diagnostic, therapeutic, and rehabilitation services to sick or injured persons who do not require hospitalization. When determining the physical location of the clinic, particularly of the hospital-based clinic, it is important to consider ease of patient access to the clinic and ease of parking. Within the clinic space itself, a variety of issues must be considered in the design of the individual treatment rooms, the floor plan, the location of stocked equipment, lighting, and the need for stretcher access or lounge chair space (Checklist 2-1). Consultation with qualified individuals early in the planning to assist with these unique clinic space issues may be beneficial.
CHECKLIST 2-1 Clinic Space and Supply Needs
✓ Individual treatment rooms with sinks
✓ Waiting area (include bariatric friendly furniture)
✓ Clean and dirty utility rooms
Hyperbaric-Related (If Applicable)
✓ Floor weight loading with consideration to wax on floor and types of lights in ceiling
Nail Care-Related (If Applicable) (see Chapter 15)
Additional means of financial viability
A hospital-based clinic can offer additional referrals to the hospital for laboratory, radiology, nuclear medicine, magnetic resonance imaging, arteriogram, and surgical procedures and even for admissions, all of which add to the clinic’s financial viability. The clinic should record these referrals and communicate to administrators in regular reports to reinforce the financial contributions of the wound center (Trendwell, 2007). Hospital outpatient clinics have the ability to obtain the facility fee for services provided by charging the facility rate when procedures are performed; this will assist in capturing some of the overhead.
Clinic operations
Chart preparation and storage
Prior to the appointment, the clerical staff should prepare the chart with necessary forms and verification of insurance authorization. New and returning patient visits require different paperwork. New patients will need to provide a history and sign consent forms and the documentation forms necessary for return visits. Locked file storage within the clinic will be necessary, with potential for offsite storage if space is limited. However, it is important to consider how accessible these charts will be if a request is made to retrieve these records. A master list for storage boxes should be maintained to assist with retrieval, sign-out, and replacement.
Obtaining consents
Preprinted consent forms (treatment, photography, surgical/biopsy) should be available and signed prior to the visit. Consents can be mailed or faxed to the appropriate authority prior to the appointment to prevent delay in treatment when the patient is unable to sign independently. A protocol for the frequency of renewing consents should be established. Some facility registration cycles require monthly consents with each new registration; others refer to this as a reoccurring series and require annual updates if the patient has continued uninterrupted visits during the course of treatment. All consents should be maintained in the legal chart.
Compliance program
With the numerous rules and regulations existing today that ultimately impact on quality of care, reputation, and payment for services, most organizations have a compliance program to oversee both corporate and regulatory issues. The objective of a compliance program is to identify potential sources of risk and implement policy and process modifications to reduce risk (Hess, 2008). Corporate compliance addresses employee behaviors and ethical issues in an attempt to protect the corporation from criminal and civil liability. This is accomplished through corporate-sponsored training activities on topics such as code of conduct (e.g., sexual harassment, interaction with vendors, ethics, publication, involvement with media), grievance without retribution procedures, and disciplinary processes.
Regulatory issues are dictated by whether the clinic is freestanding or hospital based. Most hospital-based clinics are included in annual hospital audits/surveys and are required to follow standard hospital policies; freestanding clinics may not have the same requirements. During the planning process, regulatory requirements within the geographical area need to be addressed as established by The Joint Commission, the Department of Health, and the Certificate of Need (Fusaro et al, 2008). Compliance with National Patient Safety Goals (including patient identification, appropriate hand-off communication, and medication safety) and with coding and billing guidelines is essential to the financial health of a clinic. Coding experts should be used in setting up the “charge master” (clinic billing charges linking codes and dollar amounts), training staff in coding visits and procedures, and ensuring accurate documentation that reflects compliance and maximizes payment.
The clinic staff should be familiar with and in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy rule. HIPAA was enacted for many reasons, including improving the portability and continuity of health insurance coverage and combating waste, fraud, and abuse in health insurance and delivery of health care (US Department Health and Human Services, 2009). The HIPAA privacy rule also established national standards to protect the privacy of a patient’s health information from health plans, health care clearinghouses, and most health care providers. Further information and guidance on implementing the HIPAA privacy rule are available on the websites listed in Table 2-2.
TABLE 2-2 Website Addresses Relevant to Clinic Function, Structure, and Operations
| Information Available | Website Url |
|---|---|
| Directory and information | http://www.cms.hhs.gov |
| Guidance on HIPAA privacy rules and teaching materials | http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html |
| Local information regarding coverage | http://www.cms.hhs.gov/mcd/search.asp?from2=search.asp& |
| Fee schedules | http://www.cms.hhs.gov/FeeScheduleGenInfo/ |
| CPT codes | http://www.cms.hhs.gov/PFSlookup/02_PFSSearch.asp#TopOfPage |
| Directory of fiscal intermediaries and intermediary carriers | http://www.cms.hhs.gov/apps/contacts/incardir.asp |
| Most current information regarding Medicare contractors | http://www.cms.hhs.gov/MedicareContractingReform |
| Medicare Coverage Database with current NCDs and draft and final LCDs | http://www.cms.gov/mcd/overview.asp |
| NCCI edits | http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp#TopOfPage http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage |
CPT, Current Procedural Terminology; HIPAA, Health Insurance Portability and Accountability Act of 1996; LCD, local coverage determination; NCCI, National Correct Coding Initiative; NCD, national coverage determination.
Documentation.
• Appropriate and accurate diagnoses are documented by clinic staff and physician treating the patient.
• The exact anatomic locations of all wounds treated are denoted, including specific and consistent measurements.
• Clinic and physician documentation support each other.
• Physician documentation is present, supports the necessity of treatment, and is linked to the diagnosis code (Fife and Weir, 2007).
• Treatments including the dressing specifics are recorded. Many treatment modalities and dressings (e.g., dermal substitutes, negative pressure wound therapy, debridement) are reimbursed based on the size of the affected area (Sullivan, 2007).
Additional documentation needed to complete the clinic chart is listed in Table 2-3. Documentation requirements are extensive. Compliance is easier to ensure by using checklists or template electronic documentation systems, which will prompt staff to include all necessary data, rather than handwritten notes. Appendix B provides numerous examples of clinic documentation forms.
TABLE 2-3 Items in an Outpatient Clinic Chart
| Comprehensive admission assessment | Patient’s name, gender, race, ethnicity, primary language spoken, address, phone number, date of birth, height/weight, name and phone of any legally authorized representative, past and present diagnoses, wound history, reason for visit, barriers to care, allergies, current mediations, advanced directive, family history |
| Wound assessment, compliance/teaching record | Vital signs, any medicine changes, procedure or hospitalizations since last visit, reason for visit, complete wound description and photography (if applicable); compliance to treatment plan, pain, any teaching reviewed at visit and response to teaching, treatment applied prior to discharge, vascular assessment if lower extremity wounds |
| Physician progress notes | Reason for visit and relevant history, physician examination findings and prior diagnostic test results, assessment, clinical impression or diagnosis, plan of care, rationale for ordering any test, patient’s progress and response to changes in treatment plan; codes reported on billing statement should be supported in the documentation; any consult advice provided or received acknowledges as reviewed |
| Discharge orders | Any new test or medications ordered, wound treatment orders, next follow-up appointment or consult appointment, compression or offloading directions |
| Acuity | Used by hospital-based clinic if no procedure was completed to bill evaluation and management of services based on facility resources acuity score; all resources considered should be supported in the medical record (consider acuity form a permanent documentation form to prevent charges not documented; use as a documentation and scoring tool) |
| Billing form | Complete listing of any diagnoses codes or procedure codes used for billing; supporting documentation must be in the medical record |
| Consents, insurance information, HIPAA documents | Consent for treatment, consent for photography, insurance information or copy of insurance card, HIPAA notification |
Debridement.
Wound debridement is an integral part of the day-to-day care provided in wound clinics. As required by Medicare, documentation of debridement must communicate exactly what was done and why specifically: type of tissue removed, depth of removal, instrument used (type of instrument, dressing, drug), wound size, condition of wound/bleeding stopped, and how the wound was redressed after debridement (Fife, 2007). A clear picture must be presented given the Office of the Inspector General (OIG) report revealing that 64% of claims for debridement did not meet Medicare requirements (OIG, 2007). Chapter 17 provides critical information related to debridement.
Contractor or payer audits.
Occasionally the contractor or payer will request that the wound clinic or provider furnish specific documentation demonstrating compliance. Common issues reviewed by auditors include the following:
• Every service billed must be documented because the patient’s record must contain clear evidence that the service, procedure, or supply actually was performed or supplied.
• The medical necessity for choosing the procedure, service, or medical supply must be substantiated.
• Every service must be coded correctly. Diagnoses must be coded to the highest level of specificity, and procedure codes must be current.
• Documentation must clearly indicate who performed the procedure or supplied the equipment.
• Legible documentation, which may be dictated and transcribed, is required. Existing documentation may not be embellished; however, additional documentation that supports a claim may be submitted.
• Voluntary disclosure of information by the provider is encouraged. When an error is discovered, any overpayment should be returned to Medicare (Centers for Medicare & Medicaid Services, 2004).
Checklist 2-2 lists examples of typical documentation that the contractor may request from the clinic.
CHECKLIST 2-2 Typical Documentation Items Requested by Audit Contractor or Payer
✓ Office records (progress notes, current history and physical, treatment plan)
✓ Documentation of identity and professional status of clinician
✓ Laboratory and radiology reports
✓ Current list of prescribed medications
✓ Progress notes for each visit indicating patient’s response to prescribed treatment
✓ Documentation supporting time spent with patient when time-based codes are used
✓ Required referrals or prescriptions (for many nonphysician services/supplies)
Clinic composition: staffing with a multidisciplinary team
Because wound etiology often is multidimensional, the solution often requires a multidisciplinary team approach, which in turn requires coordination among many areas. Many clinics are considered multidisciplinary, referring to the variety of physician provider specialties available as well as the range of the staff assisting with patient care. Other clinics may be nurse (Certified Wound, Ostomy, Continence Nurse [CWOCN], Certified Wound Care Nurse [CWCN]) or physical therapy (physical therapist [PT], certified wound specialist [CWS]) driven and work off physician orders and/or treatment plans. The patient must obtain a referral to an outside multidisciplinary specialist from the primary care provider. Table 2-4 lists the variety of health care professionals who should be available, some on site and some with part-time schedules or as consultants, to a wound clinic. In general, the wound clinic staff and their responsibilities will primarily be dictated by the types of wound patients who attend the clinic, the patients’ wound care needs, and the regulating bodies of the various disciplines involved.
TABLE 2-4 Wound Clinic Multidisciplinary Team Members
| Position | Onsite | Available as Consultant |
|---|---|---|
| Medical director | X | |
| General surgeon | X | |
| Peripheral vascular surgeon | X | |
| Orthopedic surgeon | X | |
| Dermatologist | X | |
| Reconstructive surgeon | X | |
| Podiatry | X | |
| Infectious disease | X | |
| Geriatrician | X | |
| Occupational therapist | X | |
| Certified wound care nurse (CWCN, CWOCN, CWON) | X | |
| Registered nurse | X | |
| Physical therapist (may be certified wound specialist) | X | |
| Medical or surgical assistant | X | |
| Office staff (e.g., receptionist) | X | |
| Diabetes educator | X | |
| Dietitian | X | |
| Billing/coder | X |
< div class='tao-gold-member'>
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
