Today's Wound Clinic - Spring 2008 - (Page 14)

inwhole that pathology (ie, the services provided). Payment is associated with different degrees of complexity of care based on key components. Each key component has four levels of difficulty. So, a physician using the 1997 Medicare Documentation Guidelines has 42 choices to consider, ultimately representing 6,144 possible combinations in order to select the correct E/M code (May 25, 2000 “Statement to the Health Task Force Committee on the Budget, United States House of Representatives, Medicare Regulatory Burden Imposed on Physicians,” www.acponline.org/hpp/hbstmt.htm). Electronic medical records systems, which automate this process, are becoming increasingly popular. bursement model used for suturing acute wounds in emergency departments. An analysis of over 5,000 outpatient wound center visits, published in Ostomy Wound Management, proved this to be an unworkable method of achieving a reasonable distribution of charges due to the relatively small size of most chronic wounds. A method of measuring staff work was much more likely to yield a fair distribution of charges. CMS has yet to make a final decision on this matter but in the interval, most facilities have adopted various acuity scoring systems. These methods utilize a scoring sheet in which the point score tallied from various work elements tracks to a particular APC rate. CMS has emphasized that the ideal billing system would result in a normal distribution (ie, a bell curve) of clinic charges over a large dataset. Clinics must be wary of scoring systems which might skew charges to the right (towards higher levels of service). Furthermore, while the clinic charges might be calculated using a scoring tool, the tool itself is not sufficient documentation of the services provided. The medical chart must still contain all the elements upon which the score is based. This can create a compliance challenge for the facility, even if the scoring method is a sound one. Debridement documentation requirements may include a description of the wound before and after the procedure, as well as the type of tissue removed (see the Fall 2007 issue of TWC). While this descriptive process sounds straightforward, it is not. Studies show tremendous variability among caregivers with regard to these documentation practices. These issues are not simple. Some documentation tools have been validated (eg, the BWAT and the PUSH tool). IT’S 10 AM; DO YOU KNOW WHERE YOU MEDICAL RECORDS ARE? As the way in which we incorporate modern technology into medical practice evolves, our understanding of the medical record must evolve. Historically, the definition of the legal health record was fairly straightforward—it was the contents of the paper chart. With the advent of various electronic media, the definition of the legal health record has become more complex. It consists of the data, stored on any medium, collected and directly used in documenting services to an individual during any aspect of healthcare delivery. Some types of documentation may physically exist in separate and multiple paper-based or electronic or computer-based databases. The HIPAA privacy rule requires that organizations identify their designated record set. As strange as it may seem, each facility must determine the specifics of the patient’s medical record. If one received a subpoena for a patient’s records, where would they go to get them? For example, in this issue photographs are discussed. How are photographs incorporated into the medical record? Does the custodian of medical records know where those photographs are kept if they had to be produced? Another example has to do with electronic databases. Unless the electronic database has been identified as the legal chart, the paper chart remains the legal chart.That means one still needs to print out copies of whatever is put into the electronic database so that the paper chart remains complete. It is best to define the legal chart HOSPITAL BASED OUTPATIENT WOUND CENTER DOCUMENTATION Outpatient wound center facility reimbursement for Medicare beneficiaries is defined by the CMS in the Hospital Outpatient Prospective Payment System (HOPPS). The HOPPS, published on April 7, 2000 in the Federal Register, was intended to revise the outpatient payment system for wound centers which were instructed to use three sets of five E/M codes: new patients—9920199205; consults—99241-99245; and established/follow-up—99211-99215. Although CMS directed facilities to bill using all of these classes of codes, there were, in fact, only three payment groups. These are also known as Ambulatory Patient Classification (APC) Codes— 610, 611, and 612. The Federal Register specified that each facility be expected to, develop a system for mapping the provided services furnished to the different levels of effort represented by the codes. Time, was readily adopted as a means of assessing the billed level of service.While easy to develop, a system based on a subjective assessment of time spent could result in healthcare workers justifying an inappropriately high-billed level of service compared to the actual work provided. In 2004, the American Hospital Association and AHIMA suggested to CMS that facility level of service be based on wound size, similar to the reim14 Spring 2008 Today’s Wound Clinic DOCUMENTATION UNIQUE TO WOUND CARE Author Note: The InStruction article describes in detail the type of documentation unique to wound care. As physical defects,wounds have length, width, and depth. Undermining and tracts can be measured. The standard unit for measurement is in centimeters. The wound bed and the periwound skin can be described. Granulation, slough, eschar, and epithelization can be described and/or assessed in percent of wound surface area. Drainage can be classified by amount and character. Pain should be assessed. Dressing products must be documented. Documentation includes, the plans for the frequency of their change and the duration of these orders. Third party payers often have specific documentation requirements for the provision of medical equipment or dressing products. http://www.acponline.org/hpp/hbstmt.htm

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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