Transcript

Nikki Johnston:

My name is Nikki Johnston, and I am the founder of Kindling Consulting.

So, the most common wound care mistake that we see a lot of new clinicians make is associating that good clinical care automatically will equal good billable care. So, what that basically means is that a lot of clinicians struggle tying what they're doing clinically into their documentation and explaining why they chose the procedures and the treatments that they chose during that time.

One of the most common incorrect code pairings is having a debridement at the exact same time that you do an E&M. In order to utilize that, you would have to have a completely distinctly separate incident in order to document that properly. But a lot of clinicians pair the 2 together and assume that they're going to get reimbursed for both procedures. And when you are in the moment of taking on that patient and seeing that patient you don't always understand what you can and can't build together, and that is one of the most common errors that we see is having a debridement as well as an E&M.

There are 2 really commonly misused or misunderstood modifiers in wound care. The first one is modifier 25. The second one is modifier 59. So, modifier 25 is frequently misunderstood, because it is only used when there is a significantly separate procedure that you are doing at the same time as an E&M. A lot of clinicians go into the scenario assuming that they can bill both their procedure and the E&M at the exact same time. And the truth is, is that those need to be separate incidences. So for example, you would need to be evaluating a brand new wound and developing a separate care plan for that wound. That would qualify using a modifier 25. The modifier 59 is sometimes overused. So the modifier 59 is used when you do 2 separate procedures on the same day. Those procedures need to be completely distinct, completely separated from each other in order to be able to utilize that modifier 59, and we see a lot of clinicians kind of just throw it in hoping that they're going to get reimbursed for both procedures, but the documentation doesn't support it.

So, most denials often happen because there's a mismatch between the assessment and the procedure performed or the plan of care that's in place. So, missing wound measurements, inconsistent staging, failing to document your response prior to the treatment. Those are all big red flags for CMS to deny your actual submission. So, really understanding how to match what you're doing to the actual documentation itself is going to be crucial to getting that pushed through. A strong medical necessity statement is going to explain why that service was needed on that specific day, not just for wound care in general, so it really ties the patient's current condition, any prior responses, and that clinical risk all together and bundles it in a way that is easy for CMS to understand why you chose the treatment plan you chose. One big question that we always have our clinicians ask themselves is, if another clinician were to go and review this, would they understand why that intervention that you just completed couldn't wait? So, really making sure that you're seeing it from the perspective of have I told the full story of what I'm doing on this particular day for this particular patient?

The biggest misunderstanding is assuming that the same services are billed the same way regardless of the location. So, site of service is crucial to being able to get your reimbursement. You have to understand the coverage requirements, the rules and regulations that are within each site that you're at so that you can understand how to build your documentation to support the efforts that you're doing for each service that you're providing. One thing we see very often is that patients are transitioning in and out of different locations. So, maybe they were in the hospital originally, and now they've transitioned into skilled nursing, you're seeing them in a nursing facility, which is going to be billed and documented completely differently, but that patient is now following you to their home. You need to make sure that you are intentionally changing that site of service to support the actual location that you're doing treatment in.

The best way to stay compliant is to standardize. I am a huge fan of standardization, making sure that you have templates built in, that you can fill in the current data automatically into, having checklists, make sure that you don't have any gaps in care or gaps in your documentation process in general. And then really utilizing any previous denials as a learning tool. Review those, look at those, understand where the error came in and how you can restructure and change some of your documentation requirements going forward so that you don't end up back into another denial episode.

Right now is such a key time to make sure that our documentation is completely buttoned up. CMS has really narrowed the scope of what we can and can't do. And those reimbursements are crucial to keeping our doors open. We don't have the luxury anymore of being reimbursed large amounts for skin substitutes. Now, we really do have to understand all the different nuances, how our codes talk to each other, how our documentation is being portrayed, because we need those reimbursements ASAP. We don't have the luxury to wait for a denial to get resubmitted and potentially approved after the fact. So, really, all of this conversation for me, personally, it just hits home that we need to make sure our documentation is buttoned up, and clinicians need to really understand what they're putting in that documentation.