OPPS and CPT Healthcare Coding for Hospital-Based Wound Care


Let’s focus on the hospital-based outpatient wound care area and talk about the facility-based charges and coding.

You want to decide whether you want to submit the claims on a per visit rather than a monthly or series. You have heard that term. Those are series of claims. So the bill would come out with multiple dates of service and the charges for that are, are you doing a per visit or per encounter claim submission. That can be quite laborious because that then establishes an individual account number for each of those visits rather than one account number that last for the month for the multiple visits the patient would have.

And again, verifying the diagnosis and making sure it's clear to be captured on that UB claim form. So you want to obtain a couple of the UBs on some of your patients. Then take that UB, look at what code numbers are listed including what was charged and validate that back to your medical record and your charge form.

Our expert speaker mentioned in a healthcare event that you must ensure the HIM coding staff work with your CDM staff to look at the CPT codes that are generated. There are multiple departments that are charged by the clinical staff or by a clerical clinical staff in the wound care area and then there's a validation process by an HIM coder who comes down to the department each day in the afternoon and validates those services or each morning for the day before. So you might want to talk about how we can put in a good compliant process and have it validated.

Quarterly updates to your charge master are going to be important as we know rules change. And certainly under the outpatient perspective payment system, OPPS, it does change. Each quarter, there are updates and that's going to be important to look at.

And then having a process where you'll have daily charge reconciliation. You have 20 patients, 15 patients seen a day. We know they were here for XYZ. It could have been just an evaluation and recheck or were they here for an actual debridement or were they here for some other type of services just addressing change. We want to validate what was charged against what was in the medical record. We can capture certainly mischarges and make charge corrections in a more timely manner in that area.

Also, we want to update formularies and basic and advanced wound care dressings and biological equipments that can begin and supplies that can be given. And that will be important for your outpatient department as well.

Now some documentation issues that we want to address. First of all, being accurate, being consistent and timely with your documentation regarding any skin breakdown that is documented, observed regardless of the cause. So, whether it be nursing, therapist, physician or other clinical staff, these individuals need to make sure they're following that basic golden rule about documentation.

Often, we have patients seen in a wound care and they have multiple wounds, many wounds. And they all are healing at a different rate, often slow rates of healing. That needs to be clearly documented as well, but also as part of that, the changes and the improvement that they're making. This is going to be important for not only quality of care but also from a utilization perspective as CMS rules, the Medicare and Medicaid Services looks at patients’ billing patterns to see that they're coming from months and months and months for the same services over and over. If they request your record, you want to be able to show that there is changes being made. There are improvements being made in the patient’s condition.

Making sure that you have visit criteria established. Yes, evaluation and management visits can be charged by the facility and should be charged on occasion by the facility. They're also charged by the physician prophy side, but we’re focusing on the facility or the clinic type outpatient environment. That’s another term we hear. Sometimes we hear - for wound care, they’ll call it a wound care clinic but it's hospital-based or they’ll call it a wound care unit but it's hospital-based.

Making sure that the clinicians have all the information they need is very important. And they shouldn’t leave out information from that assessment process. Their documentation of what they observed and what they saw and what they interpreted is very, very important as part of the assessment.

Typically, we see may be a documentation template sheet or form that’s called the wound care assessment. And in there, there is lots of areas where you can develop. There’ll be a section of the form that talks about the size that has the length, the width and the depth and measurements that can be documented.

There’ll be an area to talk about the color or the odor of the wound, if the wound has any drainage or not and where that drainage is, improvements, very important and any changes in the wound even if the changes are on the negative side -- it's getting worse or looks to be infected and improvements -- it's healing well and we’re seeing more granulation, and of their observations and using good terminology to identify that the assessment was complete and thorough.

Some other specifics in the wound care area that you can document certainly in your ongoing treatment notes and progress notes but certainly as your initial assessment is the onset on this wound, the duration of the wound and we mentioned size, any edema that’s present in the wound, the periwound area, inspecting around that tissue, surrounding tissues, any undermining that’s present - - or any tunneling that’s also present. These are key terminologies and sections that you can put on your wound care form.

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