Medical Billing Strategies to Prevent Denials in Wound Care Claims

The challenges with billing chronic wound care therapies, as well as the complexities related to wound care therapies, insurance and reimbursement vary by provider. While claim denial has revenue cycle management implications, the delayed denial of the claim and denial of the claim from an administrative and operational perspective adds to the administrative burden. There are systematic ways to ensure the denial of the claim does not occur, and prompt, effective management of the revenue cycle can occur. 

1. No Documentation, No Claim. 

As with all wound care, absence of claim documentation is the primary reason for denial of claims. There needs to be documentation of the above, by date, for all aspects of the care, and with the specifics of the wound for each treatment as well as debridement, dressing changes and negative pressure therapies. Clinical notes outline the medical necessity and document the rationale for appropriate cost containment whereas administrative notes are limited to form approvals.

2. No Claims or No Updates to ICD-10 and CPT Codes. 

In wound care, billing is predicated upon accurate ICD-10 and CPT coding, and the failure to do so with appropriate coding is a primary reason for denial of a claim. Knowledge of coding thresholds for the chronic care of wounds is equally significant as is the ability to correlate the problem to the procedures for the accurate diagnosis.

3. Insurance Coverage and Pre-Authorizations

Most advanced wound care treatment modalities require insurance prior authorizations. A verification of patient benefits prior to treatment and securing necessary authorizations protects against treatment denials and coverage-related issues. Such proactive measures eliminate frustration and shields the practice from loss of revenue capture.  

4. Claim Submission in a Timely Manner  

Claims that have been submitted late will result in automatic denials of coverage. Establishing a consistent practice for timely submission of claims and implementing routine use of automated billing software will result in timely submission of claims. Efficient follow-up of submitted claims will aid in reducing delays and will improve chances of claims approval.  

5. Denial Watch and Pattern Recognition  

Tracking and reviewing denied claims will aid in finding a documentation improvement opportunity to eliminate patterns. Common patterns include coding deficiencies, documentation omissions, and specific requirements by the insurer. Proactively correcting these issues will streamline denials in the future.  

6. Staff Training, Invest in Billing Outsourcing  

Insufficient training in wound care coding and payer rules is a common cause for billing errors. Regular staff training coupled with outsourcing to specialized medical billing services will improve defensible denial rates by improving the quality of claims submission.

Conclusion

To prevent denials in billing for wound care, it is necessary to maintain accurate records, code diagnoses appropriately, verify insurance prior to billing, and regularly review and update business operating practices. Using these methods will allow wound care practitioners to improve cash collections, decrease time spent on administrative work, and concentrate on providing excellent patient care.