Wound Care

Introduction

This case study showcases how a dedicated wound care clinic significantly improved its financial performance and operational efficiency by partnering with a medical billing company. The collaboration addressed long-standing billing inefficiencies, resulting in faster payments, fewer denials, and increased revenue.

Background

The wound care clinic specializes in advanced treatment of chronic wounds, including diabetic ulcers, pressure sores, venous ulcers, and post-surgical wounds. Despite a growing patient base and excellent clinical outcomes, the clinic experienced major setbacks in its revenue cycle due to the complexity of wound care billing and documentation requirements.

Revenue Cycle Challenges

• Incomplete Documentation: Missing wound measurements, photo documentation, and lack of medical necessity justification led to frequent claim denials.
• Incorrect Coding for Procedures: Errors in coding debridement, skin grafts, and hyperbaric oxygen therapy (HBOT) caused payment delays and underpayments.
• Delayed Charge Entry: Billing lag due to delayed provider documentation and manual processes slowed down reimbursement.
• High Denial Rates: Payers frequently denied claims for not meeting LCD/NCD guidelines or lacking prior authorization.

Objectives

• Improve Documentation Compliance: Align clinical documentation with payer requirements to avoid denials.
• Optimize Coding Accuracy: Ensure correct use of CPT/HCPCS and ICD-10 codes for wound care services.
• Accelerate Charge Entry: Reduce the time between service delivery and claim submission.
• Reduce Denial and Rework Rates: Proactively address errors to minimize back-end corrections.

Intervention

The medical billing company implemented the following targeted solutions:

• Wound Care Documentation Templates: Introduced structured templates in eClinicalWorks for proper wound assessment, staging, and photographic evidence.
• Certified Coding Team: Assigned coders with expertise in wound care-specific CPT codes (e.g., 11042-11047, G0456, C5271-C5278) and LCD interpretation.
• Charge Capture Automation: Enabled real-time charge capture integrated with provider documentation to speed up the billing cycle.
• Denial Pattern Analysis & Appeals: Set up a system to track and appeal payer-specific denial patterns, focusing on education and prevention.

Results

Conclusion

By outsourcing billing operations to a specialized medical billing partner, the wound care clinic dramatically improved its revenue cycle performance. The clinic not only enhanced financial stability but also freed up clinical resources to focus on delivering high-quality wound care.