The Use of Clinical + Operational + Regulatory + Economic/Financial Processes to Support the CMS Guideline Mapping in Wound Care

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In 2022, the Centers for Medicare and Medicaid Services (CMS) noted a $4.4 billion overpayment in hospital-owned outpatient provider-based departments due to improper documentation.¹ A poster to be presented to the Symposium on Advanced Wound Care (SAWC) Fall details the mapping of the guidelines and policies of wound care, linking the Clinical+Operational+Regulatory+Economic/Financial (CORE) processes, which can reduce the risk of overpayments.²

As poster authors Cathy Thomas Hess, BSN, RN, CWCN, and Julie Rhodovi, MBA, CWCA, LBBH, note, the proprietary process of her trademarked CORE process considers all aspects that are necessary when determining the steps in care planning, treatment, and goals of the wound care business. The poster advises that each of the four distinct parts needs to be equally assessed to best serve the patient and business.
 
The poster says following the process of CORE, while utilizing CMS policies and guidelines for wound care, will create the opportunity for proper documentation and regulatory compliance. This will lead providers to more success with payment processes, audits, and appeals. Hess and Rhodovi add that when detailing the clinical needs of a patient, building in the CORE guidelines mapping process will support the clinical treatment choice, while supporting the operations, regulations and economics, which will lessen the risk of overpayments.

References
1. 2022 Medicare Fee-for Service Supplemental Improper Payment Data, US Dept of Health and Human Services, accessed February 2023
2. Hess C, Rhodovi J. The use of Clinical + Operational + Regulatory + Economic/Financial processes to support the CMS guideline mapping in wound care. Poster presented at the Symposium on Advanced Wound Care (SAWC) Fall, Nov. 2–5, 2023.