Are you missing revenue cycle opportunities at point of care?

Published on January 15, 2014

A Wound Care Road Map

The typical U.S. hospital can easily put 7-10% of its revenue at risk due to denied claims that could successfully be corrected and resubmitted.1 MGMA estimates that 30 percent of medical claims are rejected.2 These are both big headlines, with denials being the major highlight.

Inaccuracies, unavailable data, duplicated tests, and other weaknesses in your current healthcare system are resulting in millions of dollars in financial losses for physicians and hospitals. USA Today reports that clinicians wasted an average of 46 minutes a day waiting for patient information, of which that time takes away from productive work with patients and their care. The patient access area without correct documentation has compounded among all patients and this delay translates into roughly $900,000 a year per hospital or more than $5.1 billion a year across the U.S. Healthcare system.

You can change this at the point of care within your work flow.  When utilizing information from technology to drive more accurate documentation, you can drive down the cost of delayed or denied medical claims.

Inefficiencies in diagnosing, treating and documenting cases at the point of care; in addition to lack of accessible patient information and documentation have been eroding profit at your hospital, primarily because of payer denials.  According to the U.S. government accountability office the aggregate application denial rate across the U.S. was 19%.

Increase revenue while decreasing denials.

With wound care alone, the average increased reimbursement is a range of $4500-$9500 for debridement vs. excisional debridement.  For the average 300 bed hospital, this can theoretically be more than a $1.2M opportunity per site.

meetingMedicare review of surgical debridement services showed that 29% has insufficient or no documentation and 39% were billed in a manner that did not accurately reflect the services provided. We have found this can be costing organizations millions of dollars in potential reimbursement monies. 3

Currently CDI specialists spend much of their time searching for incomplete documentation- but it can be very time consuming and inefficient process, since there are few indicators of which documentation is incomplete.  This is where M*Modal’s Natural Language Understanding can help. With specific rules and logic specifically tuned for debridement we can identify potential deficient documents and create a centralized list of documents that the Clinical Documentation Specialist can now review and take action to correct, so that the claim can be submitted correctly.

How does this work?

M*Modal’s clinical documentation solutions allow a hospitals to manage the identification and resolution of document deficiencies related to excisional debridement as well as a multitude of others.

Documentation Made Simple

M*Modal does the hard work of finding and tagging potential risks, allowing your specialists to focus on what they do best: fixing the potential deficiencies first then submitting the claim.

The 5 elements excisional debridement documentation requires to be complete are:

  • Description of Instrument (i.e. blade)
  • States “Excisional”
  • Depth of incision
  • Appearance and size of the wound
  • Type of Tissue (i.e. subcutaneous tissue)

What does this mean for CDI and Claims departments?

Less searching , More fixing

Today, it is very difficult to find all of the documents and correct in advance of the discharge of the patient or dropping off the bill. This application now makes correcting deficiencies dramatically simple. Your CDI specialists no longer have to spend countless time hunting for these issues- instead they can spend time correcting.

The opportunity for you

You can now flip the 80/20 rule for CDI Analysts and Claims Specialists.  A HIM Director indicated that 80% of the time of an analyst was spent on reviewing charts.  20% of the time was spent on follow-up with physicians on documentation deficiencies.   After seeing the new workflow, she remarked that the ratio would shift to the 20/80 rule.  20% spent on Discovery and 80% on follow-up and resolution of chart deficiencies. Her goal was not to eliminate CDI Analysts, but rather dramatically increasing their leverage toward increased revenue and reduced risk for healthcare organizations.

Financial upsides

Just think how much more productive they can be, and the potential financial benefits gained by having the deficiencies found and addressed more quickly. With this workflow you can examine the patient’s data that has been collected apply the right rules and make it available to the right person or department.

The benefits of Addressing Optimization at Point of Care

  • Accelerated revenue Cycle
  • Reduced DNFB
  • Lower administrative costs
  • Appropriate reimbursement
  • Improved efficiencies with billing and coding
  • Decreased claims rejection rates

M*Modal expands the likelihood that the information will be captured accurately and therefore will be more readily and appropriately reimbursed. Expressed in other terms, the technology helps ensure that the physician says the right thing at the right time to gain approval from coders. By identifying and addressing documentation deficiencies at the time of report creation, M*Modal technologies help physicians create more complete and higher quality documentation, thereby minimizing denails and increased reimbursement the first time.

For information on how we can help you increase your wound care reimbursements please contact us at

  1. HFMA Payment & Reimbursement Forum, Best Practices for a Denials Prevention Program, June 2008
  2. MGMA The Physician Billing Process – 12 Potholes to Avoid in the Road to Getting Paid, 2nd Edition
  3. Department of Health and Human Services, Office of Inspector General. “Medicare Payments for Surgical Debridement Services in 2004.” May 2007. Available online at