Wound Care billing and accounts receivable

Wound care runs on debridement, skin substitute application, compression for venous ulcers and hyperbaric therapy, and the claim is built out of what the note records: the tissue removed, the measurements taken, the product used. The same wound is billed visit after visit for months, so each claim has to show what changed since the last one.

Where the money leaks in wound care

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Debridement billed at a depth the note does not support, because the description names slough and fibrin rather than the deepest tissue actually removed
• No wound measurements taken before and after the debridement, so the surface area of tissue removed, which the units were billed from, cannot be traced
• Skin substitute applied without the chart showing which conservative treatments were tried and over what period they failed to close the wound
• Discarded product not documented against the package opened, so the units billed cannot be reconciled with the wound area treated and the size supplied
• Hyperbaric sessions billed from a note that calls the wound non-healing but does not grade the diabetic foot ulcer, list the standard care that failed first, or record chamber time
• Serial debridements denied as repetitive when consecutive notes carry identical measurements and the same tissue description copied forward

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working wound care, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Debridement billed at a depth the note does not support, because the description names slough and fibrin rather than the deepest tissue actually removed”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “No wound measurements taken before and after the debridement, so the surface area of tissue removed, which the units were billed from, cannot be traced”
• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Skin substitute applied without the chart showing which conservative treatments were tried and over what period they failed to close the wound”
• CO-4 — Modifier and code disagree
  The code and the modifier disagree, or a modifier the payer required was not there.
  Recovered by being corrected and resubmitted. Matched from: “Discarded product not documented against the package opened, so the units billed cannot be reconciled with the wound area treated and the size supplied”
• CO-198 — Authorization limit exceeded
  An authorization exists. The problem is that you went past what it allowed — more units, more visits, or a longer date range than was approved.
  Recovered by being answered with the document the payer names. Matched from: “Hyperbaric sessions billed from a note that calls the wound non-healing but does not grade the diabetic foot ulcer, list the standard care that failed first, or record chamber time”
• CO-226 — Requested information not supplied
  The payer asked you for something, and either nothing arrived or what arrived did not answer the question.
  Recovered by being answered with the document the payer names. Matched from: “Serial debridements denied as repetitive when consecutive notes carry identical measurements and the same tissue description copied forward”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a wound care AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

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