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Medicare Billing Protocol and Workflow

Medicare Billing Protocol and Workflow

Medicare Billing Protocol and Workflow


Billing workflow is defined as a sequence of actions performed on a claim until it is paid. Wound Care clinics continue to operate under multidisciplinary models. Implementing effective workflows is essential to producing optimal outcomes.  Determining the proper clinical and operational skill sets among staff members are necessary to manage the chronic wound care patient and is a key component to maintaining smart workflows.[1]

Revenue cycle processes that include patient registration, compliant billing, and denial management compliment the documentation process for a fiscally successful department. These processes are governed by policy and Medicare is required by the Social Security Act to ensure payment is made only for those medical services that are reasonable and necessary.[1] Improving the flow of work and eliminating waste ensures that the wound department runs as efficiently and effectively as possible.

This topic offers a sample workflow and protocol that can be easily adapted and implemented in wound and hyperbaric therapy clinics. For a protocol on Medicare Part A & B Claim Appeals in case of payment denial, see topic "Medicare Billing Protocol - Appeal of Claim". Additional, customized insights can be obtained from our advisory panel through WoundReference Curbside Consults


The interactive workflow below provides a "lean" overview of the entire Medicare Billing Protocol (Algorithm 1). Each process on the workflow is hyperlinked to the description of the process in the protocol below. 


A protocol for Medicare Billing in wound care and hyperbaric clinics is provided below. 

Process: Patient scheduling

Important tasksWhenKey points (how to execute task)Reason (why execute this task?)

Collect initial patient information (via phone)

  • Prepare for any special needs patient might have
  • Document on EMR so that staff is aware
  • Verify insurance benefits/ coverage

Schedule appointment (via phone, online)

  • Schedule patient according to patient preference (vs. provider preference/availability) (link to scheduling workflow once we have it)
  • Ask if patient wants appointment reminder (phone/ text/ email)
  • Enhance personalized care 
  • Reduce patient no- shows 

Process: patient registration

Important tasks
Key points (How to execute task?)
Reason (Why execute task?)
Verify insurance benefits/ coverage
  • Run through hospital Insurance verification system or call insurance automated voice response
  • If referral needed, contact patient via phone or email so that patient can contact referring PCP and request referral. If referral not needed, no need to call patient
  • To ensure correct claims processing
  • To prevent inconvenience and improve patient experience 
If clinic is paper-based, produce chargemaster for provider and facility
  • Label the chargemaster forms with patient information
  • Attach them to chart for nurse (facility chargemaster) and to provider (professional chargemaster)
  • To capture appropriate CPT? codes for the encounter
Collect outstanding patient information and obtain signed consents and forms (via the patient portal or upon patient check-in)
Pre-encounter and/or at Encounter (Day 0)
  • Collect patient signature for compliance documents (HIPAA), financial responsibility form, authorization for treatment  
  • Have patient fill out past medical history form and medication list
  • To ensure regulatory and institutional compliance
  • To expedite care
Check patient in
Encounter (Day 0)
  • Have patient sign-in (paper or electronic)
  • Name-banding 
  • Payer requirements Name banding for patient safety and decrease rate of incorrect procedures
Collect co-payment 
Encounter (Day 0)
  • Check co-payment amount: refer to the patient insurance card
  • Enter amount into the EMR registration screen 
  • Collect via credit card or cash 
  • Patient, provider and facility are contractually obligated to pay/collect co-payment at the  encounter

Process: Provision of Care

Important tasksWhenKey Points (How to execute task?)Reason (Why execute task?)
Assign codes, ensure documentation supports codesEncounter 
  • Provider performs Consultation or Subsequent Follow-up
  • Documents Care to ensure Medical necessity requirements are met
  • Provider marks professional chargemaster with the correct ICD-10 Codes on paper or EMR
  • Provider marks the chargemaster with the correct CPTcodes (E/M Procedures) for Part B Medicare is applicable
  • Nursing Staff marks the facility chargemaster with the correct ICD-10 diagnosis as chosen by the provider and applicable CPT codes (E/M Procedures) Facility and provider CPTs do not always match  = For Part A Medicare if applicable [2]
  • Refer to the HBO/Wound clinic chargemaster for CPT codes. Individual clinic chargemaster
  • Consultation is the "central act of Medicine"
  • A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years. 
  • Evaluation and Management charges are accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care.
  • A correct or incorrect diagnosis will follow the patient throughout the encounter. Incorrect diagnoses may lead to higher health care risk thru unnecessary testing, increased insurance rates etc. Correct Diagnosing leads to timely treatment, focused care and efficient processing of healthcare claims
  • Legally required to bill correctly
  • Reduces re-work
  • Correct billing leads to efficient revenue cycle

Process: Charge Reconciliation and Bill/claim Creation

Important tasks
Key Points (How to execute task?)
Reason (Why execute task?)
Charge reconciliation  

Day 0 on

After encounter, at the wound and HBO clinic

  • The patient sign-in sheet or scheduling template will be used to ensure that a professional and facility chargemaster is present for each patient seen in the wound/ HBO department for that date
  • Reconciliation of chargemasters ensures all services are accounted for. This will allow for timely entry of charges by the RN, RN Mgr and efficient and timely reimbursement of claims
Bill/claim creation

Day 0 on

After encounter, at the wound and HBO clinic

  • Facility Charges: enter CPT charges after they have been reconciled into the hospital billing system ensuring that each patient encounter identification number for that visit is correct.
  • Professional Charges: designated clinic staff to forward all provider chargemasters to the appropriate hospital department for charge data entry on the day of service 
Timely charge entry is crucial for a healthy revenue cycle and should be completed daily for each encounter.  If charges are not entered correctly, the result is often denied or delayed claims and potential risk for future audits. 

Process: Bill Revision, Edits and Submission

Important tasks
WhenKey Points (How to execute task?)
Reason (Why execute task?)
Bill Revision and Edits
1-3 Days after encounter, by billing/coding 
  • Designated Staff to check claim on EHR and verify Cost center code and Revenue code attached to claim
  • Claim may be reviewed by coding and billing to ensure correct ICD-10, CPT, HCPC
  • Claim may be run thru the hospital billing "scrubber module"  to ensure the correct use of modifier(s), (national correct coding initiative) NCCI Edits or Hospital payer-specific edits
  • To ensure timely claim submission
Bill Submission
1-3 Days after encounter, by billing/coding
  • Claim is submitted to carrier electronically
  • To ensure timely claim submission
  • The claim is electronically transmitted from the provider or facility's computer to the Medicare Administrative Contractor (MAC). The MACs initial edits are to determine if the claims meet the basic requirements of the HIPAA standard.[3]

Process: Claim Payment Approval or Denial (Adjudication)

Important tasksWhenKey Points (How to execute task?)Reason (Why execute task?)
Identify type of claim response
Upon receipt of notification (14-30 days after claim submission)
  • Identify if payment is approved or denied
  • Identify Medicare Remittance Advice (RA) remark codes [4]
  • If denied, identify if "Errors and Omissions" are Minor or Major Denial
Prompt attention to claims payment or denial leads to improved revenue cycle
If payment approved, process Payment
Upon receipt of notification (14-30 days after claim submission)
  • Apply payment to the line item,
  • Apply adjustments
  • Forward coinsurance to the secondary payer or apply to patient balance if no secondary insurance
Prompt attention to claims payment or denial leads to improved revenue cycle
If "Minor" Denial, correct immediately and resubmit the claim [5] 
Correct within 1-3 days after notification is received
  • Investigate reason for denial based on denial codes adjust claim as appropriate (e.g., not a covered service)
  • Refer to medical chart documentation as needed
  • Edit claim and make addendum as needed
  • Resubmit claim and addendum

If "Major" Denials, investigate, forward denial to stakeholders
Correct within 2-3 weeks after notification is received
  • For cellular based tissue products (CTP) or hyperbaric oxygen therapy (HBO) denials forward to nurse manager of HBO/wound clinic. For all other denials forward to the appropriate stakeholder
    • Refer to medical chart documentation 
  • Check trends for denied charges (are you consistently getting denials for CTP? If so, investigate)
Major denials often represent a significant loss of revenue. Correction and resubmission can result in significantly improved revenue
If "Major" Denial is related to HBO, conduct chart and claim audit
Correct within 2-3 weeks after notification is received
Major denials often represent a significant loss of revenue. Correction and resubmission can result in significantly improved revenue
If "Major" Denial is related to CTP, conduct chart and claim audit
Correct within 2-3 weeks after notification is received
  • Verify CPT? code is correct and supports the services performed
  • Verify date, time and location of the ulcer treated with CTP
  • Verify the name of the CTP and how it was supplied
  • Verify the amount of product units used
  • Verify the amount of product units discarded
  • State the reason and amount of wastage in units (This must be documented in the provider's note)
  • Determine if your local MAC requires reporting of CTP wastage using the JW Modifer on the billing claim. The JW modifier is required  in physician offices
  • Ensure manufacturer's serial/lot/batch or other unit identification number of graft material is documented in the chart. [6]
  • Make amendments as needed 
  • See topic "Cellular and/or Tissue Products"
Cellular-based tissue products are high-cost items for wound clinics. Accurate complete record documentation and billing by the physician or other qualified health professional is the best way to ensure appropriate payment and to reduce the risk of any repayment following an audit. [6]
Resubmit the claim
Within 2-3 weeks after notification is received
  • Electronic submission with associated attachments as needed
  • Prompt attention to claims payment or denial leads to an improved revenue cycle

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.


  1. Cathy Thomas Hess, BSN, RN, CWOCN et al. Today's Wound Clinic, Achieving Collaborative Clinical & Operational Workflows in the Outpatient Wound Clinic . 2015;volume 9(7):.
  2. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services . Evaluation and Management Services . 2017;.
  3. CMS. CMS.GOV Centers for Medicare and Medicaid Services Electronic Health Care Claims . 2017;.
  4. Medicare Learning Network. CMS MLN Remittance Advice (RA) Information- An Overview . 2017;volume ICN 908325():1-12.
  5. Medicare Learning Network. MMA- Section 937 - Correction of Minor Errors and Omissions Without Appeals . 2013;.
  6. Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA et al. Today's Wound Clinic: Documentation Elements & Audit Resource Guide for CTPs . 2018;volume 12(10):24-27.
Topic 953 Version 1.0