Medicare Billing Protocol and Workflow

Last updated on 3/4/25 | First published on 6/9/18 | Literature review current through Jun. 2025 [cite]

Authors: Tiffany Hamm BSN, RN, CWS, ACHRN, UHMSADS, Jeff Mize RRT, CHT, UHMSADS, Topic editors: Elaine Horibe Song MD, PhD, MBA, Amy Smith JD, RN, PHN, more...

INTRODUCTION

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.

WORKFLOW

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.

Algorithm 1. Medicare Billing Workflow (click on this link to for an interactive PDF)

PROTOCOL

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

Process: Patient scheduling

Important tasks	When	Key points (how to execute task)	Reason (why execute this task?)
Collect initial patient information (via phone)	Pre-encounter	Create new patient profile on EMR Complete consultation intake. See form "Consultation Intake Questionnaire "	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)	Pre-encounter	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	When	Key points (How to execute task?)	Reason (Why execute task?)
Verify insurance benefits/ coverage	Pre-encounter	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	Pre-encounter	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 tasks

When

Key Points (How to execute task?)

Reason (Why execute task?)

Assign codes, ensure documentation supports codes

Encounter

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 CPT codes (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

When

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	When	Key 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 tasks	When	Key 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	Verify if CPT codes and number of units of G0277 are correct Check if diagnosis meets medical necessity. See HBO Requirements Request Checklists in topic "HBO Treatment Indication with Protocol" Verify ICD-10. If needed, refer to the HBO ICD-10 crosswalk for single/dual diagnosis codes Check if authorization is in place. See form "HBO Pre-Determination/ Prior Authorization"	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.

REFERENCES

Topic 953 Version 1.0

7/3/2025 3:09:18 AM

Medicare Billing Protocol and Workflow

Medicare Billing Protocol and Workflow

INTRODUCTION

WORKFLOW

PROTOCOL

Process: Patient scheduling

Process: patient registration

Process: Provision of Care

Process: Charge Reconciliation and Bill/claim Creation

Process: Bill Revision, Edits and Submission

Process: Claim Payment Approval or Denial (Adjudication)

REFERENCES

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