Capturing the Essence of the Wound Evaluation
May 12, 2008 | Leave a Comment
Pam Unger PT, CWS; Caroline Fife, MD, FAAFP, CWS; and Dot Weir, RN, CWON, CWS
ocumentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention.
Wound care is usually best performed by a team of experts. Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice.
The examination phase of a wound consultation is assumed to be the most important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors.
Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors. In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation.
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InStruction Article
Utilizing Data for Effective Marketing
May 12, 2008 | Leave a Comment
Heidi Mueller, sales and marketing consultant for wound care companies
While repetition and communication may be the cornerstones of effective marketing; it is the use of relevant, focused data that relates to specific target markets that provides results. There are literally thousands of giveaways that will help referring practitioners with name recognition and contact information. Answer these questions: What do referring physicians remember about a clinic or its services? Do they remember the case study information and clinic services?
For most wound clinics and wound specialists, marketing budgets tend to be relatively small. Billboards, radio spots, newspaper ads, and television spots do not typically fall within the allotted dollar amounts for the budget. To focus a large portion of the budget on giveaways is not practical. While some are necessary, it is impossible for clinics to compete with the amount of swag distributed by medical companies. More importantly, the author has found that direct-to-physician marketing provides the largest number of patient referrals for the wound care specialty. The greatest challenge is the retention of referring physicians. This becomes crucial as the specialty of wound care takes a larger presence in most communities. Competition for patients and physicians is more difficult with the number of facilities and physicians increasing. Focusing resources in this area will allow your marketing dollars to stretch further.
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InFluence Article
Documentation:The 30,000-Foot View
May 12, 2008 | Leave a Comment
Caroline Fife, MD, FAAFP, CWS
Documentation is an intrinsic component of every patient encounter. The financial success of a facility depends upon the completeness of the process. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation. If you are not already convinced of the importance of accuracy in documentation, a study by the Centers for Medicare & Medicaid Services (CMS) found that of all of the improper Medicare benefit payments made during 2001, 43% were due to documentation errors. It is well known that patient quality of care is also related to quality of documentation. Furthermore, documentation is essential to meet the changing demands of regulatory bodies such as the The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Office of the Inspector General (OIG), and CMS.
The What and Why of the Medical Record
In the 19th century, the medical record was a sort of personalized lab notebook in which clinicians recorded their observations. In the 21st century, the medical record has many functions, including, serving as a basis for planning and documenting patient care, communicating among numerous health professionals, and protecting the legal interests of the patient and healthcare providers. The medical record may supply information for internal hospital auditing and quality assurance, documenting compliance with governmental regulations, and provide data for medical research. It is also a means of determining the billed revenue for physicians and hospitals. Thus, documentation must validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. What is more interesting about today’s medical records is that they serve as a way of tracking the process of care not just for an individual patient, but for groups of patients in the form of benchmarking and clinical research.
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InWhole
Lack of Documentation May Cause Loss of Dollars
May 12, 2008 | Leave a Comment
Kathleen D. Schaum, MS
E arly in their medical/clinical training, wound care physicians and clinicians learn the caution, if it’s not documented, it’s not done. Few physicians and clinicians, however, realize the enormous financial consequences that the lack of documentation can have on their practices if:
• they perform self-audits and find that their documentation did not support the codes that were billed and the payments they received and/or
•they receive a Medicare audit and find that their lack of documentation resulted in false claim submissions.
In wound care settings a variety of physicians and clinicians practice as a team to achieve excellence. Each member of that team should take personal responsibility for clearly documenting the work they perform. These professionals should not only use the documentation guidelines learned during their medical training, but should also follow the guidelines of the payers who review their claims for medical necessity. Most Medicare contractors provide educational seminars, webinars, online training, educational documents related to documentation, medical policies, and articles that include documentation requirements.
In the middle of 2007, the Office of Inspector General (OIG) released several reports regarding the wound care industry:
• May 2007: Medicare Payments for Surgical Debridement Services in 2004.
•June 2007: Medicare Payments for Negative Pressure Wound Therapy Pumps in 2004.
Unfortunately, both reports found that documentation in the medical records of wound care patients did not adequately support medical necessity of the procedure(s) performed and/or the product(s) ordered. The OIG found Medicare overpaid $64 million for false claims involving surgical excisional debridement and $27 million for false claims involving negative pressure wound therapy pumps and supplies.
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Compression Therapy: Inside the Wrap
March 17, 2008 | Leave a Comment
Words of wisdom: Get a leg up on compression systems
Val Sullivan, PT, MS, CWS; and Dot Weir, RN, CWON, CWS
Mr. RU Swollen is referred to your clinic from his primary care provider. He walks into the clinic with an antalgic gait then rests in the waiting room. On examination, both lower extremities are edematous, the left greater than the right. He has purulent draining ulcers over the left foot and leg as well as the right leg. Pedal pulses are weakly palpable and his blood glucose level is 196 mg/dL. Should this patient receive compression for his lower extremities?
Compression therapy is considered a standard of care for chronic venous insufficiency (CVI) patients. A wound care practitioner’s instinctive response is to compress the edematous leg in an effort to control the cause of the wound rather than to simply dress the ulcer. Knowing when to apply compression, what compression or support to utilize, and how to safely compress are critical in the care of these patients.
The Overall Picture
Assessment. The bedrock of the treatment plan must be a comprehensive patient assessment. Through appropriate clinical testing, the root cause of the edema must be determined. Does the patient have lymphedema, CVI, or a combination of the two? Is the patient experiencing an acute flare or episode related to another diagnosis such as deep vein thrombosis or congestive heart failure (CHF) exacerbation? A thorough history and exam should rule out disease processes (eg, arterial occlusive disease) that would put the limb at greater risk with the addition of a compression therapy. If arterial patency is in question, comprehensive arterial studies should be done before compression therapy is applied. Special consideration and precaution should be given to diabetic patients who may have a deceptively elevated ankle/brachial index (ABI) secondary to disease related atherosclerotic changes and calcification of vessels.
If it has been established that the patient’s lower extremity arterial system is adequate and compression would be of benefit, the source of the swelling (ie, edema or lymphedema) must be determined. Patients with lymphedema ideally should have been seen and treated by a clinician trained in manual lymphatic drainage (MLD) and complete decongestive therapy (CDT), a certified CLT-LANA therapist. Although edema and lymphedema patients both are treated with compression therapy, the lymphedema therapy regimen may be quite different from the management of edema resulting from CVI.
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Coding and Medicare Coverage Review
March 17, 2008 | Leave a Comment
Unna Boot and Multilayered, Sustained,
Graduated High Compression Systems
Kathleen D. Schaum, MS
Hospital-owned outpatient wound care departments (HOPDs) must routinely check their Medicare contractors’ websites for updates to their Local Coverage Determinations (LCDs) and Articles that pertain to the application of compression systems. All of the Medicare contractors seem to agree that CPT® code 29580 is the appropriate code to use when applying a zinc paste Unna Boot. However, there is great disparity among the Medicare contractors regarding the appropriate CPT® code for the application of multilayered, sustained, graduated high compression systems. This author reviewed all the available LCDs and Articles on this topic (see Table 1).
(Please note: Medicare contractors may write new and/or change existing LCDs and Articles at any time. The information in Table 1 was only accurate on the day the author drafted this column. Any or all of the Medicare contractors could have released new policies while this column was awaiting publication. Therefore, providers should assign someone to monitor all pertinent changes that are released by their Medicare contractor.)
When the HOPD program directors and physicians review the compression guidelines that pertain to them, they should ascertain the:
• Description of product applications covered by the CPT® code 29580
• Alternative CPT® code(s) recommended for non-zinc paste compression systems
• Professionals who are covered to apply the various compression systems
• Diagnoses that support medical necessity of application of the various compression systems.
Some Medicare contractors followed the American Medical Association’s coding guidelines; some followed the American Hospital Association Coding Clinic guidelines; and others chose to discount both sets of guidelines and wrote their own opposing guidelines. If providers disagree with their Medicare contractor’s LCD, they should take advantage of Medicare’s Reconsideration Process. This is a formal process to request updates to LCDs by providing clinical evidence to the contractor’s medical director. The exact steps in the Reconsideration Process are outlined on each Medicare contractor’s website. Providers also should enlist assistance from their professional society’s representative to the Carrier Advisory Committee (CAC).
The author suggests noting that the Reconsideration Process is applicable only to LCDs. It is not applicable to Articles released by the Medicare contractors. Therefore, if your Medicare contractor only wrote an Article regarding this issue, providers cannot challenge the Article. However, providers can request that their Medicare contractor create an LCD.
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InBusiness
How Much Do YOU Know About Debridement?
October 31, 2007 | Leave a Comment
Study the examples of wounds, debridement action taken, practitioner delivering care, and tissue removed. Assume the care facility is a hospital-owned outpatient wound department (HOPD). Then determine the type of debridement, documentation, and coding.
Understand that in actual practice, you would have a great deal more information about the patient in your care — eg, medications, nutritional status, previous treatment, and vascular status.Also, the information given may not match the exact history of the patients in the pictures; it was compiled to illustrate particular scenarios.
Discuss these cases with your clinical group.Then, please share your answers with TWC.Take a few moments to email your responses to our Editor at twc@hmpcommunications.com.
The Debridement Dilemma
October 31, 2007 | Leave a Comment
CAROLINE E. FIFE, MD
A chance to cut is a chance to cure.— Medical proverb
Non-viable (necrotic) material within a chronic wound has been shown to inhibit the development of vascular tissue (granulation) and the formation of skin (epithelialization). Devitalized material enhances bacterial growth while at the same time decreasing resistance to infection. The removal of such material is called debridement.
WHAT YOU CAN EXPECT FROM YOUR MANAGEMENT COMPANY
October 31, 2007 | Leave a Comment
PAT HUDSON, RN, BSN, CWCN;
SHERRILL A. WHITE; TERRY;
BEARD, RN, RRT, CHT, ACHRN
From conception to recognition as centers of excellence, wound care clinics must make education a priority. Management companies understand the importance of a knowledgeable team and have spent years refining and perfecting the education process. Not all managed companies are alike — hospital and wound clinic decision makers must understand what type of knowledge and support will be provided by the management company before partnering with them. Ultimately, the hospital should seek an accredited, comprehensive approach to education that includes all staff involved in the care and support of a wound center patient.The instruction provided should address key areas of clinic operation: wound care and hyperbaric medicine, clinical practice guidelines, advanced wound management, program operations, clinical coordination, safety, database outcomes management, quality improvement and accountability, reimbursement, patient education, marketing, and community education. The following article details what a hospital should expect from a management company in terms of education support of its wound clinic.
Staff Education: Independent versus Managed Facility
October 31, 2007 | Leave a Comment
Education is a never-ending process of acquiring knowledge and skills and developing powers of reason and judgment. In an independent wound clinic, educational responsibilities are handled in-house. The following discussion offers insights into the way one independent wound clinic, the Archbold Center for Wound Management, Thomasville, Ga, addresses staff educational and training needs.
Background. Our wound care program consists of an outpatient clinic where patients are seen both for MD appointments as well as regularly scheduled wound care.We also consult on acute care patients with complex wounds and provide any advanced wound care required during the hospitalization. Additionally, we oversee the wound management practices and round on complex cases at our four affiliate hospitals and four nursing homes.
