Cath Lab Digest

While waiting in line to pick up a prescription from a local pharmacy, the man in front of this author was taking a long time asking the pharmacist for a large bandage and an ointment to take care of what he said was a “large cut” on his leg. Every suggestion the pharmacist made was met with resistance from the gentleman. He had tried them all. He told the pharmacist, “I have had this for more than 6 months and it only keeps getting bigger.” Upon lifting his trouser leg he exposed a Stage III venous leg ulcer—with “all of the trimmings.” Everyone in line gave the obligatory gasp, and the pharmacist grimaced, “I think you had better see your doctor.” The man replied, “I have followed my doctor’s orders, there must be something else that I can do.”

After verifying the gentleman’s insurance this author provided him with the name and number of a local wound clinic staffed by a physician Board Certified in Vascular Surgery specifically trained in wound care. The gentleman’s physician had never referred him to a specialist to manage the growing venous leg ulcer. As the gentleman lumbered away, it was apparent he would finally receive appropriate medical care.

Trained to Recognize the Big Picture
Being a healthcare economist, this author realized the revenue opportunity heading to the wound clinic. Given the brief assessment due to the open disclosure of his medical history, the gentleman may require a comprehensive history and physical due to his age, obesity, arthritic joints, and family history of diabetes. Treatment may include debridement, assessment of adequacy of venous and arterial supply, compression bandaging, follow up visits; possibly negative pressure wound therapy, and perhaps placement of a skin substitute. His diagnostic findings may result in vascular repair, cardiac catheterization, and perhaps assessment of his renal function. Appropriate medical care provided by staff at the wound clinic, delivered with respect and dedication has been shown to result in developing patient loyalty. Loyal patients tend to refer others. In this case he is likely to inform his internal medicine physician, other family members and friends. This one patient properly managed is worth more to the wound clinic and hospital than any advertising campaign. The referral of the wound clinic to the patient was provided based upon the skill, knowledge, evidence of clinical success, and overall reputation of the wound clinic’s ability to manage patients with acute and chronic wounds in their outpatient and inpatient settings. While growing patient volume in an outpatient wound clinic is an overarching goal, proper processes need to be implemented to sustain revenue flow. Charges do not reflect revenue.

Recognition of cost and payment require:
1. Medical documentation supporting the provision of medically necessary and appropriate care based on clinical evidence and scientific standards where applicable,
2. clinical processes to be coordinated with cost capture,
3. analysis of revenue realization, and
4. a multidisciplinary team consisting of clinical experts teamed with representatives from hospital administration to maintain communication able to take corrective when needed to secure a positive return on investment.

The following clinical assessment flows with procedure identification, cost capture, and will provide
insight into the billing practice for revenue realization.
*Sections underlined represent services and supplies that may be considered for coding and billing. Although the example provided is for a venous leg ulcer, the process provided is applicable for any patient entering the wound clinic for alleviation of an acute or chronic wound.

Initial patient assessment—will include a diagnosis of underlying cause of venous ulceration with or without arterial involvement.

Before commencing treatment of the venous leg ulcer, it is essential that the root cause is correctly diagnosed; the inappropriate application of high-levels of pressure to an ischemic limb may have potentially catastrophic consequences. Confirmation of the underlying etiology, may be confirmed by means of a Doppler assessment, to exclude the possibility that an ulcer, which appears venous in origin but has a significant arterial component. If his lower extremity arterial system is adequate and compression would be of benefit, the source of the edema or lymphedema should be identified and medically managed.
In the example, the gentleman requires a comprehensive review of systems and history. Given his family history of diabetes and his obesity he may require a detailed assessment of his cardiac health and renal function (Current Procedural Terminology (CPT) and revenue codes on subsequent visit to a specialist). During wound clinic follow up visits he may receive compression bandage changes, and nutrition counseling, with continued management from a cardiologist.

Treatment Plan
His treatment plan can be designed once the comprehensive history and physical and collaboration of information gathered on his health by the multidisciplinary team has been studied. Clinical assessment, diagnostic tests and laboratory analysis (CPT and revenue codes) may reveal the cause of the edema; verify if he has lymphedema, chronic venous insufficiency (CVI), or a combination of the two. Given his family history it must be determined if this is an acute episode related to deep vein thrombosis or congestive heart failure (CHF), or exacerbation of undetected diabetes. The patient’s diabetic status must be clarified due to precaution given to diabetic patients who may have a deceptively elevated ankle/brachial index (ABI) secondary to disease related atherosclerotic changes and calcification of vessels.