Wound dressings and supplies — they’re usually the very last thing that any clinicians and/or providers think about when it comes to the plan of care for patients being managed for skin breakdown. Well, it’s just the opposite for the medical supply companies that are on the receiving end of the orders from the outpatient wound clinics. In fact, dressings and supplies are all that we think about every day. Our mornings are spent tracking supplies en route by FedEx,®UPS,®or courier. Our afternoons often see us cramming orders in before the shipping cutoff time and making challenging, time-sensitive phone calls to the clinics to ask for additional documentation needed to substantiate billing the claim to Medicare. Now that I have made you feel bad for us …
On July 24, 2017, the Centers for Medicare & Medicaid Services (CMS) officially activated the latest update and revision to local coverage determination (LCD) L33831 regarding the coverage of surgical dressings. The surgical dressings category is the durable medical equipment (DME) supply benefit that covers advanced wound dressings for patients to don at home by themselves or a caregiver. This LCD has produced some unruly requirements that can (and will) ultimately lead to pauses in the continuum of care and, ultimately, outcomes.
Many times, nurses and other clinicians assess patients prior to a physician’s assessment. Many times, this assessment can vary slightly from what the physician sees. This slight difference is what tends to produce documentation inconsistencies as it relates to comparing an actual physician encounter note versus the “wound assessment” form. The single most important piece of information that wound dressing suppliers need is a good, solid, consistent charting notes to show that a wound is indeed meeting the coverage guidelines, so that we can supply the patient and receive reimbursement. But it doesn’t stop there. We are constantly audited by a barrage of hired guns by CMS to “go after” claims with a fine-tooth comb and find where “I’s have not been dotted and T’s have not been crossed.” When one single inconsistency is identified, the entire claim is denied for medical necessity. What follows is a non-exhaustive list of the common reasons for some patients supply orders not being shipped the same day as the orders are received by the DME supplier:
- Chart notes do not match the wound assessment.
- Wound does not qualify due to drainage or staging.
- Frequency of change was not specified.
In addition to reasons for orders not being shipped, there are twice as many issues that can delay a claim being sent to Medicare for reimbursement. With CMS/Medicare claim-auditing outfits such as Recovery Audit Contractors, Comprehensive Error Rate Testing, and Zone Program Integrity Contractors, to name a few, looming around every corner to scrutinize every claim, one can eventually understand why we must be perfect in our records. Specifically, our company prides itself on having highly competent, helpful representatives available to coach the wound clinics (and their clinicians) on how to help us improve the process. In turn, this will help with workflow and, ultimately, patient care and outcomes (ie, healed wounds). The demographic of patients living with diabetes and those patients who are wound-prone is growing by the minute across the United States. We are a company, and an industry, that wants to identify the efficiencies that can produce outcomes now and in the years to come. It is easy to see the frustration that could mount within a wound clinic that is seeing upwards of 50 patients per day. There must be efficiencies within the office with the use of an electronic health record that can make documenting easier, make documentation better, and improve the ordering process. Physicians are constantly faced with fee-schedule cuts that force clinics to see more patients in the same amount of time. We want to help — we want to ship out every order blindly, we want to take every insurance under the sun, and we want to be around for a long time to help our clinics get their patients the supplies they need with pinpoint accuracy, on time, every time. However, we must stay in business and have confidence that every single claim is perfect.
Brett Carroll is chief executive officer at Preston Wound Care, a nationwide advanced wound dressing supplier based in McKinney, TX.