Business Briefs: The Business of Wound Care: The Physician’s Perspective

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  Last month’s Business Briefs column featured the importance of paying attention to the details required for maintaining the hospital-owned outpatient wound care department’s (HOPD) Charge Description Master, which I called the “orchestra leader” of the HOPD’s revenue cycle. This month’s column will focus on the “orchestra leaders” of the HOPD: the physicians.

  Every member of the wound care staff is one of the very important musical instruments in the wound care orchestra and knows how to perform his/her piece of music: the physician’s plan of care. Under the leadership of the wound care physicians, the wound care staff members are directed how to work together and implement a unique plan of care for each patient with a chronic wound.

  Think about the work that the HOPD staff could not perform without the physicians:
    • They could not perform wound care without “direct supervision”.
    • They could not provide wound care without a physician’s plan of care and without a physician’s order.
    • They could not send a patient for diagnostic tests without a physician’s order.
    • They could not manage a new problem without a physician’s order.
    • The HOPD staff cannot perform surgical procedures such as surgical debridement or application of skin substitute grafts.
    • The HOPD staff could not apply a multilayer compression bandage system without a physician’s order.
    • The hyperbaric oxygen (HBO) staff cannot put a patient in the HBO chamber unless a physician is there to supervise.
    • The HOPD staff could not arrange for the patient to obtain dressings for home use, negative pressure wound therapy pumps for home use, or home health nursing services without a physician’s order.

  Although the list could go on and on, it is obvious that a HOPD cannot exist without direct supervision and participation of wound care physicians, who are truly the orchestra leaders of the wound care program.

  Most wound care physicians understand they must:
    • Investigate the patient’s medical history;
    • Order the appropriate diagnostic tests to help them understand the underlying reasons that chronic wounds are not healing;
    • Arrange for and/or perform necessary surgery to restore adequate blood flow to the chronic wound;
    • Order the appropriate offloading and spend time educating the patient why offloading is important;
    • Order appropriate compression and educate the patient why he/she must comply;
    • Recognize when wounds are stalled and need cellular or engineered tissue alternatives;
    • Coordinate home care with durable medical equipment companies, home health agencies, and patients’ caregivers;
    • Surgically (11042-11047) and medically (97597-97598) debride wounds when necessary; and
    • Use HBO therapy when medically necessary.

  Some physicians appear to believe that they are not doing their job unless they are not surgically debriding every wound, keeping the HBO chambers filled with patients, and the like. When they are queried about their emphasis on a small portion of typical wound care protocols, they often respond with the question: “How does a physician make money if he/she does not perform surgical debridement or supervise HBO therapy?”

  To answer this question, let’s take a closer look at how Medicare, the largest payor for patients with chronic wounds, pays wound care physicians. Over the past few years, the Medicare Physician Fee Schedule (MPFS) has 1) been increasing payment to physicians for evaluation and management services, 2) been diminishing the financial incentive to debride wounds when not medically necessary, and 3) removed the financial incentive to use one brand of skin substitute graft over other brands.

  The following case example shows how the physicians’ financial incentives for work performed in HOPDs are aligning with doing the right thing at the right time for the patient with chronic wounds (see Table 1).

Case Example Week 1

  Physicians need to spend a considerable amount of time with new patients in order to do a thorough history and physical, make appropriate medical decisions that uncover why the wounds are not healing, educate the patients and their caregivers, order equipment and supplies for use at home, and coordinate home health agency wound care (when needed). During the first new patient visit, physicians will most likely perform a level III, IV, or V new patient evaluation and management, whose 2012 MPFS allowable rates are $74.88, $126.96, and $162.70, respectively. If the wound needs to be surgically debrided, the physician will perform the debridement and bill for the depth of tissue removed: $59.57 for subcutaneous tissue, $158.27 for muscle, and $236.56 for bone. Note the similarity in the MPFS allowable rates for evaluation and management and surgical debridement (except for debridement of bone, which is rarely performed in an HOPD).

Case Example Week 2

  When the patients return for reassessments of their wounds, physicians should have the results of any diagnostic tests that were ordered and performed, make appropriate medical decisions based on the diagnostic tests, and further educate the patients and their caregivers. These established patient evaluation and management services might be level III or IV and, in rare instances, a level V. The 2012 Medicare allowable rates for the established patient evaluation and management services are $49.69, $76.24, and $107.22, respectively. Because the wounds were already surgically debrided, they will probably not require additional surgical debridement, but they may require medical debridement, for which the 2012 MPFS allowable rate is $23.83. This is a perfect example of how Medicare has removed the financial incentive for physicians to debride.

   If the patients need to have multilayer compression bandages applied, physicians can choose to personally apply and bill for them instead of billing for the evaluation and management services. In those cases, the 2012 MPFS allowable rate for the application of the compression bandages is $12.59. Because many HOPD wound care nurses are skilled in the application of the multilayer compression bandage systems, physicians may write orders for the nurses to apply the compression bandage systems. In those instances, physicians will code and bill for the medical services they actually performed: either correct level of evaluation and management service or medical debridement.

Case Example Week 3 and 4

  When the patients return for reassessments of their wounds during the third and fourth week, physicians may perform a level II or III evaluation and management service, for which the 2012 MPFS allowable rates are $25.19 or $49.69, respectively. Or, if the wounds need additional medical debridement, the physicians will perform the medical debridement and will only bill for the debridement, for which the 2012 MPFS allowable rate is $23.83. At this point, you can see that a level II evaluation and management service and a medical debridement have nearly the same 2012 MPFS allowable rates.

Case Example Week 5 and Beyond

  By the fifth week, the wounds should be clean and making progress toward healing. If the wounds are clean but stalled, physicians may choose to apply cellular or engineered tissue alternatives. Unlike previous years, physicians do not have a financial incentive to apply one brand of product instead of another. The applications of all brands are paid the same: the payment depends on the size of the wound surface area and the anatomic location of the wound. The 2012 MPFS allowable base rates for wounds <100 sq cm are either $87.82 or $101.77, depending on the anatomic location. The 2012 MPFS allowable base rates for wounds >100 sq cm are either $209.33 or $216.14, depending on the anatomic location. The CMS has set the global surgical days for all of the application of skin substitute graft codes to 0 days. Therefore, physicians can bill for each medically necessary application of whatever product is clinically appropriate for the wounds.

  If the patient qualifies for HBO therapy, physicians may choose to use it to manage the wound. Some physicians may be surprised to learn that the 2012 MPFS allowable rate for HBO supervision is in parity with many of the other services and procedures that have already been discussed: $119.47.

Summary

  Physicians are the orchestra leaders of wound care programs. The wound care team can only play their part after the physicians direct them via their individualized plans of care and their orders. The 2012 MPFS allowable rates have begun to level the playing field and pay wound care physicians similarly for most services and procedures they perform in the HOPDs. This should make it easier for all wound care physicians to do the right thing at the right time for the right wound.

Reference

1. CPT is a registered trademark of the American Medical Association.

Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling (561)964-2470 or through her email address: kathleendschaum@bellsouth.net.