Transitioning to Packaged CTP Payments in Wound Care: No Easy Adjustment

  The new method regarding packaged payment for cellular and/or tissue-based products (CTPs) [old term “skin substitutes”] established by the Centers for Medicare & Medicaid Services (CMS) for wound care has brought with it a fair share of challenges among wound clinic clinicians and directors. In an effort to assess just how well, or poorly, hospital-based outpatient wound clinics (HOPDs) have been adjusting to the changes, Today’s Wound Clinic recently conducted a national survey of HOPD directors and clinicians that gauged such topics as the use of CTP products in HOPDs since Jan. 1, changes made to one’s charge description master (CDM), communication between clinics with private payers, and use of quality metrics for CTPs in the clinic. Surveys were returned prior to TWC’s press time from HOPDs in 31 states. Here, two of our expert editorial board members (Caroline Fife, MD, FAAFP, CWS, and Kathleen Schaum, MS) review and discuss the results for our readers. What follows is a question-by-question breakdown and analysis:   Question 1: Have you stopped using any CTP products since the OPPS packaged payment went into effect? If yes, why?    • Yes 50.8% • No 49.2%   Caroline Fife (CF): While I am thrilled so many HOPDs responded to our survey, I must admit that I’m shocked so many had not yet taken all the necessary steps to adjust to the packaging of CTPs. Now that I see the survey results, I better understand why the “confusion that reigns” is addressed in this issue’s “Business Briefs” (beginning on page 6). I am also surprised to see only half the respondents had stopped using some of the products that cost more than the Medicare allowable rates. However, I was not surprised that 92% of HOPDs that stopped using specific CTPs had stopped using “high cost” products. Kathleen, did any survey responses surprise you?   Kathleen Schaum (KS): Yes, I was very surprised by some of the responses to this question. In particular, I was surprised to see some HOPDs have denied beneficiary access to all CTPs due to the new Medicare packaged payment rules. That seemed a bit draconian to me since there are quite a few CTPs with published evidence that are still economically feasible for the HOPD. Caroline, as a physician, do you think it is medically correct to deny access to technology that is available for chronic wounds that have failed to progress with standard of care?   CF: Every clinical practice guideline and Medicare Local Coverage Determination (LCD) that I am familiar with states that qualified healthcare professionals should move to higher technology if the standard of care fails after four weeks. That technology does not have to be a CTP, but it would be too bad to deny them to patients entirely. We have to stay within the coverage guidelines of our LCDs, but I have identified a couple products that are affordable to me even though they are not products I have used before and I am quickly becoming familiar with them!   Question 2: Have you started using new CTP products since Jan. 1? If yes, which ones and why?    • Yes 29.6% • No 70.4%   CF: With the availability of several products with published clinical evidence, I was surprised to see that only about 30% of respondents have started using new CTPs. However, I was not surprised to see that those respondents are now using OASIS® Matrix (26%) and OASIS Ultra (2%), EpiFix® (23.6%), PriMatrixTM (13%), and TheraSkin® (5.2%) because they are covered by most Medicare Administrative Contractors (MACs). One product with little MAC coverage was also mentioned: MatriStem® (7.8%). But the most surprising responses were from the HOPDs claiming they were admitting patients to the hospital for skin grafting rather than using readily available CTPs with published clinical evidence. In this day and age when we are trying to reduce hospital admissions, this practice seems counterintuitive to me. Kathleen, did you see any other technologies besides CTPs in the responses?   KS: Yes, a few respondents mentioned they are trying CelluTome® and Xpansion.® The responses that worry me come from those who are going to bill dressings with the application of CTP codes.   Question 3: Have you increased or decreased use of CTP products that you used prior to Jan. 1? If increased, which ones and why?   Increased - 55.8%   CF: The respondents who have increased the use of particular products said they are using such products as EpiFix, MatriStem, OASIS Matrix, OASIS Ultra, and TheraSkin. Kathleen, do you wish to make any other comments about the third question?   KS: I am still concerned about the respondents who said they stopped using CTPs. With all the products with published clinical evidence, I am worried about denying advanced technology access to Medicare beneficiaries. You may also question why some providers would decrease the utilization of a product while others may increase utilization of the same product. As with any survey, we asked general questions. Therefore, certain pieces of information may not be clear. For example, some HOPDs may have been ordering only one particular size of a particular product. Those HOPDs reporting that they are decreasing the use of that product are doing so because they rarely need product that large in an HOPD. These same HOPDs or other HOPDs reported that they’ve increased the utilization of a smaller size of the same product because it is a more appropriate size for the wounds in their HOPDs and fits into the packaged payment system. Another reason for the decrease of the same product by one HOPD and the increase by another HOPD may be due to the different wage indexes that affect the packaged payment rate. For example, an HOPD in a low-wage index area may have decreased the utilization of TheraSkin while an HOPD in a high-wage index area may have increased its utilization.   For these reasons, each HOPD should reflect on its own situation when selecting CTPs for patients.   CF: There is no question that as a result of Medicare package pricing some products are not going to be available to Medicare beneficiaries (at least not until their cost, their size, or both decrease[s] significantly). But, there are some products that can still be used. The question is whether the system has now become so confusing that clinics just can’t manage the complexity of the process. They may give up out of frustration.   Question 4: If you’ve decreased the use of CTPs, what are you now using to manage these chronic wounds?   CF: The responses here are very surprising:     • 45% said they would try to do a better job than before with the standard of care and optimal choice of dressings. The most common technologies mentioned were compression, offloading, debridement, negative pressure wound therapy, MIST Therapy,® total contact casting, and collagen dressings.     • 14% are using CTPs they believe are still affordable. The most frequently mentioned affordable product was OASIS Matrix. Others mentioned include Apligraf,® EpiFix, and MatriStem.     • 9% said they were admitting patients to the hospital for traditional surgical skin grafting.     • 6% said they are going to use CelluTome and Xpansion.     • A few respondents mentioned Regranex.®   KS: Now let’s move to the revenue cycle survey questions.   Question 5: Have you made any changes to your CDM due to packaging of CTPs? If yes, what did you change?    • Yes 44% • No 56%   KS: Here is a key point: 44% of respondents have made CDM changes. Their changes have consisted of adding the new C5271-C5278 codes and descriptions for the application of “low cost” CTPs, revising the descriptions of the 15271-15278 codes, updating charges for 15271-15278, adding charges for C5271-C5278, adding new CTPs, and removing “Q” codes from the CDM. I am very concerned that 56% of respondents did not make the required changes to their CDM.   These changes should have been made on Jan. 1. This lack of attention to detail will negatively affect the 2014 revenue cycle of HOPDs and will affect the Medicare allowable rates in 2016.   I am also concerned about those who removed the “Q” codes from their CDM. If they do not include the “Q” codes on their Medicare claims, the claims will not be paid.   CF: Kathleen, I am sure you are also disappointed by the responses to the next question.   Question 6: Have you contacted the private payers about their continued separate payment for the CTPs and their adoption of C5271-C5278?    • Yes 18.1% • No 81.9%   KS: HOPDs should verify insurance benefits for all services, procedures, and products they offer. Beginning Jan. 1, HOPDs should be asking each private payer, Medicare Advantage, Medicaid, TRICARE,® etc., if they are using the new C5271-C5278 Healthcare Common Procedure Coding System codes. Then, HOPDs must work with their revenue cycle team to establish a process for using C5271-C5278 when billing Medicare for the application of “low cost” CTPs and continuing to use 15271-15278 when billing other payers (that are not using C5271-C5278) for the application of the same products. The fact that nearly 82% of respondents have not contacted these payers about this important topic is disappointing. Hopefully, when HOPD personnel read this article, they will be inspired to begin speaking to these payers about the use of C5271-C5278.   CF: After reading the responses to question 6, the responses to our next question are not surprising.   Nearly 71% of respondents answered “no” to Question 7: Have you decided how to manage the coding and billing for “low cost” CTPs when private payers have not adopted C5271-C5278?    • Yes 29.1% • No 70.9%   CF: The responses from those who answered “yes” are quite diverse. Some said the HOPD is responsible for knowing the codes to report to each payer. Others said the billing department makes adjustments to the codes. The most fascinating responses pertained to the electronic medical record (EMR). Some said their EMR can be programmed to report codes that are recognized by payers. Others said their EMR could not handle this function. Therefore, HOPD staff must manually override the coding for insurance companies that don’t use the same codes as Medicare. Kathleen, do you have any comments?   KS: I hope all readers who work in an HOPD will work with their entire revenue cycle team to handle this important coding and billing function.   Question 8: Have you changed the size of the CTP product(s) that you purchase? If so, to what size(s) and why? Prior to 2014, what size product(s) did you typically purchase?    • Yes 27.5% • No 72.5%   CF: I was surprised to learn 72.5% of responders have not changed the size of CTPs used to better match the size of the wounds and to minimize wastage and cost.   KS: Agreed! However, I was very proud of responders who have made conscious decisions to match the size of the products to the size of the wound. I would have been even more proud if they had discussed reducing the size of the product used as the wound decreases in size.   Question 9: Has your evaluation of CTPs changed since the packaging of the cost of the product within the OPPS payment for the procedure?    • Yes 32.3% • No 67.7%   CF: This question elicited strong sentiments by responders who have changed their evaluation methods. Nearly everyone said cost has become more prominent in CTP evaluations.   KS: I am surprised such a small percentage of HOPDs are considering cost when they evaluate CTPs. First, they should consider published clinical evidence. Then they should consider ease of use. Then they should consider cost to be sure the patient and the HOPD will be able to afford the product given the new Medicare packaged payment.   Question 10: Have patients made any comments regarding changes in bioengineered skin substitutes they may have been using in 2013 who now may be required to use a lower-cost product?    • Yes 14.3% • No 85.7%   CF: As a physician, I wonder if the reason that only 14% answered “yes” means one of the following:     • the physician continued the patients’ treatment regardless of the new Medicare packaged payment system, or     • the physician switched to another product and did not tell the patients, or     • the patients have not yet seen their Medicare claims summary.   Physicians should discuss changes in wound management and in the Medicare payment system with patients. I had to explain to some of my patients why I couldn’t reapply the same CTP that I used the last time and why I selected a different CTP for their next application. It was an awkward conversation to be sure, but physicians should always keep their patients informed and engaged in their care.   Questions 11 and 12 pertain to tracking the clinical and financial impact of the new Medicare payment system:   Has your hospital/HOPD implemented a tracking program to show the positive or negative clinical impact of the packaging of CTPs?    • Yes 15.3% • No 84.7%   Has your hospital/HOPD implemented a tracking program to show the positive or negative financial impact of the packaging of CTPs?   • Yes 16% • No 84%   CF: This is an area where the wound industry really needs to improve. We need to prove we are delivering the best clinical outcomes at the lowest total cost of care, and with the greatest patient satisfaction. Kathleen, please share any closing thoughts.   KS: I would like to thank all respondents for answering honestly. Responses have shown that changes in coding, payment, and coverage are not quickly accepted and implemented. We still have a lot of work to do to provide the “right size CTPs with clinical evidence” to the “right patient” at the “right time” and at the “right price.” I refer readers to the “Business Briefs” columns in this issue, the November/December 2013 issue, and the January/February 2014 issue. Readers can also get an in-depth review of 2014 packaged payment pertinent to HOPDs through the free webinar “2014 Medicare Reimbursement Information for Implementation” at www.woundsresearch.com/2014reimbursement. Caroline Fife is chief medical officer at Intellicure Inc. and Kathleen D. Schaum is director, medical products, reimbursement, biotherapeutics at Smith & Nephew.