The Value of The Wound Care Playbook Information

  As I’m sure that you all will agree, the management of an outpatient wound center requires constant diligence and attention to all of the nitty-gritty details required for addressing and balancing the “business” side of the equation with the clinical desire and obligation to provide the highest level of care for our patients.

  The sportswear slogan of “Just Do It” certainly doesn’t apply to our care because although we may feel, for example, that due to the chronicity of a particular lower extremity wound that a debridement, application of a biological device, support with a multi-layer wrap and hyperbaric oxygen would hasten this patient’s healing and significantly lessen the threat of limb loss, I have just described 4 different sets of “rules” that must be followed in order to accomplish that. Additionally, that is just if the patient is covered by Medicare; these “rules” may change if there is a private insurance involved, even if that insurance is just a supplement to Medicare. Add to that the peculiar situation that we have in our practice, in that our hospital is covered under one Medicare Contractor, and our physicians are covered by another. So that just raised our number of “rules” to 8 for this patient. And we are supposed to get it all straight?

  The “rule books” that all of this information can be located in are called Local Coverage Determinations, or LCD’s. While this should be seemingly straightforward, the questions arise such as; do we know where to find them? How often do they change? Do they make perfect sense or leave us with more questions? If we have more questions, who can we ask? What if we get it wrong, and a denial is issued, does the patient have to pay? Are we obligated to bill the patient or do we have to accept the loss because we didn’t get it right in the first place? What if we got it wrong and we get paid, only to find out later that we didn’t follow the “rules”, do we repay the reimbursement?

  Scary stuff, isn’t it? What’s also scary is the amount of miss-information that abounds, mostly unintentionally on blogs, websites, word of mouth, and amongst colleagues. We want to do the right thing, so before we “Just Do It”, we need to “Just Get It”.

  To that end, welcome to this issue dedicated to helping us all gain a better understanding of these reimbursement “rules”. Our “playbook” specialist, Kathleen Schaum, will again provide us with insight and guidance to help us navigate this maze and elevate our awareness and understanding of the language and intent of these policies that we must abide by.

Dot Weir, RN, CWON, CWS, Co-Editor of Today’s Wound Clinic

  About 5 years ago, I was the CME course director for a meeting on limb salvage, which took place in Las Vegas. Since I was speaking about non-invasive vascular testing, I decided to look at Nevada’s “LCD” on transcutaneous oximetry (TcPO2). As Kathleen Schaum discusses in her insightful article on this subject, an LCD is a “Local Coverage Determination,” which is a decision by a Medicare Administrative Contractor (MAC) whether, and under what conditions, a service will be covered on a MAC-wide basis. These policies provide the “fine print” which you need to follow in order to get paid for a particular service. I was accustomed to the policies of “TrailBlazer” for TcPO2 since I practice in Texas. Their policies specifically denied payment for routine vascular screening, leg pain, or absent pulses. To my surprise, (at the time) Nevada’s LCD specifically COVERED TcPO2 as a screen for (among other things) claudication, rest pain, gangrene, and planning foot and ankle surgery, as well as in the immediate post operative period if pulses were lost or there were signs of ischemia, and for monitoring after bypass at 3 month intervals for the first year, and post angioplasty. That LCD was the “wish list” of almost everything that I needed to properly implement TcPO2 for my wound center’s limb salvage program. I had no idea that policies could vary so much from region to region. So, I called Kathleen. “How can I get a policy like Nevada’s in Texas?” I asked. The fact that we still do not have a uniform, logical policy for non-invasive vascular screening across all Medicare regions tells you that I did not do a very good job implementing the advice Kathleen gave me five years ago, but if you read her article you will at least begin to understand how it might be possible to tackle such a task. At the time, despite considerable effort, I was not able to get all the “players” moving in the right direction on behalf of patients with limb ischemia. In part, the problem is that vascular screening does not represent a significant revenue stream so there was little financial motivation for anyone to devote the needed attention to these policies. The main interest I had in improving LCD language for TcPO2 was that better vascular screening protocols were needed if we were ever going to decrease U.S. amputation rates. There are many things our patients’ need, which we may not be able to provide unless we proactively work with the MACs on the “fine print” of LCD language. We don’t get involved in these policies because of financial gain, but because there are patient care issues at stake. That is the “proactive” side of LCD policy efforts by clinicians, the process of which Kathleen explains.

  On the other hand, not knowing the details of your regional LCDs could certainly COST you a lot of money. Let’s look at the LCD from Trailblazer, the MAC for Jurisdiction 4 (J4), for the bioengineered skin-substitutes, including Apligraf and Dermagraft (available at: https://www.trailblazerhealth.com/Tools/LCDs.aspx?ID=3332&DomainID=1)

  This LCD lists the conditions under which these skin substitutes will be covered and detail the documentation required to justify payment for their application. I will not list them here, but there are more than 25 specific criteria, which must be documented in the physician’s procedure note to ensure reimbursement for a skin substitute. In some cases there are things, which must be ABSENT, and in other cases, there are things, which must be PRESENT (e.g. no vasculitis, no high dose steroids, no infection, no tendon exposed, the presence of sufficient blood flow, etc.). This is in addition to the various documentation requirements for the procedure itself regarding the size of the wound, how many pieces of bioengineered skin are used, and how many square centimeters are “wasted.” The introduction of new G codes has increased the complexity of billing for these products. The note must also specifically state that the skin substitute was provided in accordance with the material’s Food and Drug Administration- (FDA) approved package label. To make things even more challenging, there are now 15 jurisdictions, each with its own MAC, and THEIR POLICIES ARE DIFFERENT from each other.

  If you dictate these notes for someone to transcribe, or type your own from templates, then human compliance monitors will be needed to ensure that you have managed to include all the required information in every note. It is possible for an electronic medical record to automate the compliance process with “structured notes,” obviating the need for human monitoring, but there is still a potential problem. Just because all the elements are IN the note does not mean that you are in compliance with the policy. If, for example, your LCD says that bioengineered skin cannot be used if tendon is exposed, and your chart documents that tendon is exposed, and then at least theoretically, your charge for this procedure could be denied should it undergo post payment review. Some additional mechanism is needed to ensure that not only are all the necessary elements INCLUDED in your documentation but that they were in COMPLIANCE with the specific policy of your LCD! There are technological answers for LCD compliance, which an EHR can provide (crosschecking your documentation with the LCD), but this trend of increasingly burdensome documentation requirements is likely to increase and represents a huge challenge for the advanced practitioner. It means that clinicians must not only KNOW the details of an LCD, but also proactively decide how they will handle LCD requirements from a compliance standpoint. So, LCDs have implications on whether and which documentation system you use and how you use it.

  It soon becomes apparent why the inner working of a wound center feels a lot like the mechanism of a Swiss watch. Every part has to work perfectly with every other part or it breaks down entirely. If you don’t know the details if your LCDs then you don’t know the specific coverage policy for the services your patients require. Your documentation will be incomplete, your patients may not receive needed services, and you may not be paid for the services you provide. You can effect changes to LCDs on behalf of your patients, although the process is time consuming. However, LCDs are the perfect example of how what you don’t know can hurt you, and why you really do have to “read the fine print.”

Caroline Fife, MD, FAAP, CWS, and Co-Editor of Today’s Wound Clinic