Realizing Revenue from a Wound Clinic

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.

If he has lymphedema he will require manual lymphatic drainage (MLD) and complete decongestive therapy (CDT) (CPT codes). Although edema and lymphedema patients both are treated with compression therapy, the lymphedema therapy regimen may be quite different from the management of edema resulting from CVI. Once the patient’s wound care has been initiated he may be recommended for medically necessary follow up with a nutritionist and cardiologist and perhaps a rheumatologist (CPT codes). If the medical care he is provided is done in a kind, caring, and focused manner that enables him to regain a positive state of health, it is likely he may refer other family members and friends of similar socioeconomic status.

Revenue Opportunity or Not?
On average each patient treated in an outpatient wound clinic represents approximately $165 of revenue for each visit.1 The patient in our example may require conservatively two visits per week for 8 weeks producing $2,640. The approach provided by a multidisciplinary team will be able to reduce the patient’s time to healing by knowing when to intervene with advanced techniques, including revascularization procedures, placement of a skin substitute/graft, and/or refer the patient for further consults to improve his underlying nutritional and physical status. By reaching out to the wound care clinic utilizing a multidisciplinary approach to heal the wound by addressing the underlying cause, the patient will return to an improved level of health. The feedback process allows the multidisciplinary team to build upon their database of evidence based best practices.

The Snapshot—capturing the charges for medical services, diagnostic tests, and laboratory tests, properly documenting the service, identifying the most relevant CPT codes, and assigning revenue codes where applicable for supplies does not complete the revenue capture process.

Revenue capture analysis requires members of the multidisciplinary team to include representation from compliance, finance, billing, health information systems and reimbursement. Once the team has identified the proper cost capture, and billing processes, the wound clinical manager should receive a report that breaks out the reimbursement for direct patient care, supplies used and procedures referred for outpatient surgical interventions or inpatient admissions. By tracing the treatments used to correct the underlying causes exacerbating the wound progression, the complete value of the wound clinic becomes more apparent to hospital administration.

Attracting Patients
How hospitals attract and keep patients is critical to success in competitive markets. Current regulatory changes to be adopted by Medicare and other third party payers may further erode revenue therefore all revenue opportunities are critical to a hospital’s survival. On April 14, 2008, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would update payment policies and rates under the hospital inpatient prospective payment system (IPPS) for fiscal year (FY) 2009, beginning for discharges on or after October 1, 2008. The IPPS final rule, July 31, 2008 added three more hospital acquired conditions, one from the National Quality Forum, to the list of eight conditions that have been determined to be reasonably preventable through proper care. These specific events represent patient care that is high cost and/or high volume. The CMS Fact Sheet and complete list of conditions in the final rule for fiscal year 2008 and 2009 may be found at www.cms.hhs.gov/apps/media/fact_sheets.asp. The proposed rule lists specific events that are high cost and/or high volume that should never happen to patients admitted to the hospital. Several of the conditions have been identified by the National Quality Forum (NQF) as Serious Reportable Adverse Events (also called “never events”). The CMS Fact Sheet may be found with a complete list of existing and proposed conditions affected by the HAC payment provision.
One way to do generate service line revenue is to establish primary services aimed at targeted patient populations, nurture relationships with patients and their families over a long period of time, build loyalty by providing great service and engaging patients at numerous points across the hospital system. Wound care fits this competitive strategy. Even without high margins in the wound care clinic, wound care brings in patients requiring a wide range of hospital services, setting the foundation for loyalty that will generate revenue into the future and provide patients to the cardiac, orthopedic, vascular surgery, gynecology, and plastic surgery service lines. Due to the experience of the wound care multidisciplinary team they are adept at creating and then monitoring a surveillance process to proactively prevent “never events”. If one of the “never events” does occur, this team can act quickly to address the problem and achieve healing in a cost effective manner.
The overall revenue impact of a multidisciplinary team effort from the wound clinic is significant. Wound care patients tend to require a diagnostic regimen ranges from imaging to vascular studies, at times with an inpatient stay necessary to establish the wound healing process if an intervention is needed. In wound care, clinical quality and customer service are the big winners. Healing results are dramatic and noticeable. Patients become loyal allies will to educate their physicians, family, and friends.n

Leah Amir, MS, MHA, is CEO and President VantageView and VantageLinks, LLC and executive director for the Institute for Quality Resources Management in
St. Louis, Mo.