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TODAY’S
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Contemporary Approaches to Wound Clinic Management
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WOUND CARE HEALTH REFORM
EVOLUTION OF QUALITY MEASUREMENT O P E R AT I N G A C O S , N E W C T P PAY M E N T S
ALSO IN THIS ISSUE: Wound Care Certification Business Briefs
SAWCSPRING March 2014 www.todayswoundclinic.com
the symposium on advanced wound care
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TODAY’S
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Volume 8, Number 2, March 2014 • www.todayswoundclinic.com
Table of Contents • Feature Articles 12
10
READER SURVEY RESULTS The Evolving Landscape of Healthcare Reform: Impacts On Wound Care?
Transitioning to Packaged CTP Payments in Wound Care: No Easy Adjustment
As an interdisciplinary treatment that is provided within essentially all settings throughout the care continuum, wound care will continue to experience far-reaching effects of healthcare reform. This article discusses the role of wound care providers within collaborative-care models, the evolution of quality measurement under the Affordable Care Act, and the effects of coverage provisions brought about by reform.
A new packaged payment method for cellular and/or tissuebased products established by CMS has brought with it a fair share of challenges for wound care clinicians and directors. In an effort to gauge just how well, or poorly, HOPDs have been adjusting to these changes, Today’s Wound Clinic conducted a national survey to gauge use of CTP products since Jan. 1. Here, two of our expert editorial board members review and discuss the results.
Roshunda Drummond-Dye, JD
Caroline Fife, MD, FAAFP, CWS & Kathleen D. Schaum, MS
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Choosing & Implementing the ‘Right’ Management Style for Your Clinic Since the signing of the Affordable Care Act in 2010, time has ripened for wound centers to offer effective patient care while still experiencing financial profit. With the shift of focus toward preventative care, savvy hospitals will emphasize outpatient services that offer controlled costs and efficient service. This article will discuss different approaches to outpatient wound clinic management while addressing the respective pros and cons inherent with each. Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA; Michael Comer & Melissa Bailey TODAY’S WOUND CLINIC® (ISSN 1938-6311), is published by HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. TODAY’S WOUND CLINIC® website, www.todayswoundclinic.com, is registered with all major Internet search engines. Full content is available online to TODAY’S WOUND CLINIC print subscribers. SUBSCRIPTIONS: TODAY’S WOUND CLINIC® annual rates for US subscriptions: $99.00 annual; single copies, $39.00. Single or replacement copies of TODAY’S WOUND CLINIC® are subject to availability. To subscribe to TODAY’S WOUND CLINIC®, call (800) 237-7285, ext. 221, write to TODAY’S WOUND CLINIC®, Circulation Department, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, or visit us online at www.todayswoundclinic.com. REPRINTS: Bulk professional-quality reprints (minimum quantity 100) of articles may be purchased. Contact the Managing Editor at (610) 560-0500 for information.
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HEALTHCARE REFORM Q&A TWC Exclusive: Interview With ACO Physician In an exclusive interview with Today’s Wound Clinic, Parag Agnihotri, MD, medical director at Sharp Rees-Stealy Medical Group, speaks about his organization’s involvement in the 32-member Pioneer ACO established by CMS. We discussed the initiatives within his ACO, including its clinical and financial successes and outlook.
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EDITORIAL STAFF
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FOUNDING EDITORIAL BOARD Kathleen Schaum, MS Christopher Morrison, MD Valerie Sullivan, PT, MS, CWS Dot Weir, RN, CWON, CWS
Volume 8, Number 2, March 2014 • www.todayswoundclinic.com
Table of Contents • Feature Articles Assessing the Value of Wound Care Certification
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In today’s sophisticated and consumer-driven healthcare market, specialty credentials can be that much more valuable. What are the impacts on one’s career and practice when attaining certification? A credentialed wound care specialist shares his experience and insight with Today’s Wound Clinic. Joe Darrah
ICD-10-CM Diagnosis Coding Documentation Tips For Open Wounds & Amputations
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In the fourth installment of our special column on ICD-10-CM implementation, we provide tips for the categories S01.1-S98.9. Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA
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From the Editor
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Caroline E. Fife, MD, FAAFP, CWS
Business Briefs Confusion Reigns: 2014 Coding, Coverage, & Payment for CTPs Kathleen D. Schaum, MS
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83 General Warren Boulevard, Suite 100, Malvern, PA 19355 Editorial Correspondence should be addressed to Managing Editor, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-0500 /Fax: (610) 560-0502. Editorial policy: TODAY’S WOUND CLINIC® seeks to provide practical, timely insight into clinical and operational issues inherent to the success of an outpatient wound center. Program Directors, Medical Directors, and Clinical Managers (including Nurse Practitioners and other professional wound care providers across multiple disciplines) will benefit from the interactive nature of feature articles and regular departments that address medical and practice management options and perspectives affecting fiscal and, most importantly, patient outcomes of wound clinics. Articles from knowledgeable, experienced practitioners are invited and will be subject to Editorial Board review.
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CONTROLLER Meredith Cymbor-Jones DIRECTOR OF E-MEDIA AND TECHNOLOGY Tim Shaw SENIOR DIRECTOR OF MARKETING Corey Krejcik SR. MANAGER, IT Ken Roberts
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fromtheeditor
TODAY’S
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EDITORIAL BOARD
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his week I had lunch with Dr. Guy L. Clifton, MD, author of Flatlined, Resuscitating American Medicine, a book that “delves into the realities of good people caught in a bad medical system.” The former chairman of neurosurgery at the University of Texas Health Science Center in Houston, where I was also once employed, Dr. Clifton also spent two years in Washington, DC as a health policy fellow with the Robert Wood Johnson Foundation. He is now creating healthcare clinics designed to Caroline Fife Editor of TWC work within the new healthcare system. Lately, the wound care community has been focused on some “trees in the forest” issues such as the package pricing of cellular and tissue-based products (CTPs). Talking to Dr. Clifton is a good way to see the big forest of healthcare reform. I will list just a few of the forces converging on the marketplace here, but an important one is the sustainable growth rate formula that sets the yardstick for physician payment. Since 2009, Congress has been putting off the 10% cut in Medicare payments to physicians required by this formula. Delinking the cost and volume of physician services will cost $262 billion over 10 years. The money is not there. Doctors are simply going to get paid less money in the future, and what they do get paid for will be tied to quality metrics. Diagnosis-related groupings (DRGs) brought inpatient spending under control, but outpatient spending is on a runaway train. The package pricing of CTPs was the first small step in the direction of a much larger change, which will result in either outpatient DRGs, capitation, or some other form of controlled payment rate for outpatient services. The payers themselves are changing drastically with the effects of Obamacare sending shockwaves through the private insurance industry. As Medicare evolves into (at the very least) an HMO, the private payer system will dramatically change along with delivery of care. Payers are using quality data to select physicians for their networks and reimbursement packages for physicians who will increasingly become employees of the institutions willing to go at risk in a new marketplace.Those institutions are the ones willing to bet that they can provide better care at a lower cost while pocketing the rest.The outpatient wound center of the future is the one that can achieve the best outcomes with the least use of resources.
FOUNDING EDITORIAL BOARD MEMBER & EDITOR OF TODAY’S WOUND CLINIC Caroline Fife, MD, FAAFP, CWS FOUNDING EDITORIAL BOARD MEMBERS Dot Weir, RN, CWON, CWS Christopher A. Morrison, MD, FACHM, FCCWS Valerie Sullivan, PT, MS, CWS Kathleen D. Schaum, MS EDITORIAL BOARD MEMBERS Leah Amir, MS, MHA Desmond Bell, DPM, CWS Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA Moira Hayes, MHA, RRT, CHT Cathy Thomas Hess, BSN, RN, CWOCN Harriet Jones, MD, BSN, FAPWCA Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA Pamela Scarborough, PT, DPT, MS, CDE, CWS Susie Seaman, NP, MSN, CWOCN Tere Sigler, PT, CWS, CLT-LANA Pamela G. Unger, PT, CWS, FCCWS Randall Wolcott, MD, CWS EMERITUS EDITORIAL BOARD MEMBERS Andrew J. Applewhite, MD, CWS, UHM Robert S. Kirsner, MD, PhD
Efficacy Over Volume There is a famous quote attributed to General Motors: “We lose money on every car, but we will make it up in volume.”The days of payment for volume are over. Our “cost effectiveness” studies need to be redone and our approach to wound care products and advanced therapeutics completely turned upside down. Ask yourself: If you had $10,000 to heal a Wagner Grade 2 diabetic foot ulcer and you could keep any money you had left over — which interventions would you choose? How many times would you see the patient? Which products would you use? We are now looking for efficiency rather than volume. The organization that can provide the best outcomes for the lowest cost is going to win in this new world. And, by the way, Dr. Clifton has agreed to speak at SAWC Fall on “Healthcare Reform: A Simplified Practical Update for Clinicians.” Don’t miss it. n Caroline Fife, MD, FAAFP, CWS 4
March 2014 Today’s Wound Clinic®
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businessbriefs Confusion Reigns: 2014 Coding, Coverage, & Payment for CTPs Kathleen D. Schaum, MS
Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The ultimate responsibility for verifying information accuracy lies with the reader.
T
he 2014 packaging of cellular and/ or tissue-based products for wounds (CTPs) [old term “skin substitute”] by the Centers for Medicare & Medicaid Services (CMS) has tested the revenue cycle acumen of hospital-based outpatient wound care department (HOPD) teams throughout the country. Not a day goes by that this author does not answer at least a dozen phone calls pertaining to this topic. Therefore, the editorial board of Today’s Wound Clinic decided to conduct a survey to learn whether or not HOPD clinical and financial teams are “dotting all their I’s and crossing all their T’s” to implement this new packaged payment change. (For full analysis on this survey by TWC editorial board experts, please see page 12.) After answering hundreds of questions and reviewing the survey responses, this author can sum up the success of CTP packaging implementation among wound care clinics across the country in two words: Confusion reigns! Following are some of the wise and questionable decisions that HOPD teams have made in relation to CTPs: A) Wise Decisions • Continued to use CTPs with published measurable clinical evidence that the patient, HOPD, and payer can afford. 6
March 2014 Today’s Wound Clinic®
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• Ordered a variety of CTP sizes (rather than one size) to minimize wastage as the wound closes. • Added new Healthcare Common Procedure Coding System (HCPCS) codes for the application of “low cost” CTPs to the charge description master (CDM) and paper/electronic charge sheets. • Continued to bill Medicare for “Q” codes and add-on codes. • Contacted private payers, Medicare Advantage Plans, Medicaid, TRICARE, etc. to learn if they will be using the new HCPCS codes C5271-C5278 or if they will continue to use 15271-15278; made accommodations in the CDM for these situations. • Refined the CDM to reflect the correct charge per sq cm of the CTPs they use. • Ran “dummy” claims to be sure the claims reflect all the correct application codes, add-on codes, and CTP codes; all the correct units; and all the correct charges. • Educated patients about their coinsurance responsibilities. • Reviewed the local coverage determination (LCD) revisions their Medicare Administrative Contractor (MAC) released regarding coverage of CTPs. • Implemented a tracking program to show the positive and negative clinical impacts of packaging of CTPs. • Implemented a tracking program to show the positive and negative financial impacts of the packaging of CTPs. B) Questionable Decisions • Continued to use CTPs that cost more than the Medicare allowable rate. • Ignored budgets and ordered all “high cost” CTPs. • Started to use CTPs that are not covered by their MAC. • Started to use products that do not have
published clinical evidence. • Started denying access to CTPs. • Admitted patients to hospitals for skin grafts rather than using CTPs in the HOPD. • Did not update the CDM and paper/ electronic charge sheets to accommodate coding and payment changes. • Did not make accommodations for private payers who may still use 1527115278 for application of “low cost” CTPs. • Removed the “Q” codes and add-on codes from the CDM because Medicare does not pay separately for them. • Began billing surgical dressings with the codes for the application of “low cost” CTPs. • Stopped using “JW” modifier when required by their MAC. • Assumed Q4100 was covered by all MACs. This list could go on and on . . . To calm the confusion, the remainder of this article will discuss key considerations that HOPD teams must address when implementing packaged Medicare payment of CTPs.
CLINICAL CONSIDERATIONS TO IMPLEMENT PACKAGED PAYMENT HOPD personnel and qualified healthcare professionals (QHPs) who work in HOPDs should review the CTPs that are ordered and applied in the HOPD. Published clinical evidence and clinical practice guidelines should be “top of mind” for QHPs. With the plethora of CTPs on the market, QHPs should always contact the medical affairs department of CTP manufacturers to obtain reprints of published clinical trials and should research ongoing clinical trials that must be listed on www. clinicaltrials.gov. QHPs should select the www.todayswoundclinic.com
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businessbriefs “right”product with the“right”evidence for the “right patients” at the “right” time. This should include selecting the “right” size product for the wound as it decreases in size. NOTE: The aforementioned survey showed numerous QHPs have switched to products without proof of published clinical evidence. Some even switched to products that claimed to be CTPs but have been assigned surgical dressing codes by CMS. The survey also showed that many HOPDs only order one size of product, which leads to a lot of wastage. HOPD teams should review the products with published clinical evidence available in a variety of sizes.
FINANCIAL CONSIDERATIONS TO IMPLEMENT PACKAGED PAYMENT HOPD personnel and QHPs should also consider the price of the CTPs (for the patient, the HOPD, and the payer). The new packaged Medicare payment makes it financially cumbersome to consistently use CTPs that cost more than the Medicare allowable. QHPs should work with their HOPDs to balance the use of “high cost” and “low cost” CTPs. HOPDs should work with their revenue cycle team to: 1. Update the CDM with the correct charge per sq cm for each CTP used in the HOPD. NOTE: Our survey showed many HOPDs have not correctly adjusted their charges for the CTPs. Remember: The 2014 charges for the CTPs to Medicare will determine the packaged payment rate for HOPDs in 2016. HOPD revenue cycle teams need to pay serious attention to setting the charges correctly to reflect their actual costs and overhead and to verify the correct charges actually make their way onto Medicare claims. Caution: Upon reviewing the 2012 Medicare claims data (which set the 2014 Medicare allowable packaged rates for the application of the CTPs), it was found that HOPDs actually only billed for 60% of the cost of CTPs. If that continues in 2014, the packaged payment rates will reduce further in 2016. 2. Ensure they are correctly reporting www.todayswoundclinic.com
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the number of sq cm opened for the patient encounter and that the correct number of units is submitted on the Medicare claims. NOTE: Our survey showed: A) that many HOPDs are still incorrectly reporting a unit of “1” when they should be reporting the total number of sq cm opened for the patient and B) that the HOPD has not established a process to audit the submitted claims. These major errors cause two “negative” things to happen: 1. The MACs pay the HOPD for only 1 sq cm rather than for the total number of sq cm opened for the patient and 2. CMS receives incorrect charge data on which to pay the claim and to set the future Medicare packaged payment allowable rates. 3. Adjust their CTP charges when manufacturers release price changes. NOTE: Our survey showed some HOPDs are lackadaisical about updating the CDM to reflect price changes. Some even report they only make changes to the CDM on an annual basis. Once again, this provides incorrect pricing information to CMS. 4. Select the right size product for the wound as it gets smaller and document wastage in the medical record and on the claim form (if required by their MAC). QHPs and HOPD personnel should research their MAC’s direction pertaining to wastage. NOTE: Our survey showed QHPs are not following their MAC’s directions for documenting wastage in the medical record and reporting/not reporting wastage on the Medicare claim form. 5. Collect the patient’s coinsurance, either from the patient or from the secondary payer, for the application of the CTP. NOTE: Our survey showed HOPDs are not consistently collecting patient coinsurance. In fact, some HOPDs reported that they look to the CTP manufacturer to pay for the coinsurance directly or in-kind.The hospital’s contract with Medicare states that the hospital will hold the Medicare beneficiary responsible for the coinsurance. Therefore, HOPDs should not look to the CTP manufacturers to pay for the
coinsurance directly or in-kind.
CODING CONSIDERATIONS TO IMPLEMENT PACKAGED PAYMENT HOPDs should update their CDM and paper/electronic charge sheets with codes for the application of “high cost” CTPs (15271-15278) and “low cost” CTPs (C5271-C5278). They should continue to use the add-on codes and the “Q” codes for the CTPs.They should work with their revenue cycle team to handle coding for payers who do not intend to use the C5271-C5278 codes. They should not use C5271-C5278 for the application of products that have surgical dressing codes. HOPDs should also verify that the correct units opened for the patient are reported on their paper/electronic charge sheets, that the CDM is set up to correctly handle those units,and that the claim contains the correct number of units. The only way to verify this is to either run “dummy” claims or to conduct audits on paid/denied Medicare claims for CTPs. NOTE: Our survey showed many HOPDs have switched to CTPs that map to the new “low cost” HCPCS application codes. However, many HOPDs reported they did not add the new C5271C5278 codes to their CDM. In addition, the survey showed many HOPDs ceased reporting the “Q” codes for the products. Both of those errors will prove to be disastrous:Their claims will be denied and their Medicare allowables will drop in 2016.
PAYMENT CONSIDERATIONS TO IMPLEMENT PACKAGED PAYMENT HOPDs should update their charges for 15271-15278 to reflect their true costs for labor, supplies, dressings, etc. when the QHP applies “high cost” CTPs. In addition, they should establish charges for C5217-C5278 to reflect their true costs for labor, supplies, dressings, etc. when the QHP applies “low cost” CTPs. When submitting their claims to Medicare, HOPDs should take great care that the “Q” codes for the CTPs designated by Medicare as “high cost” are submitted with 15271-15278; if they are not, the claim will not be paid. Likewise, HOPDs should take great care that the “Q” codes for the CTPs designated by Medicare as Today’s Wound Clinic® March 2014
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businessbriefs “low cost” are submitted with C5271C5278, as this will prevent claims denial. The correct charge for the entire CTP piece purchased for the patient should be submitted to Medicare even though the payment for the product is packaged into the application payment. HOPDs should also still include the add-on codes along with the correct number of units and the correct charges when CTPs are applied to wounds larger than the base codes (25 sq cm or 100 sq cm). NOTE: Our survey showed many HOPDs have not: 1) updated the charges in their CDM, 2) continued to include the charges for the CTPs on their claims, and 3) continued to include the charges for the add-on codes on their claims. In addition, very few HOPDs have established a process to verify that the correct codes, units, and charges are actually on the claims. Additionally, numerous HOPDs have begun using products that have not been designated by Medicare as “high cost” or
“low cost” CTPs. Those claims will be denied. Finally, most HOPDs have failed to discuss the packaged payment system with their patients. When the patients start seeing their claims and their new coinsurance amounts, they may be upset that they were not informed.
COVERAGE CONSIDERATIONS TO IMPLEMENT PACKAGED PAYMENT Everyone knows the existence of a code and a payment rate is not a guarantee of Medicare coverage. HOPDs should monitor their MAC website for CTP coverage changes. As of TWC press time, several MACs had updated their LCDs, one MAC had retired its LCDs and listed the non-covered CTPs in the “non-covered services” LCD, and the other MACs had remained silent about the packaged payment changes. (Keep looking for their coverage guideline updates.) Three themes are resonating in the updated LCDs: 1. Documentation of medical neces-
sity and use of the product according to FDA label instructions is of utmost importance. 2. Minimizing wastage and documentation of wastage is very important to the MACs. 3. The MACs intend to monitor appropriate usage through postpayment reviews. Therefore, selecting the “right product” with the “right evidence” in the “right size” for the “right patient” at the “right time” has never been more important. NOTE: Our survey showed many HOPDs believe they can ignore their MAC’s LCD and use any CTP now that Medicare payment for the CTP is packaged. Nothing is further from the truth. The MAC’s coverage rules should still be your “rule book.”n Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached at kathleendschaum@bellsouth.net.
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A complimentary webinar brought to you by Smith & Nephew
2014 Medicare Reimbursement
“Information for Implementation” By Qualified Healthcare Professionals (QHPs), Hospital-Based Outpatient Wound Care Departments (HOPDs), and Ambulatory Surgery Centers (ASCs)
Presented by:
Kathleen D. Schaum, MS Director, Medical Products Reimbursement, Biotherapeutics Smith & Nephew, Inc.
This 60-minute webinar will provide information from the 2014 Medicare Final Rules (OPPS, MPFS) related to the wound care products of Smith & Nephew’s biotherapeutics business. You and your team will find this information very useful when implementing your 2014 reimbursement process updates, specifically for cellular and/or tissue-based products for wounds (CTPs) [old term “skin substitutes”] and surgical/medical debridement. The main topics that will be covered during the webinar are: • Coding and coverage changes that may affect your Medicare reimbursement in 2014 • Medicare payment changes that may impact QHPs, HOPDs, and ASCs • Documentation and billing procedures that should be implemented in January 2014
View webinar: www.woundsresearch.com/2014reimbursement Supported by
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THE EVOLVING LANDSCAPE OF
IMPACTS ON WOUND CARE? Roshunda Drummond-Dye, JD
I
n this dynamic post-reform healthcare climate, wound care clinicians must understand the implications of the Patient Protection and Affordable Care Act of 2010 (PPACA) and other reform programs on their practice. As an interdisciplinary treatment that is provided within essentially all settings throughout the care continuum, wound care is and will continue to experience far-reaching effects of healthcare reform not only in terms of the provider community but also the patient population. Many notable provisions of the PPACA have already taken hold and have produced a major impact on the US healthcare system, such as those related to a small-business health insurance tax credit, high-risk pools, and mandated coverage by insurers. Arguably, the cornerstone provisions of the history-making law become effective in 2014 with the creation of health insurance exchanges, the expansion of Medicaid, and individual and employer mandates. From a provider perspective, the federal healthcare reform agenda can be broken down into three key areas: innovative practice models, quality measurement, and outcomes and healthcare expansion. It is through each of these areas that the Department of Health and Human Services is meeting the goals of the Center for Medicare & Medicaid Services’ (CMS) Triple Aim Initiative, which seeks to improve care and outcomes for individuals and patient populations while lowering growth in expenditures. This article will discuss the role of wound care providers within similarly emerging collaborative-care models, the evolution of quality measurement under the PPACA, and the effects on wound care providers commensurate with the expansion of coverage provisions such as Medicaid expansion and essential health benefits brought about by reform. 10 March 2014 Today’s Wound Clinic®
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INNOVATIVE PRACTICE MODELS
The integration of healthcare providers such as wound care clinicians into one entity that provides seamless care and is incentivized to streamline processes, reduce redundancies, and increase efficiencies are the basic tenets behind the three emerging models of care: accountable care organizations (ACOs), bundled payment models, and patient-centered medical homes (PCMHs). The main vehicles for ACOs are the establishment of Medicare’s Shared Savings Program and the Pioneer ACO model managed by the Center for Medicare & Medicaid (CMS) Innovation (CMMI). ACOs are networks of physicians, hospitals, physical therapists, and other providers that are encouraged and incentivized to work together to provide quality care and achieve savings within Medicare feefor-service. In order to achieve success, ACO providers must coordinate care for a defined patient population and meet certain quality metrics that include patient/ caregiver experience, care coordination/ patient safety, preventive health, and atrisk populations and frail/elderly health. (For an exclusive Today’s Wound Clinic Q&A with a physician participating in the Pioneer ACO, see page 19.) The eligible providers who form ACOs are physicians, hospitals, networks of individual practices, partnerships, joints ventures between physicians and hospitals, critical access hospitals, rural health clinics, and federally qualified health centers. All other providers such as PTs in private practice, home health agencies, skilled-nursing facilities (SNFs), outpatient rehabilitation facilities, and comprehensive rehabilitation facilities are eligible to participate in an ACO but cannot form ACOs on their own, as the statute explicitly lists only the eligible providers aforementioned as those who can form ACOs as a singular provider. These providers and suppliers must
form contractual relationships with ACOs that define the scope and duration of their involvement and their applicable percentage of shared savings to be derived at the end of each ACO performing year over a three-year contractual obligation. According to CMS, 343 ACOs are currently operating through the Shared Savings Program in 47 states plus the District of Columbia and Puerto Rico. More than half are physician-led and serve fewer than 10,000 beneficiaries while 20% include a community health center, rural health clinic, or critical access hospital. While ACOs are responsible for the comprehensive care of a defined patient population, PCMHs are keenly focused on improving primary care.The American Academy of Family Practitioners defines a PCMH as a patient-centered comprehensive system that provides an ongoing, active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive, and chronic care management through all stages of life. Many of the resources in the PCMH have been focused on the state level, as state entities have been provided grants through PPACA to create medical homes based on unique state constituency needs. PCMHs have shown great promise to achieve outcomes among pediatric and Medicaid populations. To specifically address cost containment, PPACA mandated the pilot testing of bundled payments, which represent single payments made for a defined group of services that may cover services furnished by a single entity or items and services furnished by several providers among multiple care-delivery settings. Bundled payments may be conducted for a single negotiated episode payment of a predetermined amount for all services paid prospectively or retrospectively. In order to carry out the bundled paywww.todayswoundclinic.com
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woundcare&healthreform ment mandate, CMMI launched its Bundled Payments for Care Improvement Initiative in January 2013 for organizations to volunteer to enter into payment arrangements that include financial and performance accountability for episodes of care in four different models. Under model No. 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare will pay the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare will continue to pay physicians separately for their services under the Medicare Physician Fee Schedule. In model No. 2, the episode of care will include the inpatient stay in the acute care hospital and all related services during the episode. The episode will end 30, 60, or 90 days after hospital discharge. For model No. 3, the episode of care will be triggered by an acute care hospital stay and will begin at initiation of postacute care services with a participating SNF, inpatient rehabilitation facility, longterm care (LTC) hospital, or home health agency. The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end either a minimum of 30, 60, or 90 days after the initiation of the episode. With model No. 4, CMS will make a single, prospectively determined bundled payment to the hospital encompassing all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Each model allows participants to select up to 48 different clinical condition episodes. If the pilot project is deemed successful, such payment bundling practices can be extended and made permanent.
QUALITY MEASUREMENT & OUTCOMES
The second major theme of the PPACA is linking payment to quality. Over the past several years, CMS (along with the quality community, namely the National Quality Forum) has worked to create www.todayswoundclinic.com
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consensus-based process, structural, and outcomes measures that assess the impact of specific interventions on patient care across the continuum.These programs are referred to as pay-for-performance in the Medicare outpatient setting while valuebased purchasing is the correct nomenclature in the post-acute care arena. In the past, these programs have merely sought to achieve accurate and consistent reporting, but in this era of reform, CMS has moved from quality reporting to basing payment on the data collected. This is especially true among the new innovative models such as ACOs and bundled payment. Both initiatives are specifically linked to a set of quality indicators that measure the success of these models on patient care. If better outcomes are achieved at a lower cost, providers are incentivized to continue this behavior by being awarded bonus payments from the derived savings. Of particular interest to wound care clinicians is the standardization of readmissions and pressure ulcer measures in the acute care and inpatient rehabilitation facilities. Wound care complications play key roles in hospital readmissions. Therefore, hospitals are relying heavily on wound care clinicians to ensure that quality care is provided to avoid costly conditions associated with pressure ulcers and other wounds. Medicare payment reductions were estimated to impact 1,400 hospitals in fiscal year (FY) 2013 and more than 2,200 acute care hospitals in FY 2014 by as much as 5% for each Medicare claim.
HEALTHCARE EXPANSION
The Medicaid program has transformed from a welfare benefit program to a complex system of care that plays three main roles: providing health insurance to more than 52 million individuals (including 25 million children) who otherwise would be uninsured, covering LTC services to Medicare recipients and lower- and middle-income families, and providing subsidies to safety net providers. Per the Supreme Court case, National Federation of Independent Business v. Sebelius, state Medicaid programs have the option of expanding coverage to nearly all people younger than age 65 with incomes of $14,856 per year for individuals and $30,657 per year for a family of
four based on federal the poverty level for 2012. A few states have obtained waivers from CMS to cover populations whose incomes are well above these levels. The reality, however, is that most states do not offer such coverage, as they are struggling financially to cover the minimum populations mandated by federal law. In addition, the PPACA required most US citizens and legal residents to have health insurance by 2014. Tax credits and subsidies will be available to help people obtain coverage, but individuals who lack health insurance will be subject to penalties. To purchase health insurance, individuals can go to state-based exchanges or federally facilitated exchanges, depending on their state. Through these exchanges, individuals and small employers can buy insurance through private insurers or multi-state health plans. The “essential” health benefits that must be included in the plans offered within the exchange and Medicaid expansion must contain ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services including oral and vision care.Wound care may be covered under a number of the “essential health benefits” such as ambulatory patient services, rehabilitative care, hospitalization, preventive and wellness, and chronic disease management. There are several opportunities for the wound care community to play a pivotal role in healthcare reform. The initiatives discussed here are just a sampling of the prime areas in which access to quality wound care can impact outcomes, improve population health, and decrease costs. It is imperative that wound care clinicians actively seek out opportunities to show the value of their services as part of the interdisciplinary team by collecting and disseminating meaningful data through clinical data registries and other quality-measurement initiatives. Roshunda Drummond-Dye is director of regulatory affairs in the public policy, practice and professional affairs unit with the American Physical Therapy Association,Alexandria,VA. Today’s Wound Clinic® March 2014
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Transitioning to Packaged CTP Payments in Wound Care: No Easy Adjustment Caroline Fife, MD, FAAFP, CWS & Kathleen D. Schaum, MS
New Hospital Outpatient Prospective Payment System (OPPS) rules governing payment for use of CTPs are officially in effect. But are wound care clinics embracing and following measures appropriately? The answer may surprise you.
T
he new method regarding packaged payment for cellular and/or tissuebased 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?
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n Yes 50.8% n 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?
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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? n Yes 29.6% n 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
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woundcare&healthreform 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?
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.
n 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-
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? n Yes 44% n No 56% KS: Here is a key point: 44% of respondents have made CDM changes. Their
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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 C5271C5278? n Yes 18.1% n 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. Today’s Wound Clinic® March 2014 13
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woundcare&healthreform 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? n Yes 29.1% n 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? n Yes 27.5% n 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
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changed since the packaging of the cost of the product within the OPPS payment for the procedure? n Yes 32.3% n 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? n Yes 14.3% n 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 pa-
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tients 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? n Yes 15.3% n No 84.7% Has your hospital/HOPD implemented a tracking program to show the positive or negative financial impact of the packaging of CTPs? n Yes 16% n 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.
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CHOOSING & IMPLEMENTING THE ‘RIGHT’ MANAGEMENT STYLE FOR YOUR CLINIC
Wound care management is under the microscope from a quality and financial perspective by an environment created by healthcare reform. Are you appropriately managing your clinic?
Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA; Michael Comer & Melissa Bailey
S
ince the Affordable Care Act (ACA) was signed in 2010, time has ripened for wound centers to offer effective patient care and still manage to experience financial profit. With the shift of focus toward preventative care, savvy hospitals will emphasize outpatient services that offer controlled costs and efficient service. Wound centers are continuing to be practical options to reduce inpatient stays for nonhealing wounds. Whether you’re revitalizing a facility or starting from the ground up, there are management options that should be considered to ensure that the effectiveness of your wound center is sustainable. This article will discuss different approaches to outpatient wound clinic management while addressing the respective pros and cons inherent with each.The authors will then break down the various operational components that should be included regardless of management approach.
DETERMINING MANAGEMENT STYLE Changes in healthcare law have created an outpatient-focused landscape. Population health has displaced the focus from successfully treating symptoms to offering preventative care that results in fewer inpatient hospital stays and surgeries. In today’s environment, wound centers must find ways to maintain profit margins, offer effective care, and keep driving their goals in order to achieve clinical and financial success. Researching and committing to a specific management style is crucial to such success. There are three predominant styles of management when it comes to providing wound care. The first option to consider has historically dominated the industry’s landscape: employing a comprehensive management company that charges a yearly fee to run the center. The second option operates as a services-based approach that manages various components of a wound center in areas such as auditing, staffing, marketing, technology, and education while 16
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leaving the overall operations in the hands of the wound center and/or hospital.With the third model, the center refrains from any outside management involvement, allowing complete control to rest in the hands of whichever entity owns the center (self-management).What follows is detailed information on each approach. Comprehensive Management In a comprehensive management model, an outside company is hired to direct day-to-day operations. A comprehensive management company will be paid a yearly fee to manage and maintain operative control of the center. With this model, a contractual agreement is reached to provide comprehensive management that begins with implementation and extends to financial support, staffing, technology, education, and marketing, etc. Oftentimes, a comprehensive management company requires little to no initial financial investment from the hospital, but will require a contract to protect the investment. This management style can be a worthwhile option for an existing center. A reliable management company will conduct a thorough assessment of the clinic and slowly take control of managerial responsibilities. The company will monitor billing and coding, implement new policies and procedures (if necessary), provide staff training, and create a robust marketing program to ensure a strong referral and patient base. Much like a start-up, most management companies will require a long-term contract to manage the center. Historically, hospitals partnered with management companies to direct smaller revenue sources such as wound centers. It was easier to place the center in someone else’s hands and rely upon them to keep it functional rather than deal with the challenges (eg, billing and coding, staffing, electronic health records) that came with the daily operations of running the clinic.With decades of experience in which to analyze this approach, several primary weaknesses
have surfaced:The yearly management fee can severely cut into profits and in instances where a contract with the management company ends, the clinic stands to lose everything provided by the management company (including key personnel, policies and procedures, and equipment). The comprehensive approach continues to work well when the wound center enters a flexible partnership with the management company. Reasonable fees should be offered so the center can achieve profitability. Should the clinic be ready to operate without a management company, agreements that allow the center to keep policies and procedures, equipment, key staff, etc. need to be in place. Instead of seeking complete control, a vibrant partnership should be desired where the management company seeks to pass down knowledge as well as provide management based on contractual obligations. Services-Based Management Similar to a comprehensive management approach, services-based management begins with an honest assessment of the center. Instead of contracting for a complete management takeover, this model allows the center to pick and choose areas that need outside management assistance. Typically, services offered include implementation, billing, auditing, marketing, technology support, staffing, and education. In this management style, the bulk of control still rests in the hands of the clinic director while a partnership is forged between the wound center and the management company that offers a collaborative and team-based approach. Before entering into a service-based agreement, clinic administration should be knowledgeable of the state of its program (eg, finances and healing rates). This may seem like an obvious component of the process, but oftentimes directors are simply unaware of potential weaknesses, especially in the areas of finances and patient care. Even if a management www.todayswoundclinic.com
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woundcare&healthreform company provides an assessment, the director should be able to correctly evaluate his/her center independent of the initial assessment. The key to making this approach work is to protect all aspects of the facility from outside ownership. This includes policies and procedures, key staff, and equipment. If a services-based management company insists on owning the piece that it manages, the center becomes dependent on the management company to operate. One of the greatest benefits of this approach is flexibility. It allows the center to employ a management company and still maintain control of the clinic. As long as the management company is willing to assist without a long-term contract, the relationship will be mutually beneficial. Self-Management For some wound centers, when faced with the mire of management company choices, the possibilities of self-management become more attractive. Self-management allows a wound center to build itself from the ground up. This is by far the most difficult model in terms of risk assessment, as it puts the full weight of both management and financial responsibility upon the hospital. This includes implementation, staffing, billing and coding, policies and procedures, marketing, education, equipment, and technology. At the same time it may also be the most emotionally rewarding method when success is experienced. In order to flourish, the self-management approach requires a team of committed professionals that is willing to learn and acquire the necessary skills to run a profitable wound center. Centers that desire self-management might benefit if this is the goal, not the starting line. If desirable, a wound center could build a strong partnership with a like-minded management company that can eventually assist the center in reaching a self-management model.
OVERVIEW OF CORE CLINIC COMPONENTS Regardless of which type of management style chosen, there are some common components that warrant consideration. Implementation, auditing, staffing, 18
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marketing, education, and technology are all important aspects that affect the operations of an effectual wound center. Implementation Implementation encompasses the overall development of the center, including geographical placement, equipment accrual, and initial setup. The management company will also assist in creating clear policies and procedures to serve as the foundation for the center. Clear implementation is necessary to ensure that a center begins appropriately from Day 1 and continues moving in the right direction. Auditing With the landscape of today’s healthcare reform, strong financial support may be the difference between success and failure for a wound center. Having a financial team in place to monitor charts and track changes in coding creates an extra layer of protection should the center face an audit and assists staff in staying current on new regulations and regulation changes.The proper auditing support ensures the center is being reimbursed for each provided service. Staffing Securing quality personnel is vital to clinical and financial success. A management company can assist the center in finding the best people and provide necessary training in specialized wound care. Rather than focusing on the specific position, a reliable management company will take the time to learn the company culture and seek passionate candidates who will take ownership of their position within the clinic. In this model, hiring from within the industry is often not the best approach as focus can be placed on intangible commodities such as personality and work ethic before seeking clinicians experienced in wound care. If a management company is doing its job well, it should be able to relay and transfer industry knowledge to the right candidate, regardless of specific medical expertise. Marketing A strong marketing partnership estab-
lished with a management company can also be provided. This can assist with such needs as building a database of patient referrals, maintaining relationships with local doctors and hospitals making those referrals, and providing promotional and advertising materials as necessary. Even in this crucial component of the process, the goal should be on sustainable programs that increase revenue for centers. Effective marketing models must be customizable for your specific center, taking into consideration community demographics and company needs. Education and Technology The two final services that management companies can provide are the technology to manage and run an electronic medical record system and the educational pieces for both patients and clinical staff.The two often go hand in hand as patients become more technically savvy and require education that meets the demands of a digital world. Another important component of educational resources is training on the current reimbursement guidelines of the Centers for Medicare & Medicaid Services. Hospital systems must be ready to implement ICD-10-CM codes by Oct. 1. The new coding system will use both numbers and letters, forcing system updates to ensure compatibility. There has also been a major shift in biologics as products have been divided into “high cost” and “low cost” options with varying reimbursement rates. If not closely monitored, clinics may be using expensive products and not recouping out-of-pocket expenses. A management company should provide these services to help the clinic stay focused on what it does best: healing patients. Regardless of choosing an outside management company or conducting selfmanagement, the clinic must possess and work toward a long-term vision. Know where you are with your center before partnering with a management company, if that’s the chosen route. n Trisha Markowitz is a member of the TWC editorial board. Michael Comer is chief executive officer and Melissa Bailey is director of education at Wound Care Advantage, Sierra Madre, CA. www.todayswoundclinic.com
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HealthcareReformQ&A
Interview With ACO Physician
A
s part of our special edition on the state of health reform in wound care, TWC offers this exclusive Q&A with a member of the nationally distinguished Medicare Pioneer ACO. On Jan. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) launched its Pioneer Accountable Care Organization (ACO) Program, a collaborative of healthcare entities selected to participate in an initiative to examine the clinical and Parag Agnihotri, MD financial effects of a Medicare ACO shared-savings program. Overseen by the Center for Medicare & Medicaid Innovation (CMMI), the Pioneer ACO is designed to work in coordination with private payers by aligning provider incentives that will improve quality and health outcomes for patients across the ACO and achieve cost savings for Medicare, employers, and patients. Applicants were chosen to launch the ACO on Jan. 1, 2012, based on previous engagement in similar programs that featured coordinated patient care and quality metrics. According to CMS officials, savings from both the Pioneer ACO, which is operating on a three-year pilot venture during which clinical outcomes and cost savings will be evaluated, and its Medicare Shared Savings Program,an initiative that helps eligible providers, hospitals, and suppliers form ACOs that’s currently accepting applications, have exceeded $380 million. Today’s Wound Clinic recently spoke with Parag Agnihotri, MD, medical director, continuum of care, with Sharp Rees-Stealy Medical Group, San Diego, a facility among the 32 Pioneer ACOs. We discussed the initiatives within the Sharp HealthCare ACO, including those directly impacting wound care; the clinical and financial motives behind his ACO; the estimated success
of the ACO; and the future plans for the ACO. What follows is an excerpted Q&A from our conversation. Today’s Wound Clinic (TWC): Who are the members of your ACO? Parag Agnihotri (PA): The Sharp HealthCare ACO includes three partners — Sharp Hospital, Sharp Rees-Stealy Medical Group, and Sharp Community Medical Group. TWC: What has been the most significant impact on your wound program since the ACO formed? PA:I think we are looking at a team-based model of delivering wound care in the most timely manner. It’s all about getting the right person the right care in the right time period. We recently partnered with a clinic-based wound care specialist,but there are also many patients in the home who cannot make the journey to the wound care clinic on a regular basis, or it’s a significant burden. But because of our ACO relationship we’ve been able to build a home care program where nurse practitioners (NPs) are seeing patients in the home and providing ongoing virtual consultation through telehealth interface and providing that wound care specialty expertise so that we can avoid unnecessary hospital visits and hospitalizations. And we couldn’t have done this without the ACO or the new payment model. TWC:Whathavethefinancialimpactsbeen? PA: Before the ACO, if you were seeing a non-managed care patient there was never a financial incentive for the healthcare industry to really manage the sickest of the sickest patients well. Now, from a business point of view, there is a big financial incentive to manage the sickest patient and to reduce the burden of chronic disease because of cost savings. We’re not seeing more money just for seeing these patients; it’s all about the ACO payment model and meeting quality benchmarks. I think that what we’re seeing is an over-
www.todayswoundclinic.com
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all reduction in admissions to hospital and emergency room visits, and I’m pretty sure that there are patients with wound care issues who we’re able to also keep out of post acute care and the nursing home by caring for them at home and demonstrating the cost savings there as well. TWC: HowisyourACOpaymentstructured? PA: There are two ways you’re paid through the ACO relationship: On top of the traditional fee-for-service payments, if you can demonstrate that you’ve provided quality care — for example, with a wound care patient you ensured that they received a pneumonia vaccination,or their diabetes is under control, or their cardiovascular conditions are well managed — that’s a gateway into a shared-savings bucket.So,if tomorrow the wound care patient uses fewer hospital visits for patients,Medicare keeps 50% of the money and the other 50% comes back to the group. And you can apply that money in different ways, so not only do you get paid for submitting claims for Medicareapproved charges, but you get the extra incentive dollars for meeting quality standards. TWC: How are quality measures tracked? PA: We have 33 specific measures from CMS that we have to report to Medicare, which include preventive care, care coordination, taking care of chronic diseases, etc. We not only have to show that patients had access to care and were satisfied with their care,but things like vaccination records,their cancer screenings, fall screenings, etc. For wound care patients, one of the most important things is nutrition,so for Medicare patients we now have to show how they’re doing with their nutritional status.Are they declining? Are they overweight? And most of the time with seniors it’s under-nutrition. So our participation in this ACO has helped us be proactive with our patients in their nutrition management. TWC: How did CMS provide you with your ACO patients? PA:There is a complex attribution model through which CMS assigns you patients who they believe should be part of the ACO. Today’s Wound Clinic® March 2014 19
3/12/14 11:08 AM
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Limb Regeneration: Neuro-Responsive Prosthetics and Beyond
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A Patient-Centered Approach to Dressing Selection
The Challenge of Chronic Osteomyelitis: Diagnosis and Treatment
Complex Wound Closure: Primary Vs. Secondary Intention
Woundologist: Transitioning Care Givers in Our Emerging Specialty
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WWW.SAWCSPRING.COM Co-Chair Robert Kirsner, MD, PhD Co-Chair Dot Weir, RN, CWON, CWS Intended Learners This conference is designed for physicians, nurses, physical therapists, researchers, podiatrists, and dietitians involved in wound healing or wound care issues. Learning Objectives Employ an interdisciplinary approach to wound prevention, treatment, and limb salvage Describe the comprehensive management of patients with venous, arterial, and diabetic wounds Provide optimal healthcare delivery through improved understanding of payment schema, healthcare reform, and the use of novel wound care delivery technologies that allows for better wound care documentation Implement the latest best-practice strategies to prevent and manage pressure ulcers. Develop a systematic approach for assessing patients with skin problems, generate differential diagnosis of skin lesions, and determine treatment options for some common and unusual skin conditions Describe various factors that inhibit wound healing including medical comorbidities, commonly used drugs and devices, and patient behavioral challenges
Review challenging cases of difficult-to-heal wounds where current and emerging wound therapies were used Assess existing evidence-based criteria for efficacy of commonly used wound care treatments including negative pressure wound therapy and hyperbaric oxygen therapy Accreditation Information This activity has been planned and implemented by North American Center for Continuing Medical Education, LLC (NACCME) and the Wound Healing Society (WHS). NACCME is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Physicians NACCME designates this live activity for a maximum of 30.00 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity. 5.5 AMA PRA Category 1 Credits™ for WHS Day 1 4.0 AMA PRA Category 1 Credits™ for the pre-conference 17.5 AMA PRA Category 1 Credits™ for the main conference 3.0 AMA PRA Category 1 Credits™ for the post-conference AAPA accepts certificates of participation for edu-
cational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 30.00 hours of Category 1 credit for completing this program. Nurses This continuing nursing education activity awards 5.5 contact hours for WHS Day 1, 4.0 contact hours for the pre-conference, 17.5 contact hours for the main conference, and 3.0 contact hours for the post-conference. Provider approved by the California Board of Registered Nursing, Provider Number 13255 for 5.5 contact hours for WHS Day 1, 4.0 contact hours for the pre-conference, 17.5 contact hours for the main conference, and 3.0 contact hours for the post-conference. This continuing nursing education activity awards up to 3.25 pharmacology hours. Podiatrists North American Center for Continuing Medical Education, LLC (NACCME), is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine. This program is approved for 5.5 contact hours for WHS Day 1, 4.0 contact hours for the pre-conference, 17.5 contact hours for the main conference, and 3.0 contact hours for the post-conference.
Dietitians North American Center for Continuing Medical Education, LLC (NACCME), is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). CDR Credentialed Practitioners will receive 5.5 continuing professional units (CPEUs) for WHS Day 1, 4.0 continuing professional education units for the pre-conference, 17.5 continuing professional education units for the main conference, and 3.0 continuing professional education units for the post-conference for completion of this activity/material.
the online general survey and the online evaluation form for each session by May 27, 2014. Complete the forms at http://www.myexpocredits.com/naccme. Once complete, participants may immediately print documentation of credit. For questions regarding this educational activity, please call 609-371-1137. ADA Statement North American Center for Continuing Medical Education complies with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call 609-371-1137. CDR Accredited Provider #HM001 Cancellation Policy Please note the cut-off date for cancellation is March 22, 2014. All cancellations Level 3 Synthesis Level must be received in writing postmarked by that date. Physical Therapists North American Center for Full registration (less a $100 processing fee) will be Continuing Medical Education, LLC (NACCME), will refunded only to cancellations received in writing apply for pre-approval accreditation in California, before the above date. No refunds will be issued after Florida, Louisiana, Ohio, and Texas, which require March 22, 2014 – without exception. Registrations are preapproval. If you practice in another state, please transferable at any time. consult its PT board. *Information contained herein is subject to change Requirements for Credit To be eligible for documen- without notice. tation of credit for each session attended, participants must participate in the full activity and complete
woundcare&healthreform
TWC: How is the ACO aligning with healthcare reform? PA: There are a couple care-delivery programs that we are advancing within the medical group to align with healthcare reform. One is a post acute care model based in the nursing facilities, where the goal is to make sure patients are receiving the appropriate skin care for the right duration of time.The second is a home-based program for NPs whose roles are to care for our frail seniors who are unable to get into the clinic or our younger patients who have chronic medical conditions.Transportation can be a major barrier for many patients. We’re also looking into telehealth
programs to remotely improve the lives of our patients who are living with chronic conditions. TWC: Was your hospital responsible for hiring any of the qualified healthcare professionals who may have had independent practices as part of the ACO? PA: The ACO has a governance board of members from Sharp Medical Group, an independent practice association, and the hospital. As part of the governance board, the hospital does have a voice in which independent practitioners can be part of the
ACO Fast Facts
Based on billing data and algorithms,it’s been determined that in some form these patients have used Sharp HealthCare in prior years. At that point we reached out to all those patients who reside in the community so that we can maintain an ongoing relationship with them. Based on risk stratification we identified the top 10% of our high-risk patients, and for them we deploy different resources, whether it be a case manager, or home health nursing, or NPs.
• In 2009, there were fewer than 40 ACOs; today, there are now more than 500. • Physician groups have overtaken hospitals as the largest backers of ACOs. • From 2010-12, Medicare spending per beneficiary grew at 1.7% annually, more slowly than the average rate of growth in the Consumer Price Index and substantially more slowly than the per capita rate of growth in the economy. • In 2012, hospital readmissions for Medicare patients dropped significantly, with an estimated 70,000 readmissions avoided due to a variety of new incentives for hospitals to keep patients well and avoid these costly events.
ACO. But most of them come through the Sharp Community Medical Group, which is the independent practice, and they decide who comes on board and who does not. TWC: Are you involved in any other risk-sharing contracts with private payers? PA: Most of our managed-care contracts are risk-sharing. We assume full risk for almost all of our commercial contracts, which means we take the full hospital risks, skilled nursing homes risk,pharmacy risks,etc.If the wound care management doesn’t go well it does affect the financial risks. n • Costs for the more than 669,000 beneficiaries aligned to Pioneer ACOs grew by only 0.3% in 2012, whereas costs for similar beneficiaries grew by 0.8%. • All 32 Pioneer ACOs successfully reported quality measures and achieved the reporting rate for the first performance year. • Overall, Pioneer ACOs performed better than published rates in fee-for-service Medicare for all 15 clinical quality measures for which comparable data are available. *Resources: Centers for Medicare & Medicaid Services; MedPage Today
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ASSESSING THE VALUE OF
WOUND CARE CERTIFICATION In today’s increasingly sophisticated and consumer-driven healthcare market, specialty credentials can be that much more valuable.
By Joe Darrah
N
ot long ago, Stanley K. McCallon, PT, role, recently took the time to speak with DPT, CWS, considered himself a bit Today’s Wound Clinic about his wound care of a generalist as a healthcare provid- career, how his certification has excelled er. After launching his career in the mid- that career, and why he believes wound 1990s, McCallon spent his first five years in care certification is becoming an increaspractice working in a traditional physical ingly valuable commodity for those in the therapy role, caring mainly for rehabilita- industry across all clinical scopes of practice. tion patients. But as time passed, one patient population remained particularly in- CERTIFICATION OPTIONS triguing. Before long, he knew that he was Administered by the American Board most needed in caring for those living with of Wound Management (ABWM), the chronic, nonhealing wounds. CWS,® or certified wound specialist, is a for“I developed such a passion for wound mal recognition of a master-level knowlcare through some of those patients I was edge and specialty practice in wound seeing at the time,” said McCallon, 45, di- management that demonstrates a distinct rector of clinical services at and specialized expertise in LSU Health, Shreveport, LA. the practice. “So it became a field that I Available to licensed healthdecided to dedicate myself care professionals holding a to completely.” bachelor’s, master’s, or doctoral Today, that dedication is cedegree with three or more mented not just by his full-time years of clinical wound care commitment to the field, but experience, the CWS was the by the wound care certification ideal choice for McCallon as Stanley K. McCallon, he’s held nearly 13 years. one who wanted to earn and PT, DPT, CWS It’s that specialty stamp on demonstrate a proficiency and the credentials following his expertise in wound care from name that has greatly helped to shape his the vantage point of multiple care settings career and strengthen his impact on others inherent in his profession as a PT. — from patients to colleagues, staff mem“This is the wound care certification for bers, and residents. And as his involve- multidisciplinary practitioners,” he said.“It’s ment within the wound care industry not just reserved for PTs, nurses, or physihas increased with the advanced educa- cians; it brings in all of the disciplines — tion and experience he’s acquired, so too those who are primary providers in wound has that passion. management. It’s always been the true mulMcCallon, who oversees the faculty tidisciplinary exam and certification that’s wound clinic at LSU (as well as a large cohesive and brings everyone under one faculty clinical practice across all LSU al- umbrella in this field, even if there are adlied health programs) in his present clinical ditional specialty exams today.” 22 March 2014 Today’s Wound Clinic®
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Those specialty options offered by the ABWM include the certified wound specialist physician (CWSP®) and the certified wound care associate (CWCA®), which targets a host of professionals including associate degree nurses and nursing assistants, PT assistants, dieticians, researchers, administrators, and even marketing professionals. “The CWSP is geared specifically toward physicians because there was a need for an examination that really addressed their skill set,” explained McCallon, who once served on the board of directors that developed the credential and currently serves as a member of the American Physical Therapy Association and Louisiana Physical Therapy Association.“The CWCA can also be members of industry or sales representatives — that examination was really created to cover an area that we were missing before.”
BENEFITS TO SPECIALTY CERTIFICATION
Beyond the personal satisfaction that comes with acquiring an advanced level of education in one’s field, McCallon said the advantages to attaining his certification have been evident from all aspects of a career perspective. “When any individual gets into an area of interest and ultimately becomes board certified in that area, it serves as a portal into a career path that will keep them plugged into that field and actively learning as it evolves,” he said. The proof is in his own personal evolution: at the time that he earned his CWS he was working in a long-term acute care hospital (LTACH) setting where he would ultimately be promoted to director of rehab and wound care for three different hospitals. He then took a similar position with another LTACH where he also served a role in marketing. “Certification honestly has impacted my career in terms of salary increases and job enhancement, said McCallon, who joined the LSU Health faculty five years ago. “[Money] wasn’t the primary motivator, but from an employment-opportunity standpoint and a marketability standpoint there were many benefits to certification.” The benefits also have included improved stature among colleagues and patients. “It’s an opportunity that allows your peers to know that you’ve met particular standards and proficiencies,” he said. “And www.todayswoundclinic.com
3/12/14 11:07 AM
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Course Faculty Carolyn Cuttino, BSN, RN, CWCN Certified Wound Care Nurse Carolina Wound Care Mount Pleasant, South Carolina Heather Hettrick, PT, PhD, CWS, CLT Associate Professor Nova Southeastern University Department of Physical Therapy Fort Lauderdale, Florida Greg Patterson, Md, FACS, CWS Medical Director General and Vascular Surgery, Bariatric and Metabolic Surgery Archbold Center for Wound Management and Hyperbaric Medicine Thomasville, Georgia Lee C. Ruotsi, MD, CWS, UHM Medical Director, Advanced Wound Healing Centers Catholic Health System Cheektowaga, New York Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA Director of Public Policy and Education American Medical Technologies Irvine, California
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Dot Weir, RN, CWON, CWS Osceola Regional Medical Center Kissimmee, Florida Intended Learners Physicians, podiatrists, surgeons, physical therapists and PTAs, occupational therapists and OTAs, nurse practitioners, physician assistants, master’s prepared nurses, registered nurses, associate degree nurses, dietitians, sales and marketing specialists within wound care Learning Objectives After completing this activity, participants should be able to: Outline the etiology of chronic wounds and extrinsic factors that contribute to and affect wound-healing outcomes Describe the phases of wound healing and the associated microenvironment, cellular components, and their functions in wound healing Identify the anatomy of the skin and other important structures Assess research and evidence related to wound management Describe specific diagnostic tests, examination tests, lab tests, and measures related to wound assessment and management Identify the components of wound assessment and documentation Identify methods for recognizing soft tissue
and bone infections, bioburden management, and treatment of local and systemic infections Discuss nutritional factors and the underlying deficiencies that impact wound healing Relate the psychosocial and cognitive aspects to patient outcomes in wound repair Describe specific treatment interventions for chronic wounds including debridement, topical therapies, and biophysical expertise Activity Overview Taught by three nationally recognized experts and educators in Wound Care, the Wound Certification Prep Course is an intensive 17-hour seminar that provides a comprehensive review of topics related to wound management. The course also includes valuable practice tests and test-taking strategies. Accreditation North American Center for Continuing Medical Education, LLC (NACCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team. Physicians NACCME designates this live activity for a maximum of 17.0 AMA PRA Category 1 Credits™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity. Nurses This continuing nursing education activity awards 17.0 contact hours. Provider approved by the California Board of Registered Nursing, Provider Number 13255 for 17.0 contact hours. Podiatrists North American Center for Continuing Medical Education, LLC (NACCME), is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine. This program is approved for 17.0 contact hours. Dietitians North American Center for Continuing Medical Education, LLC (NACCME) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). CDR Credentialed Practitioners will receive 17 Continuing Professional Education units (CPEUs) for completion of this activity/material. CDR Accredited Provider #HM001 Level 3 Synthesis Level Physical Therapists North American Center for Continuing Medical Education, LLC (NACCME) has received approval for this course from the
following physical therapy boards: California: Memorial Medical Center: 1.7 CEU. This symposium has been approved for 17 contact hours. (Approval MMC2014-002) Florida Physical Therapy Association: 17.0 hour(s) earned. The maximum allowable hours for this program are 17.0. (Provider # 20-425440; Course # CP140322264). Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors. Louisiana Physical Therapy Board: This course has been approved for 17.0 clinical hours. Ohio Physical Therapy Association: This course has been approved for 17.0 contact hours. (Approval 14S0027) Nevada State Board of Physical Therapy: This course has been approved by the Nevada State Board of Physical Therapy Examiners for 1.5 units of continuing education. NACCME has also applied for pre-approved accreditation in Texas, which requires pre-approval. If you practice in any other state, please consult its PT Board. Independent Clinical Reviewer: Robert S. Kirsner, MD, PhD, Vice Chairman, Professor and Stiefel Laboratories Chair, Department of Dermatology University of Miami School of Medicine,
Miami, Florida Nurse Planner: Susie Seaman, NP, Sharp Rees-Stealy Wound Clinic, San Diego, California Requirements for Credit To be eligible for documentation of credit of this live event, participants must attend the full activity and submit a completed evaluation form. Participants who complete the evaluation form online will immediately receive documentation of credit. For questions regarding this educational activity, please call 609-371-1137. ADA Statement North American Center for Continuing Medical Education complies with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please call 609-371-1137. Copyright © 2014 by North American Center for Continuing Medical Education, LLC. All rights reserved. No part of this accredited continuing education activity may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from North American Center for Continuing Medical Education.
2/21/14 2:37 PM
woundcertification over the years we’re seeing more prospective patients who are seeking out providers who have that additional training and expertise. That’s come with time and education, but consumers are more savvy today concerning the advanced qualifications of their healthcare providers.”
CONSUMER CONSCIOUSNESS
Of course, there are other organizations that offer specialty credentials for those within the wound care industry “that are valuable and can be considered,” noted McCallon, a former ABWM president who served from 2008-10. “And that’s made the ABWM more cognizant of the need to have a very strong certification process and to have different avenues for clinicians,” he continued. “I don’t think you would have seen the CWCA or the CWSP come into existence if it had not been for other groups [offering credentials].Assuming that everything is market-driven to an extent, consumers are looking for options. It’s good for us to have that competition.” As a clinician consumer himself, McCallon said he leaned toward the ABWM not just because he was attracted to the range of what the CWS covered, but also because the organization is a nonprofit. “In the world of certification, I think there is more credibility with a group that exists solely to promote and move the wound management profession forward,” he said. “That is a big distinction. I’m not putting any group down, but if you’re looking at all the certifying options, it is important that the ABWM is a nonprofit organization. I believe the ABWM is the gold standard for certifying bodies and that its offerings are superior. The ABWM has an excellent reputation and strong presence in the wound care community.” McCallon said he was also inspired to pursue CWS certification by Joseph M. McCulloch, PhD, PT, FAPTA, CWS, a colleague and dean of the school of allied health professions at LSU Health who also serves as president on the board of trustees for the ABWM Foundation, a notfor-profit group that supports the work of the ABWM. “I had been exposed to certification
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through Dr. McCulloch, who was literally one of the first clinicians to attain a CWS and has always been a big advocate and proponent of the certification process,” McCallon said.
PAYING IT FORWARD
In an attempt to also serve as an inspiration to others, McCallon helped establish a wound management residency program in physical therapy at LSU Health.To date, all three residents who have completed the program have sat for and earned the CWS designation, McCallon said. “We gear the entire residency toward an endpoint of successful passage of board certification,” he explained. “We don’t mandate certification, but we highly encourage it. It’s important for the clinician to have that personal drive and desire to get it for their professional development. I don’t want somebody to get certified just because they want to make more money.That should never be their primary motivation.” He stresses that just as it pertains to the pursuit of education in general, the value of certification only goes as far in one’s clinical practice as the clinician allows. “As with any job, only so much weight is carried by your degree or certification,” McCallon said.“You don’t just get certified and then everything magically falls into place.And it won’t carry you very far if you don’t have the work ethic and clinical skills to back it up.” It is also crucial for one to adequately prepare for certification examination, said McCallon, adding that the LSU Health residency administers standardized examinations that are scheduled during the program to help prepare the resident for the board examination.
A UNIQUE PARTNERSHIP
For those working within any healthcare setting, the ABWM Foundation also has shown initiative in strengthening applicants’ testing skills by forming alliances with organizations like the North American Center for Continuing Medical Education (NACCME), a continuing medical education provider based in Millstone Township, NJ, that offers Wound Certification Prep Courses (WCPC) throughout the year.
“The ABWM Foundation works diligently to support the education of individuals seeking certification by the American Board of Wound Management,” McCulloch said. “This involves the development of study guides, practice tests, and preparation courses. NACCME and the ABWM Foundation will be working together to offer a series of in-person and online Wound Certification Prep Courses that will be taught by ABWM-certified specialists. We are excited to participate in this endeavor.” At NACCME, which along with TWC publisher HMP Communications LLC forms HMP Communications Holdings LLC, chairman and chief executive officer Jeff Hennessy echoed McCulloch’s praise of the collaboration. “As the leader in providing education to wound care clinicians, we are always striving to push the envelope and provide the highest standards in education to ultimately increase successful patient outcomes,” said Hennessy. “We are excited to announce the new Wound Certification Prep Course will be strengthened by being utilized in conjunction with our Symposium on Advanced Wound Care to assist wound care providers in earning the CWSP, CWS, and CWCA certifications.” According to McCallon, LSU also funds participation in prep courses such as the WCPC in an effort to maximize residents’ opportunities for board success. “The candidate for certification is strongly advised to prepare for what is a very rigorous examination,” he explained. “The WCPC and other available tools such as the practice exams and study guides are an excellent, comprehensive way to prepare for the broad range of content covered in the board exams.” For more information on the ABWM Foundation, visit www.abwmcertified.org. For more on the WCPC, visit www. woundprepcourse.com.
Joe Darrah is managing editor of Today’s Wound Clinic. Maggie Pajak, marketing communications manager with HMP Communications, contributed to this article.
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3/12/14 11:07 AM
These three mechanisms of action draw exudate, slough, wound debris, bacteria and deleterious cytokines into the dressing for optimal wound bed preparation.1
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ICD-10-CM ICD-10-CM DIAGNOSIS CODING DOCUMENTATION TIPS FOR OPEN WOUNDS & AMPUTATIONS (CATEGORIES S01.1-S98.9)
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The arrival of ICD-10-CM is on the horizon, and it will soon be essential for all wound care practitioners to refine their documentation skills in preparation for the new coding format. In an effort to assist our readers as they transition from ICD-9-CM, Today’s Wound Clinic will feature an assortment of ICD-10-CM documentation tools on particular disease states or medical conditions that have been developed to help improve documentation habits, which will be vital to the success of wound clinics in the ICD-10-CM environment. The tools may also contain information on coding guidelines where appropriate. This month’s tool covers the category of open wounds and amputations. (Refer to our October 2013 issue for the tool on infectious diseases, the November/December 2013 issue for neoplasms, and the January/February 2014 issue for the tool on current burns/corrosions.) ICD-10-CM Diagnosis Coding Documentation Tips for Open Wounds & Amputations (Categories S01.1-S98.9) Topic
ICD-10-CM Code Ranges
Documentation Tips/Guidelines
Requirement of a 7th Character for Trauma Codes
All injury occurrences (Categories S01.1-S98.9)
A = Initial Encounter, used when patient is receiving active treatment for the condition (ie, surgical treatment, emergency department, or evaluation and treatment by a new physician). D = Subsequent Encounter, used for encounters after the patient has received active treatment and is now receiving routine care for the healing and recovery phase (Eg, cast change, removal fixation device, medication adjustment, and aftercare/follow up visits). S = Sequela, used for complications or conditions that arise as a direct result of the condition such as scar in a burn. You need to code both the injury code that caused the sequel and the code for the sequel itself. The “S” is only added to the injury code, not the sequela code. The sequel is sequenced as the first-listed diagnosis with the injury code as a secondary diagnosis.
Code Wounds by Wound Type and Site
Categories S01.1-S98.9
There are now separate codes for each wound site. Look for documentation of wound site, laterality (right, left, bilateral). Specific wound type must be documented: Specify whether the wound is a laceration, puncture, open bite; if there are foreign bodies, amputation; or muscle, ligament, and tendon involvement.
Cavity Area Specifications
Open wound of chest wall and back (chest wall = S21.101A - S21.95 XA, S28.1XXA, S29.021A, S29.029A; back = S21.201A-S21.259A, S29.022A, S31.000A-S31.050A)
Document whether cavity is open or not.
Traumatic Amputations
All traumatic amputations of fingers, arms, and hands (S68.110AS68.129A - MCP and S68.610A-S68.629A - transphalangeal); wrist (S58.111A-S58.129A, S68.411A-S68.429A); forearm (S58.911AS58.929A); and transmetacarpal (S68.710A-S68.729A)
Be sure to document MCP vs. transphalangeal as well as complete vs. partial amputation.
Amputation of toe, foot and leg: toe (category S98.1 and S98.2); foot (category S98.0, S98.2, S98.3, and S98.9); leg (category S78.0, S78.1, S88.0, and S88.1)
Document with or without complications; complete/partial, specific toe(s); foot, ankle, or leg amputation level.
Blood Vessel Injuries are coded if applicable
Iliac artery = S35.511A-S35.515A; upper extremity = S45.801A-S65.999A; lower extremity = S75.001A-S95.999A
Document specific veins/arteries by exact location, laterality, and 7th character for type of encounter.
Superficial Injuries
Category T07, L08.89
Document multiple abrasions, friction burns, blisters, and insect bites. Note any localized infection and episode of care.
Contusions
Finger (categories S60.0-S60.1); contusion, lower limb (S70.10XAT28.99X5)
Document specific site of contusion and (if fingers or toes) document any nail involvement, if applicable. National Center for Health Statistics: www.cdc.gov/nchs/icd/icd10cm.htm
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As a reminder, refer to the original ICD-10-CM article in the October 2013 issue of Today’s Wound Clinic for instructions on how to properly use this grid to begin your documentation improvement program. Pointers: Remember to have any operative reports and documentation regarding the circumstances surrounding the injury readily available. Stay tuned for a new ICD10-CM topic next month! n www.todayswoundclinic.com
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One matrix for the advanced management of challenging wounds Recent reimbursement changes applicable to OASIS® Matrix and other cellular- and tissue-based products could impact you in 2014. Watch the Smith & Nephew Webinar on the 2014 Medicare Final Rules (OPPS, MPFS) at http://www.woundsresearch.com/2014reimbursement to learn more. INTENDED USE: OASIS® Matrix is indicated for the management of wounds including: partial- and full-thickness wounds, pressure ulcers, venous ulcers, chronic vascular ulcers, diabetic ulcers, trauma wounds (abrasions, lacerations, second-degree burns, skin tears), draining wounds, surgical wounds (donor sites/grafts, post-Mohs’ surgery, post-laser surgery, podiatric, wound dehiscence). This device is not indicated for use in third-degree burns. CONTRAINDICATION: This device is derived from a porcine source and should not be used in patients with known sensitivity to porcine material. PRECAUTION: OASIS® Matrix should not be applied until excessive exudate, bleeding, acute swelling, and infection are controlled. POTENTIAL COMPLICATIONS: The following complications are possible. If any of these conditions occurs, the device should be removed: infection, chronic inflammation (initial application of wound dressings may be associated with transient, mild, localized inflammation), allergic reaction, excessive redness, pain, swelling, or blistering.
©2014 Smith & Nephew, Inc. All rights reserved. OASIS is a registered trademark of Cook Biotech, Inc. TM1743-0214
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TWCnewsupdate Stethoscopes May Be Spreading Germs & MRSA Experts are warning physicians and other healthcare professionals that contaminated stethoscopes may be as dangerous or may be more likely to spread germs and infections, including antibiotic-resistant staph, than are dirty hands. According to theWorld Health Organization, stethoscopes should be among those instruments that are disinfected after each patient encounter. “By considering that stethoscopes are used repeatedly over the course of a day, come directly into contact with patients’ skin, and may harbor several thousands of bacteria collected during a previous physical examination, we consider them as potentially significant vectors of transmission,” said Didier Pittet, MD, MS, director of the infection control program and the WHO Collaborating Centre on Patient Safety at University of Geneva Hospital, Switzerland, and lead author of a study that examined transmission of infectious disease via stethoscopes. “From infection control and patient safety perspectives, the stethoscope should be regarded as an extension of the physician’s hands and be disinfected after every patient con-
tact,” he said. According to Pittet and his research team, 71 patients were examined by one of three doctors using sterile gloves and a stethoscope. After each examination, the tube and diaphragm of the stethoscope as well as physicians’ hands were checked for bacteria, with the diaphragm showing more contamination than hands (except fingertips).The tube was also said to be covered in more “bugs” than the back of the hands. The study is said to be the first to make a direct comparison of bacterial contamination of hands and stethoscopes. n
CMS Announces Test Schedule To Aid ICD-10 Conversion In an effort to help healthcare providers determine how well they’re progressing toward a transition to ICD-10-CM, the Centers for Medicare & Medicaid Services (CMS) has launched a series of tests that can be voluntarily completed over the course of the next few months. The four-part series to the exams launched in early March by allowing providers to send test claims to evaluate potential of acceptance and the adaptability of their facility’s billing system. End-to-end testing will reportedly be offered this summer with more information expected to be announced by CMS. For more information, visit www.cms.gov/ outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/ downloads/SE1409.pdf n
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DFU Expert Earns
Amputation Advocacy Award Michael Edmonds, MD, a consultant physician at King’s College in London, has been chosen as the 2014 Edward James Olmos Award for Advocacy in Amputation Prevention honoree by the Diabetic Foot Global Conference (DFCon). A world-renowned expert in the field of diabetes and care of the diabetic foot, and a globally recognized pioneer in utilizing a multiMichael Edmonds, MD disciplinary approach for treatment, Edmonds opened what’s considered the world’s first diabetic foot clinic in London in 1981. He has lectured at events around the world, including giving the inaugural Roger Pecoraro Lecture at the American Diabetes Association’s annual meeting. He has also served as co-chairman of an annual conference on the diabetic foot in the United Kingdom (UK) since 1995. Throughout his career,Edmonds’work has earned him numerous honors,including the Royal Society of Medicine’s Alan Edwards Memorial Prize for best case presentation and Honorary Fellowship of the Society of Chiropodists and Podiatrists. He is also a two-time recipient of the King’s College Hospital Commendation for Outstanding Contribution to Patient Care and a member of the awardwinning 2007 UK Hospital Doctor Diabetic Team of the Year. Most recently, Edmonds was selected as the Diabetes1 Hero, which honors healthcare professionals for being leaders in their fields of expertise, providing the highest standards of care for patients and impacting their profession on a global scale. He recently received a Lifetime Achievement Award from the Diabetic Foot Study Group of the European Association for the Study of Diabetes. Olmos himself presented Edmonds with the award during DFCon this month.n
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3/11/14 4:39 PM
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Advertiser’s Index Advanced Tissue (Wound Care Supplies).................................................................................8 Angelini Pharma (BioPad)........................................................................................................31 Derma Sciences (MEDIHONEY).................................................................................... Cover 2 KCI (CelluTome).........................................................................................................................5 Net Health (WoundExpert)............................................................................................. Cover 3 Organogenesis (Apligraf)......................................................................................... Cover 4, 32 Osiris Therapeutics Inc. (Grafix)..............................................................................................15 Progressive Medical Technology (IodoFoam BlackGold)........................................................21 Sechrist Industries (HBOT Chambers)......................................................................................3 Smith & Nephew (OASIS)........................................................................................................29 SteadMed Medical (Drawtex & Xpansion).........................................................................25, 27 Wound Care Advantage (Management Services)................................................................... 17
Apligraf® Essential Prescribing Information Numbers in parentheses ( ) refer to sections in the main part of the product labeling. Device Description: Apligraf is supplied as a living, bi-layered skin substitute manufactured from cells processed under aseptic conditions using neonatal foreskin-derived keratinocytes and fibroblasts with bovine Type I collagen. (1) Intended Use/Indications: Apligraf is indicated for use with standard therapeutic compression in the treatment of uninfected partial and/or full-thickness skin loss ulcers due to venous insufficiency of greater than 1 month duration and which have not adequately responded to conventional ulcer therapy. (2) Apligraf is indicated for use with standard diabetic foot ulcer care for the treatment of full-thickness foot ulcers of neuropathic etiology of at least three weeks duration, which have not adequately responded to conventional ulcer therapy and extend through the dermis but without tendon, muscle, capsule or bone exposure. (2) Contraindications: Apligraf is contraindicated for use on clinically infected wounds and in patients with known allergies to bovine collagen or hypersensitivity to the components of the shipping medium. (3, 4, 5, 8) Warnings and Precautions: If the expiration date or product pH (6.8-7.7) is not within the acceptable range DO NOT OPEN AND DO NOT USE the product. A clinical determination of wound infection should be made based on all of the signs and symptoms of infection. (4, 5) Adverse Events: All reported adverse events, which occurred at an incidence of greater than 1% in the clinical studies are listed in Table 1, Table 2 and Table 3. These tables list adverse events both attributed and not attributed to treatment. (6) Maintaining Device Effectiveness: Apligraf has been processed under aseptic conditions and should be handled observing sterile technique. It should be kept in its tray on the medium in the sealed bag under controlled temperature 68°F-73°F (20°C-23°C) until ready for use. Apligraf should be placed on the wound bed within 15 minutes of opening the package. Handling before application to the wound site should be minimal. If there is any question that Apligraf may be contaminated or compromised, it should not be used. Apligraf should not be used beyond the listed expiration date. (9) Use in Specific Populations: The safety and effectiveness of Apligraf have not been established in pregnant women, acute wounds, burns and ulcers caused by pressure. Patient Counseling Information: VLU patients should be counseled regarding the importance of complying with compression therapy or other treatment, which may be prescribed in conjunction with Apligraf. DFU patients should be counseled that Apligraf is used in combination with good ulcer care including a non-weight bearing regimen and optimal metabolic control and nutrition. Once an ulcer has healed, ulcer prevention practices should be implemented including regular visits to appropriate medical providers. Treatment of Diabetes: Apligraf does not address the underlying pathophysiology of neuropathic diabetic foot ulcers. Management of the patient’s diabetes should be according to standard medical practice. How Supplied: Apligraf is supplied sealed in a heavy gauge polyethylene bag with a 10% CO2/air atmosphere and agarose nutrient medium. Each Apligraf is supplied ready for use and intended for application on a single patient. To maintain cell viability, Apligraf should be kept in the sealed bag at 68°F-73°F (20°C-23°C) until use. Apligraf is supplied as a circular disk approximately 75 mm in diameter and 0.75 mm thick. (8) Patent Number: 5,536,656 Manufactured and distributed by: Organogenesis Inc. Canton, MA 02021 REV: December 2010 300-111-8
Please see complete prescribing information at www.Apligraf.com © 2013 Organogenesis Inc. OI-A1112 All rights reserved. Printed in U.S.A. 4/13 Apligraf is a registered trademark of Novartis.
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For information on support programs and tools available from Organogenesis Inc., call 1.888.HEAL.2.DAY (1.888.432.5232–Option 3). Please see accompanying essential prescribing information, or visit www.apligraf.com for complete prescribing information. References: 1. Carlson M, Faria K, Shamis Y, Leman J, Ronfard V, Garlick J. Epidermal stem cells are preserved during commercial-scale manufacture of a bilayered, living cellular construct (Apligraf®). Tissue Eng Part A. 2011;17(3-4):487-493. 2. Apligraf® [package insert]. Canton, MA: Organogenesis Inc.; 2010.
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