By Kathleen D. Schaum, MS
Qualified healthcare professionals (QHPs), such as physicians, podiatrists, physician assistants, nurse practitioners, and clinical nurse specialists, are taught to diagnose the reasons that chronic wounds aren’t healing and to create plans of care for aggressively managing the wound until it heals. Wound care professionals—nurses and therapists—are taught to implement those plans of care. All of these highly skilled wound care professionals know how to manage chronic wounds from identification through healing.
Unfortunately, many wound care professionals don’t currently have the opportunity to follow patients with chronic wounds from beginning to end because the patients move from one site of care to another before their wounds heal. Suppose, for example, a patient with a chronic wound is in an acute-care hospital, then moves to a skilled nursing facility, then returns to his or her home under the care of a home health agency, and is later referred to the care of a hospital-based outpatient wound care department. The same wound care professionals rarely follow the patient through all these site changes. In addition, the plans of care and the wound care products may change because each site of service has different staff and a different Medicare payment system. This lack of consistency leads to:
- nonspecific or inconsistent diagnoses
- duplicate tests
- inconsistent clinical practice guidelines or plans of care
- incomplete documentation or documentation not transferred to the next site of care
- wasted dressings
- inconsistent use of devices or advanced technology
- selection of services, procedures, or products based on reimbursement to the provider
- lack of wound care–related quality measures.
Nearly all, if not all, of this inconsistency can be traced to the lack of a consistent wound care QHP leader and a consistent wound care case management team that directs the wound care as the patient moves to various sites of care. However, the current unique site-of-service Medicare payment systems don’t provide the incentives for wound care case management across the continuum of care.
A new way
The Centers for Medicare & Medicaid Services (CMS) and private payers also recognize the need to develop new payment systems that will provide excellent outcomes, at the lowest total cost of care and with excellent patient satisfaction. Therefore, the payers (both CMS and private payers) have released a variety of demonstration projects and risk-sharing contracts that will incentivize providers to think outside the box to manage care throughout the continuum rather than within their silos of care. This should be great news for wound care QHPs and wound care professionals. As a wound care professional, you will finally be able to use your skills to manage wounds from the beginning through to healing.
The first step you need to take to reap the benefits of payment system changes is to recognize when networks are being developed to participate in these demonstration projects and risk-sharing contracts. Some of the first clues that networks are forming in your community include:
- multiple QHP practices joining together
- multiple hospitals joining together
- multiple sites of care joining together into one large health system.
As soon as you notice these activities, seek out the leader of the initiative and request a meeting. During the meeting, first learn the reason for the consolidation. After listening carefully to the leader, share some ideas of how QHP case management teams can provide high-quality wound care that will result in excellent outcomes, at the lowest total cost of care, and with a high level of patient satisfaction.
Once you capture the attention of the leader, he or she will start opening doors for you to participate in the network. At that point, you will have to start thinking innovatively to develop wound care case management teams that can service this new network. Remember, the new network will usually be paid some type of bonus if it can reduce overall spending of the payer on the population group that it services, if it achieves excellent outcomes, and if it achieves a high level of patient satisfaction.
Medicare patients will have two parallel payment systems: their current Medicare volume-based payment system and the new value-based system that wound care QHPs and wound care professionals will help to design. You will now be incentivized to:
- provide evidence-based patient-centered care
- coordinate care with all stakeholders
- improve efficiency
- eliminate unnecessary tests
- reduce duplication of effort
- reduce medical mistakes and postsurgical complications
- reduce hospital and emergency department readmissions
- reduce waste
- emphasize prevention
- use data to show quality of care provided.
Therefore, this is your opportunity to gain further recognition as a wound care specialist—but only if you open your eyes to what’s going on in your medical community and develop case management teams that can service the new network design by providing the right patient-centered care, for the right reason, at the right time, and for the right total cost of care. Yes, this will require you to step out of your comfort zone, but you will be stepping into your new, exciting future where you can manage wounds from start to finish. This can be your mission, if you choose to accept it.
Wound care QHPs and wound care professionals are often frustrated because payers don’t understand the complexities involved in treating patients with chronic wounds and often deny coverage for needed treatments or advanced technology. When making coverage decisions, payers rely heavily on the diagnosis codes and the documentation in the health record. Wound care QHPs must realize their responsibility to show what they know about each patient encounter and to paint that picture for the payer through the use of diagnosis codes and documentation. Unfortunately, these activities are typically wound care QHPs’ weaknesses.
Granted, the current ICD-9-CM diagnosis codes don’t offer wound care QHPs the opportunity to explain the total complexity of treating their wound care patients. Luckily, this 40-year-old system is going to be replaced with the new ICD-10-CM coding system on October 1, 2015. (You can view the ICD-10-CM codes and specific descriptions at http://www.cdc.gov/nchs/icd/icd10cm.htm.)
When these new codes take effect, wound care QHPs will finally be able to describe the complexity of each patient encounter through diagnosis codes, owing to the work of QHPs who designed the new ICD-10-CM. To maximize the use of these new diagnosis codes, wound care QHPs and wound care professionals must learn the specificity that’s built into the descriptions of the new diagnosis codes. You will probably not memorize the ICD-10-CM code numbers (because there are too many of them), but you can easily memorize the level of specificity about each patient encounter that must be documented in the health record.
When the ICD-10-CM is introduced, documentation will be more important than ever before. Wound care QHPs and wound care professionals should take advantage of the period before the implementation of ICD-10-CM by identifying the top 20 current ICD-9-CM diagnoses that define their patients’ conditions and then identifying the level of specificity that will be required in the new ICD-10-CM codes that define those same conditions. Wound care QHPs and wound care professionals should then work on improving their documentation for one major condition every 3 weeks. Once the documentation for that condition becomes a new habit, they can move on to improving their documentation for the next condition on their list.
Prepare for the future
The beauty of improving your documentation is that it will help you communicate your patients’ conditions to payers today while preparing you for the documentation that will be required to prove medical necessity for your work when ICD-10-CM takes effect on October 1, 2015. Wound care QHPs and wound care professionals should take this opportunity to prepare for their future wound care case management roles by improving their clinical documentation, which will help them justify aggressive wound management and demonstrate their patient outcomes and the quality of their work. You have 10 months to improve your clinical documentation so that you can easily slide into ICD-10-CM. Prepare now; don’t procrastinate!
Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, Florida. Contact her with questions or consultation requests at 561-964-2470 or [email protected].
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.