Solving the mysteries of wound care reimbursement.

Fast-moving wound care technology and slow-moving insurance bureaucracies make an uncomfortable mix - and the Medicare PPS is adding complexity. A guide through the maze.

The complications to nursing home care brought about by the PPS system are perhaps nowhere more confusing than in the case of wound care. Yet, far too few nursing facilities are prepared for these complex changes. Wound care, specifically the kind of high-tech wound care that transcends simple gauze and tape dressings, is a major reason for admission into subacute or skilled nursing care settings under Medicare Part A. But because Medicare is totally changing the rules that govern payment for wound care, there is a tremendous need for skilled nursing facilities to learn how to use wound care technologies and still be paid for them.

First, let's clarify the ground rules as much as possible. Until PPS, wound care for Medicare Part A residents could be billed separately as a Part B expense. Nursing homes purchased wound care products through their suppliers, and invoices were sent to one of four regional carriers known as a Durable Medical Equipment Regional Carrier (DMERC). The DMERC was billed for the unbundled costs, therefore the nursing home didn't worry about quantities used or the specific coverage requirements and billing information. Now, with PPS, all Medicare claims for all residents, even those under a non-Part A stay, must be submitted under that facility's number. For residents on a Part A-covered stay, services under Part B will be included in the Part A bill.

In addition, there's another complication. In January, SNFs were to begin consolidated billing, under the Balanced Budget Amendment, for non-Part A wound care, but this move has been put on hold "indefinitely." Consolidated billing means that an SNF that used to rely on an outside medical provider to bill for wound care products would have to learn to identify these products for itself and know which ones are covered and for what purpose. It must learn to identify dressing types and to match dressing use to wound characteristics, utilization parameters and billing codes. It must realize that many supplies are not covered under Part B, including skin sealants or barriers, wound cleansers or irrigating solutions, solutions used to moisten gauze, such as saline, topical antiseptics and antibiotics, and gauze and other dressings not left on the wound. Compression wraps are not generally covered as well.

Wound dressings that are covered under Part B include primary (those applied directly to the wound) and secondary (those used to secure or protect dressings). But these can only be those used on surgical wounds or where reasonable and medically necessary debridement (mechanical, enzymatic and autolytic, as well as surgical or sharp debridement) was used. Surgical dressings are not covered for a Stage I pressure ulcer, a first-degree burn, a wound caused by trauma not requiring surgical closure or debridement, venipuncture or arterial puncture, or drainage from a cutaneous fistula not surgically created. (For further information resources on wound care products, coverage and utilization, see "Suggested Reading," p. 00.)

All of this means that nursing homes now have to learn to deal with the monstrosity known as the DMERC. To be covered under Part B, claims for wound care supplies must now be submitted by the nursing home directly to the DMERC, and the SNF must use the appropriate ICD-9-CM diagnosis code for the type of wound. DMERCs have a whole set of coverage and payment policies for wound dressings. In addition, the DMERC may request information during review of residents or suppliers with significantly high utilization. To be reimbursed, facilities will have to submit a great deal of documentation about their use of dressings and their medical necessity.

Medicare policy for wound care in an SNF covers sterile dressing changes, care of extensive pressure ulcers, monitoring of an unstable condition, pain control for terminal malignancy cases, and whirlpool treatment of open wounds. SNF documentation must show that the care can only be provided by or under the supervision of licensed nurses. It must state the reason why the patient is certified as a Medicare resident, include records of vital signs and other conditions being monitored, a description of the treatment regimen and expected results, and notations of progress or decline.

It is important to focus on the nursing process when documenting. Assess the resident, identify problems, plan goals, implement the care plan, and evaluate effectiveness - and document all of this. You must maintain current clinical information, both on admission and on a daily basis, to include in a monthly report. Specify the type and number of wounds; their location, size and depth; the amount of drainage; the frequency of dressing changes required; the number of dressings used per wound; and the necessity for the type and quantity of the surgical dressings provided. Remember, failing to document and to complete resident assessments in conformance with Medicare timelines could have severe financial consequences. Late assessments will result, at the very least, in a lower payment rate.

In certain wound dressing categories, there is a 7% denial rate, and treatments such as collagen IC, are given individual consideration and price review. What's more, it can take three months to get notification of denials of payment - the administrator's worst cash flow nightmare.

You must also document any acute problems: an increase of drainage, the amount of necrosis, any infection, and the development of additional wounds. The DMERC should be contacted for clarification on problem cases. Also, you should work with the medical suppliers, because their staffs know dressings, other related products and their codes.

The general rule for obtaining reimbursement today is to use the right dressing at the right time for the right wound. You may feel tempted to simplify everything by "just using gauze instead." Don't give in to the temptation.

You have to prepare for these changes - but how? Staff education - and a lot of it. Nurses must, of course, be educated on current wound care practices, but administrators and the billing department need just as much training in this area. That means that this initiative has to come from the top down. Not only does the facility need to document the wound clinically, it needs policies that allow for the use of high-tech wound dressings and the know-how to get claims for them paid. A good consultant who understands Medicare policies and codes can work wonders at an in-service, and I would recommend taking time to find one. Other recommendations I would offer:

* Develop a formulary limiting staff to a choice of about five dressings that are proven effective and which have clear reimbursement and documentation guidelines.

* Create checklists (or "cheat sheets") on what dressing to use and when.

* Streamline your record keeping, and make sure that the accounting department is kept involved. It is important that clinical and financial people work together.

* Have in-house utilization reviews to examine your own use of resources before you get into trouble with outsiders.

In wound care, as in other fields, technology marches on. There are new product categories, such as dressings incorporating silver to fight infection, for which the government does not yet even have codes, leaving no hope for reimbursement. It is enough for now, though, to prepare for PPS's effect on traditional wound treatment, and it is most definitely time to get started.

Glenda J. Motta, RN, MPH, ET, is a principal at GM Associates based in Mitchellville, Maryland, and a leading consultant on wound care. For further information, phone [phone].