Solving the mysteries of wound care reimbursement

Nursing Homes, Nov-Dec, 1998 by Glenda J. Motta

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.