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Who among health care providers hasn’t faced the woes of insufficient reimbursement from managed care companies or Medicare? Complaints about unjustifiably denied or reduced payments for clearly necessary care litter the arena of health care these days. Reimbursement for wound care is certainly no exception. Yet very little attention has been devoted to the financial aspect of this growing niche in specialty health care, leaving many providers with an incomplete understanding of just what they need to do to obtain maximum reimbursement for wound patients.
Many clinicians who treat wounds and complain about reimbursement shortfalls often neglect some basic guidelines that could eliminate or at least mitigate the situation, says Glenda Motta, BSN, MPH, ET, president of GM Associates in Mitchellville, MD.
Motta and her colleagues, who regularly advise clients on reimbursement issues, suggest that clinicians adhere to these basic protocols when documenting wounds with the objective of getting maximum reimbursement for products and services used:
• Assess the wound.
The most critical task is to complete a comprehensive wound assessment, which includes documentation of wound size, description of exudate, and amount of necrosis and granulation tissue.
"These descriptions must be quantifiable and measurable, not vague," Motta emphasizes. "Terms like wound is healing or improving’ are too gen-eral. It would be better to describe in detail the percentage change in necrotic debris in one week or the amount of the growth of clean granulation tissue."
Make sure that wound assessments are done in conjunction with a total patient assessment, adds Gwen Turnbull, RN, BS, CETN, a wound care consultant in Yardley, PA. "Look at and describe the patient’s whole medical condition, and assess the treatment delivered to see if the wound is responding to what’s being recommended."
• Follow a plan of treatment.
Payers want to see this. If the wound doesn’t respond to treatment in a reasonable time or if the patient’s condition changes, show payers that adjustments are being made to accommodate these events, suggests Turnbull.
• Document outcomes.
Do this carefully through regular reassessments and by setting measurable treatment goals at timed intervals, says Motta. "Medicare is really pushing this issue for home health patients. Set goals such as, In two weeks the wound will complete the autolytic debridement process,’ which are timed and measurable."
• Weigh total treatment costs against end results.
Payers want to see that treatment costs justify the clinical outcome, especially when treatment is expensive, says Motta. High cost is not necessarily a red flag if you can show that the treatment resulted in, for example, faster debridement, the use of fewer resources, early discharge, fewer home visits, and decreased total treatment costs, even if the modalities are more expensive than conventional gauze dressings.
• Document necessity.
Document the medical necessity for products or services you’re providing from the outset of treatment. "Our system is based on the medical model, so we must say why we need something. Demonstrate medical necessity by proving a diagnosis that supports your actions. If a patient has a diabetic neuropathic foot ulcer, state that as the diagnosis. Be very specific. Don’t just write down that the patient is diabetic," says Motta.
If you determine that a patient will benefit from being turned regularly, Medicare doesn’t care, says Motta. "But if you say the patient is immobile and prone to skin breakdown, that’s the medical connection they’re going to look for."
• Know where to turn.
For Medicare patients, refer to the Durable Medical Equipment Regional Carrier to find out the specific policy requirements for documentation. "Medicare Part B submission requirements are extremely specific. If the documentation isn’t there, reimbursement will be denied," Turnbull stresses.
Motta agrees. "They’ll never give you the benefit of the doubt. You must spell it out according to their criteria, and if the claim is denied then go back and do it again," she says.
• Be specific.
All products and services must be ordered by a physician and documented, both Motta and Turnbull emphasize. "Orders should specify the type of dressing, the size, and the number to be used at one time, the frequency of dressing changes, and the expected duration of need," Turnbull tells Wound Care.
"Always explain why a treatment is appropriate," adds Motta. "For instance, if you’re using a pulse lavage debriding agent because the wound is necrotic and needs to be debrided, tell the payer just that or they may wonder why you’re doing it."
• Try, try again.
Any time a reimbursement claim is denied, resubmit it with additional documentation if possible, says Motta. Including photos or drawings to show payers the situation is always a plus. "If you send a picture of the wound, you’re a step ahead because then you’re not relying only on words to get the payer to envision a serious wound, for instance. In all fairness to those who consider the cases, they can’t see it, so a photo helps everybody, Motta says.
Managed care companies often limit the number of home care visits or outpatient clinic visits. However, says Motta, by accurately and consistently documenting the patient’s condition, the treatments given, and the rationale for them, you stand a good chance that your request for additional visits will be approved.
• Learn Medicare procedures.
Follow Medicare’s lead if in doubt as to what documentation to present to managed care companies. "Medicare is the benchmark that most insurers follow," explains Turnbull. "But if you’re not certain, the best thing to do is call the managed care company and find out specifically what documentation they require for wound care, or if there is even coverage."
In addition, documentation requirements vary depending on the care setting. Rules for acute care hospitals, subacute facilities, skilled nursing facilities, and home health often require different levels and types of documentation. (For more information on various care venues, see story on p. 27.)
Motta tells of one home health agency caring for a patient who had 30 wounds. Trouble was expected when they submitted the claims to the managed care company. But the agency did it right by sending in photos and a detailed treatment plan. The claim was denied at first because of the huge volume of services and products required, but it was accepted after resubmission with even more documentation showing all the wounds had healed in six months.
While many of these steps seem based on common sense, many practitioners still don’t understand how to properly document medical necessity and other factors of wound care, Motta says. "It’s a very simple concept, but people don’t do it. Nurses in subacute care are always telling me that they never get the reimbursement they need, but often I find they haven’t submitted the proper documentation."
On the other side of the equation sit those who make reimbursement recommendations for managed care, many of whom are nurses. They’ve told Motta on numerous occasions that they are not out to battle providers. They would like to grant reimbursement requests in many cases but are hindered by improper or skimpy documentation. "I speak with nurses working for managed care payers who say that they really want to pay for good claims, but they just don’t get the supporting evidence they need," she says.