Medicare Compliance & Reimbursement

The Centers for Medicare and Medicaid Services will reportedly publish on Nursing Home Compare a list of 4,000 nursing facilities that have high quality measure scores on high-risk pressure ulcers or physical restraints. Quality Improvement Organizations (QIOs) will be offering the facilities assistance in the areas of pressure ulcer prevention and care and/or restraint reduction.

CMS initially released the list of facilities in February. The agency has said repeatedly that the list is not intended to identify poor-performing facilities but rather those where there may be an opportunity for improvement, says Evvie Munley, spokeswoman for the American Association of Homes & Services for the Aging. Whether facilities accept help from the QIOs is up to the facilities.

Problems: The pressure ulcer QMs currently don't differentiate between pressure ulcers present at admission and those that occur in-house. Thus leading-edge wound providers can end up on the list.

CMS also released the QIO-related list in the same timeframe as a complete list of 131 poor-performing nursing homes in the agency's Special Focus Facility program. As a result, some media reports linked the two lists.

While AAHSA supports the opportunity for quality improvement, Munley says, "some AAHSA members have expressed frustration at being identified on the QIO list because they have no or an extremely low rate of facility-acquired pressure ulcers." Also, "facilities with small numbers of residents can be included based on a very limited number of occurrences" of pressure ulcers, she adds.

One AAHSA-member facility on the QIO list whose last five surveys have been deficiency-free was identified by the local media as a poor performing facility. The facility participates in both the Advancing Excellence Campaign and Quality First -- and already works with its state's QIO. The administrator of the facility responded by writing each resident and family a letter explaining the purpose of the QIO list.

More to come? Attorney Howard Sollins in Baltimore says there's no reason to believe that CMS won't continue to update the list of outliers on pressure ulcers and/or physical restraints -- or extend it to other QMs.

MDS strategies: Code the minimum data set accurately to ensure the facility's QMs are on the mark. For one, make sure you don't code non-pressure-related wounds as pressure ulcers in Section M. "The physician or physician extender plays a big role in documenting the origin of wounds and documenting the diagnosis for the wound," says Christine Twombly, RN, a consultant in St. Petersburg, FL.

Also: Checking J5c for a resident with end-stage disease and six or fewer months to live excludes a resident from a number of survey quality indicators/measures and the publicly reported QMs (pressure ulcers isn't one of them). The physician has to document that a resident's life expectancy is six months or less, however, before you can code J5c.

Even though the revamped MDS 3.0 will allow facilities to identify pressure ulcers present at admission, the quest to lower the overall prevalence of pressure ulcers in nursing homes is a "shared responsibility" across care sites, according to Steven Levenson, MD, a nursing home medical director in Baltimore.

He believes state physician groups and long-term care organizations need to work with hospitals on the issue.

Also, later this year, CMS will no longer pay hospitals for "never events," which include stage 3 or 4 pressure ulcers that developed after admission to the hospital. In that type of P4P environment, says Levenson, a hospital will either implement standardized practices to prevent and treat pressure ulcers -- "or the hospital might become increasingly self-protective" in claiming pressure ulcers didn't occur on their watch.