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Medicare Compliance & Reimbursement

REIMBURSEMENT:

Is A Patient's Wound 'Not Healing?' The Right Answer Just Got Trickier

Published on Thu Aug 10, 2006

Tap new surgical wound guidance to boost revenues.

An audit of how your field staff is assessing wounds could enhance your Medicare reimbursement by as much as $900 per episode.

Effective July 27, the Centers for Medicare & Medicaid Services (CMS) has adopted a new view on what constitutes a healing--or non-healing--surgical wound. The basis for the shift is "OASIS Skin and Wound Status M0 Items," a guidance document issued in July by the Wound Ostomy & Continence Nurses Society (WOCN).

"[We encourage] clinicians to follow the guidance suggested in the WOCN Guidance Document ... in the assessment of surgical wounds, specifically in the assessment of M0488 Status of Most Problematic (Observable) Surgical Wound," says CMS on its OASIS Users Manual Web site.

Old way: You should no longer use the presence or absence of a palpable healing ridge as a criteria for classifying a wound as "not healing" for M0488.

New way: Under the new guidance, clinicians should base a "not healing" classification on incisional necrosis or signs and symptoms of infection. In the absence of those findings, the score should be "2-early/ partial granulation" or "1-fully granulating," according to the WOCN guidance.

The manual changes reflect medical advances in wound care achieved over the last five years, notes a WOCN spokesperson. CMS has also updated key definitions related to wounds, including the one for pressure ulcers, she notes.

Opportunity: If an audit shows that your clinicians have failed to follow the new guidance in its first month, consider resubmitting claims, advises Judy Adams of LarsonAllen in Chapel Hill, NC. She estimates that if incorrect coding stands, an average an agency could lose anywhere from $200 to $900 depending on the functional and service scores.

Note: To view the guidance from WOCN, go to this URL: www.wocn.org/education/pdf/WOCNOASISguidanceRev072406.pdf.

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