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Reimbursement:

WHAT YOU DON'T KNOW ABOUT SURGICAL WOUNDS CAN COST YOU THOUSANDS

Published on Fri Apr 08, 2005

Use these 5 steps to staunch the losses.

A patient with a 60-day episode of daily wet-to-dry dressings - the type most commonly used in home care - can cost your agency nearly $6,000 more than the episode pays.

Wound care patients often are money losers for home health agencies, experts report. And 27 percent of episodes requiring wound care are for surgical wounds, says wound care consultant Patti Johnston with Woodlands, TX-based Healthcare Quality Solutions. Focusing on improving your clinicians' knowledge and competency is your key to providing quality care in a cost-effective way, she says.

One cause of clinical and financial problems is lack of consistency in answering OASIS wound items, Johnston told listeners in an OASIS Answers Inc. April 21 teleconference, "Best Practices for Improvement in Surgical Wounds," sponsored by the quality improvement organization Quality Insights of Pennsylvania. Quality wound management includes both assessment and intervention, Johnston says, but "the OASIS assessment drives both the plan of care and the reimbursement," she reminds agencies.

Closed Surgical Wounds Require the Right Touch

To put your surgical wound care back on track, follow these five dos and don'ts:

1. Don't  take M0488 lightly. Knowing how to stage wounds accurately directly affects your agency's financial survival (see box, in the article titled "Wound Care").

Surgical wound care reimbursement depends on the answer to M0488 - Status of most problematic (observable) surgical wound. The answers NA (no observable surgical wound) or "1" (fully granulating) add no points to the patient's clinical severity domain, "2" (early/partial granulation) adds seven points and "3" (not healing) adds 15 points. These points can add from $200 to $600 to the episode reimbursement if they move the clinical domain score from minimal to low or low to moderate.

2. Do know which wounds to count. The wound questions in the OASIS assessment are not intuitive. Be sure your clinicians understand which are broadly defined and which questions are defined narrowly. 

  • M0440 broadly defines wound or lesion. But only a few kinds of wounds observed in M0440 are addressed in other OASIS questions. Other than peripheral IVs and anything ending in "ostomy," the Centers for Medicare & Medicaid Services considers any areas of "pathologically altered tissue" to be a wound or lesion. This includes sores, ulcers, bruises, scars, rashes, crusts, cysts, abrasions and reddened areas. Despite this broad definition, "it's surprising" that only about 47 percent of OASIS assessments answer "yes" to M0440, indicating the patient has a lesion, Johnston says.
     
  • M0482 defines surgical wounds more narrowly. An incision that is still healing is considered a surgical wound, but a scar from a healed incision is not a surgical wound (although it is a wound or lesion in M0440), Johnston explains.

    Heads up: Avoid these common surgical wound mistakes:

    Pressure ulcers. When a muscle flap surgically replaces a pressure ulcer, the pressure ulcer disappears and becomes a surgical wound. But when a pressure ulcer is surgically debrided or covered with a skin graft, it remains a pressure ulcer and does not become a surgical wound, CMS explains in its OASIS questions and answers. The skin graft donor site, however, is a surgical wound.

    Access devices. Implanted venous access devices, peritoneal dialysis catheters and medi-port or port-a-cath sites - whether being accessed or not - are considered surgical wounds. Peripheral IV sites are not surgical wounds.

    Gastrostomies. If a gastrostomy is surgically closed, a surgical wound results. But if the gastrostomy is being allowed to close on its own, it is neither a wound or lesion for M0440, nor a surgical wound for M0482.

    Miscellaneous. Pin sites and wounds with drains are surgical wounds. Do not count staple sites separately from the incision they close.

    Riddle: When can a wound be considered both peripheral and not peripheral? When it's a PICC line and you're answering OASIS questions.

    Even though peripheral IV sites are not considered wounds or lesions in M0440, a PICC line is considered a wound or lesion, because it's a central line, CMS says. But even though central lines are considered surgical wounds in M0482, CMS says a PICC line is not a surgical wound because it is peripherally inserted, Johnston tells Eli.

    3. Don't expect M0484 to accurately reflect wound improvement. Consider M0484 a "flawed item," Johnston says. This OASIS item requires you to count the current number of observable surgical wounds. But if a surgical incision is in the process of healing and has partially closed, leaving two or three openings where there was originally one, you must count that as two (or three) surgical wounds, CMS instructs. So even though the healing process is progressing nicely, this question does not reflect that progress.

    4. Do consider waiting if the dressing is non-removable. If you are unable to assess the status of the surgical wound for M0486 to M0488 - and you expect the dressing to be removed in a few days - you can wait to complete this item, Johnston explains. You have five days from start of care to complete the assessment, and the points - and reimbursement - from M0488 may depend on that delay.

    Caution: Check your agency's policies to be sure you're allowed the extra time to complete the assessment.

    5. Do communicate confidently. If a physician orders daily or twice daily wet-to-dry dressings, you need to be able to talk with the physician about what that means for your agency, Johnston says. Using dressings that not only improve healing, but also require visits only two or three times a week can mean the difference between floating and sinking financially.

    Mistake: Don't debate the benefits of various dressing types over wet-to-dry.

    Much better: Instead, explain the cost impact under the prospective payment system. For example, if the wound is non-infected, reimbursement will be about $2,200, while 60 visits will cost more than $8,000, using an average visit cost of $135. You then present your agency's plan for more appropriate care for a non-infected wound, emphasizing that your clinicians are knowledgeable in this area, Johnston advises.

    Tip: Emphasize HHAs' switch to evidence-based care that is outcome-oriented, recommends wound expert Dorothy Doughty with Atlanta-based Emory University. Explain that clinicians will carefully monitor the wound, increase visit frequency if needed and promptly report any problems to the doctor, she says.

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