Cracking the code

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Tracking a resident with a wound requires crystal-clear documentation.
Tracking a resident with a wound requires crystal-clear documentation.

It seems the only things more complex than wounds today are the rules about getting paid for treating them.

That's likely what many smaller nursing home administrators will say as they ponder thin staffs and all the attendant disconnects that come from high turnover and a seemingly endless flow of too much information.

And under the specter of healthcare reform, and pressures to keep people out of hospitals, the situation gets more complex.

At the heart of it all is the Minimum Data Set, which the Centers for Medicare & Medicaid Services uses to mandate clinical resident assessments in Medicare- and Medicaid-certified nursing homes.

The late 2010 revision to the MDS guidelines on skin conditions, most commonly referred to as “Section M,” is intimidating, observers agree. The 52-page section in CMS' 3.0 manual is almost entirely devoted to documenting the risk, presence, appearance and change of pressure ulcers. There is cursory attention to other skin ulcers, wounds, or lesions, and the revision documents some treatment categories related to skin injury or avoiding injury.

Some observers say the changes have created special challenges for long-term care providers. The requirements are so onerous, in fact, that they create exponential documentation demands many facilities are ill-equipped to handle, stakeholders say.

Skin care has never been a more pressing issue in long-term care, and care costs are nearly $3 billion a year. Nearly five million patients currently suffer from one or more types of debilitating chronic wounds at any given time, with close to two million new cases each year. And the lack of documentation or poor documentation of skin conditions not only is costing facilities valuable reimbursement dollars, but adds to serious legal issues as well. According to WoundRounds, a web-based point-of-care wound management and prevention solution, close to 40% of all long-term care-related lawsuits are nearly impossible to defend because of poor documentation. Skin and wound allegations are considered the second leading cause of litigation in long-term care.

The staging conundrum

Experts concur the No.1 challenge with wound care today is not wound care, but identifying wounds and chronic skin conditions. Ironically, red flags go up when claims handlers see an abnormally high number of pressure ulcers in a facility, when in fact, there are actually far fewer.

“The problem is, once a facility uses the National Pressure Ulcer Advisory Panel staging system to code a wound, it becomes a pressure ulcer in the eyes of claims handlers,” says Rosalyn Jordan, senior director of clinical services, Recovercare, LLC and McKnight's Ask the Wound Care Expert. “Only pressure ulcers are staged. The problem is many facilities are staging all wounds.” 

Jordan says suspected deep tissue injury (SDTI) wounds most often are misidentified as pressure ulcers, but any kinds of wounds are fair game, including those related to diabetic neuropathy, surgical incision, trauma or vascular disease. 

“MDS coordinators are only going to code what's in the medical record and that's the legal way to do it,” Jordan says. “They aren't trained or qualified to question how wounds are identified, only to code whatever is in the medical record. And if it stages, that's how it's coded.”

Jeri Lundgren, RN, director of Consulting Services at Pathway Health, says the situation is systemic.

“I have worked with many facilities that code incorrectly,” she says. “It comes down to clinical competency. If they don't know what they are dealing with or how to assess it clinically, they will code it wrong.”

Disconnects in care settings

The staging conundrum is exacerbated by the profound differences in how wounds are classified in hospitals and nursing homes, experts say. 

Essentially, hospital nurses typically stage all wounds, a practice that is not allowed in long-term care, explains Reta Underwood, president, Consultants for Long Term Care Inc.

“Hospitals aren't expected to classify a wound as unstagable,” she says, adding that there needs to be consistency from one level of service to another. When acute care nurses deal with swing bed patients, and transition to nursing home duty, that's when problems arise. 

“They're taught one way in the acute setting, and the next day, they may be working in a SNF, which operates under a completely different set of rules,” she says. 

Pre-assessments can help eliminate surprises when a resident moves from the hospital or home into a SNF, notes Randall R. Carson, the director of government affairs and reimbursement-North America at Smith & Nephew.  

“A hospital often doesn't have that area of expertise compared to the skilled side,” he notes. The former assistant administrator adds, “we had field nurses who would do assessments. We wanted to gather as much information as we can. You want it to be an easy transition.”

But even with a facility doing “best practices” in assessment and documentation, care coordination issues persist. Developers producing electronic medical record software are far more knowledgeable of acute care terminology, making the issue potentially even more challenging in the years to come. 

“One of my main clients is a large hospital chain with a lot of swing beds and the software documentation challenges with the EMR are mind-boggling,” Underwood says. 

“There's a big disconnect in terms of terminology and the flow of information that the nurse is documenting into the MDS.”

Conflicting standards?

Many observers feel long-term care providers wrestling with MDS 3.0 are hindered even more by a lack of consensus in existing wound care standards.

“One of the things CMS routinely states in all of its rules is we have to follow an evidence-based standard of practice,” says Pat Boyer, president, Boyer & Associates and McKnight's Ask the Payment Expert. “Obviously, NPUAP is an acceptable standard of practice. But CMS says we don't have to follow those. We can use any standard.”

Problems arise when those standards aren't consistent with MDS 3.0, she adds. For example, some facilities will document PUSH scores but fail to include actual wound measurements, which result in MDS red flags when claims are submitted.

“Facilities need to use guidelines that are consistent with the MDS,” asserts Debbie Gulley, RN, clinical operations consultant at Boyer & Associates. 

“Otherwise, you can't code correctly on the MDS. Therefore, this doesn't lead you to a care plan and really raises a lot of problems for you in terms of compliance and reimbursement.”

Knowledge gaps

Experts agree front-line caregivers are behind the knowledge curve when it comes to wound documentation.

“MDS coordinators are relying strictly on the information given by the frontline workers. If they aren't getting good information, they are unwittingly coding these claims wrong,” says a supplier rep who asked to remain anonymous. “That's why fundamental education is so important. Two people can look at the same wound, and depending on their experience and education, they may come up with two different stages or descriptions of that wound and the MDS coordinator responsible for documentation and claims process is relying on those front-line observers.”

 Adds Underwood: “Providers aren't necessarily having a difficult time complying with the new coding rules, but they are having a difficult time finding the time to educate their staff.”

In a recent article she wrote for the Wound Source, Glenda Motta, RN, notes: “The most astonishing phenomenon is the lack of knowledge regarding basic wound care. We might assume that nurses are routinely trained in this area, but evidence proves that this is not the case. Even when staffing includes a wound care expert, the attitude of nurses is ‘that's not my job.'”

Indeed, access to even fundamental wound care education continues to frustrate many providers. Complicating matters are extraordinary turnover rates.

“Many providers find it very difficult to make headway,” says Elaine McGowan, vice president, clinical affairs, DermaRite Industries, and a strong advocate for training. “So they have to be smart about leveraging technology to do that education.”

Judith Morey, RN, senior consultant, Wound & Continence Services, Pathway Health Services, believes many front line workers are missing the forest for the trees. “Many caregivers worry first about what dressing to apply when actually this is the last thing to look at,” she says. “We have to find a way to teach the staff to look at the underlying etiology of why events occur. They are often too eager to label everything a pressure area because they haven't had that piece of education during their studies.”

“Nurses get very little wound care education in school,” adds  Pathway Health's Lundgren. “Very little is taught on lower extremity wounds and diabetic ulcers. Consequently, they lack the foundation to properly identify etiology, and describe and manage wounds.”

The consequences

The fallout from such challenges can be profound — from dollars left on the reimbursement table to needless hospital readmissions.

Observers are somewhat divided on the latter, however.

“If caregivers aren't measuring or classifying wounds correctly when a person comes through the door upon admission, it creates a huge challenge,” says Gulley. 

But Underwood believes long-term care providers are doing a much better job with pre-admission assessments. 

“Our case management efforts show that nursing homes are becoming much more knowledgeable about the condition of the patient prior to taking them on,” she says. “Some providers actually are assessing incoming residents at the hospital. So they've done a much better job protecting themselves, in my opinion.”

Underwood believes many have overlooked the progress long-term care providers have made in wound care: “I also applaud CMS for acknowledging several years ago that it is the providers' responsibility to properly assess wounds on incoming patients. This forced facilities to understand the importance of identifying a new resident's condition. That kind of standard in documentation is where the deficiencies are either negated or you're going to hand them on a silver platter to the surveyors.”

Meanwhile, many providers wrestling with MDS reimbursement sometimes fail to consider comprehensive wound therapy. Recent controversies over so-called “upcoding” for therapy reimbursement claims have given many providers pause. Even conventional therapies such as debridement and whirlpools are waning, adds Boyer. “To provide these things, facilities need a trained therapist on staff, and many don't have one,” she said. “The type of therapy I'm talking about could actually be helpful to a facility because it could give them a higher RUG level because they're providing more therapy time.”

“I think many facilities don't want to be under the microscope for indulging in too much therapy,” added Gulley. “If they can't get details on what they can and can't code and bill for with these new MDS revisions, they're not going to do it because they can't take the chance of a RAC review.” 

Successful strategies

Given all of the challenges with standards, terminology, turnover and education, skin and wound care coding and reimbursement issues can be mitigated.

One successful approach is having a multidisciplinary wound care team.

“Skilled nursing facilities put themselves in jeopardy if they don't have a wound care team,” says Gulley. “I call it my ‘heart attack' theory. If you have just one person in charge of wound care, and that person isn't seen or heard from in a week, what next?” Who will pick up the pieces and keep things consistent?”

Adds Boyer: “We don't see enough of this team approach to assessing and discussing wound care anymore. We sometimes get tunnel vision in our industry and so one person looks at wounds, another passes meds, another does MDS, and we get in these silos and don't have that cross-communication that helps a facility have better documentation and continuity of care.

Under tight staff constraints, consider subcontracting the services of a certified wound care nurse, advises Underwood.

“Having a full-time person on staff can be an impractical solution unless you're a facility that specializes in wound care or has a lot of issues,” she says. For example, many facilities establish relationships with part-time ET nurses or wound specialists. “It is Part B billable and pays for itself in the long run,” she adds.

And don't overlook credentialing, advises Jordan. “Ensure that your nurse providing that wound care is not only educated but has shown that through credentialing to provide that care,” she says, adding that wound care certification can be obtained three ways: the Wound Care Education Institute (multi-disciplinary); Wound, Ostomy and Continence Nurses Society™ (WOCN®), a nursing specialty requiring a minimum BSN; and through the American Academy of Wound Management.

Finally, tap into the wealth of available educational resources, many of them free and on the web, experts say.

McGowan notes, for example, that DermaRite provides a wealth of education tools and resources, including webinars, DVD product training videos and on-site in-services for clients. 

The value of vendor education was not lost on Jordan during her prior days as an administrator.

“I used to have a sign on my door that told reps not to bother me unless they had something new to show me,” she recalls. “If they did, my door was always open.” 

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