WoundRounds: Clinical Reimbursement and Wound Care webinar slides

Clinical Reimbursement

in Wound Care

Sponsored by:

• WoundRounds

• Post Acute Consulting LLC

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About the Speakers

Speaker

• David Rokes, RN, is COO of Post Acute Consulting and has 19 years experience in skilled nursing and home health settings, specializing in the clinical and financial management.

• He has extensive experience driving reimbursement results while maintaining the utmost compliance.

• Dave is President of the American Association of Clinical Reimbursement Specialists

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About the Speakers

Moderator

• Debra Kurtz is the moderator of

the event and industry expert. She

is the president of Kurtz

Consulting Inc. which provides

healthcare organizations with

sales and marketing solutions.

• www.DebraKurtz.com

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CLINICAL REIMBURSEMENT

AND WOUND CARE PRESENTED BY DAVID ROKES, RN

C.O.O. POST ACUTE CONSULTING, LLC

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Objectives

Discuss the pressure ulcer staging.

Describe how to measure pressure ulcers.

Discuss importance of interdisciplinary collaboration for wound differentiation.

Code Section M correctly and accurately.

Impact on RUG-III/RUG-IV

Effects on Quality Measures, P4P & 5 Star Reporting

Expense Management

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SECTION M AND THE MDS 3.0

SKIN CONDITIONS

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Major Changes to Section M1

Risk assessment

Staging • No more “reverse” staging

• Deepest pressure ulcer

• Worsening pressure ulcer

• Separate items for unstageable and suspected deep tissue injury pressure ulcers

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Major Changes to Section M2

Pressure ulcer present on admission/ reentry

Date of oldest Stage 2 pressure ulcer

Dimensions in centimeters

Type of tissue

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Clinical/ Administrative Interface

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Organizational Assessment

Look at your systems

• Clinical/ administrative intersection

• Who does the data collection and how does it flow?

• How is documentation done? Who is responsible? Is it consistent?

Review your current: • Pressure ulcer policies and guidelines

• Process for pressure ulcer risk

• Process for developing and implementing a care plan for at risk residents

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Clinician Skills Needed

Risk assessment

New pressure ulcer staging

Ulcer measurement

Wound identification

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NPUAP Pressure

Ulcer Definition

CMS has adapted the NPUAP 2007 definition of a

pressure ulcer as well as categories/ staging.

A pressure ulcer is a localized injury to the skin

and/ or underlying tissue usually over a bony

prominence, as a result of pressure or pressure

in combination with shear and/ or friction.

http://www.npuap.org

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DETERMINATION OF PRESSURE ULCER RISK

RISK OF PRESSURE ULCERS

Items M0100 & M0150

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Pressure Ulcer Risk Factors1

Immobility and decreased functional ability

Co-morbid conditions (ESRD, thyroid, diabetes)

Drugs such as steroids

Impaired diffuse or localized blood flow

Resident refusal of care and treatment

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Pressure Ulcer Risk Factors2

Cognitive impairment

Exposure of skin to urinary and fecal

incontinence

Undernutrition, malnutrition, and hydration

deficits

Healed pressure ulcer that has closed

• Higher risk of opening up due to damage, injury, or pressure

• Due to loss of tensile strength of the overlying tissue

• Tensile strength of skin overlaying a closed pressure ulcer only 80% of normal skin

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Is This Evidence of a Risk Factor?

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Healed PU = Risk of PU

Presented with

Stage 4 ulcer

Ulcer healed

in 3 months

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M0100 Determination of Pressure Ulcer Risk

Reflects multiple approaches for determining

a resident’s risk for developing a pressure ulcer.

• Presence or indicators of pressure ulcers

• Assessment using a formal tool

• Physical examination of skin and/ or medical record

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M0100A Risk Factors

Non - Removable Device

Healed (Closed) Pressure Ulcer

Non - Removable

Dressing

Existing

Pressure

Ulcer

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M0100B Formal Assessment/ Tools

Braden Scale© • www.bradenscale.org

• www.hartfordign.org

Other • Institution scales

Norton Scale • http://www.ncbi.nlm.nih.gov/b

ookshelf/br.fcgi?book=hsahcpr

&part=A4521

http://www.bradenscale.org/

http://www.hartfordign.org/

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsahcpr&part=A4521



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M0100C Clinical Assessment

Imperative to determine etiology of all wounds and lesions

Consider using mnemonics that capture key risk factors

HALT© for example

© Ayello

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HALT©1

H – History of pressure ulcer/ patient events

• Immobility

• Decreased functional ability

• Undernutrition, malnutrition hydration deficits

A – Associated diagnoses/ co-morbidities

• Advancing age

• Medications (e.g. steroids)

• Hemodynamic instability, blood flow impairment

• ESRD, thyroid disease

• Diastolic pressure below 60 © Ayello

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HALT©2

L – Look at the skin

T – Touch the skin • Temperature changes

• Exposure to incontinence

© Ayello

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M0150 Risk of Pressure Ulcers

Recognize and evaluate each resident’s risk factors.

Identify and evaluate all areas at risk of constant pressure.

Determine if resident is at risk.

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UNHEALED PRESSURE ULCER(S)

Item M0210

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M0210 Unhealed Pressure Ulcers Coding Instructions

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CURRENT NUMBER OF UNHEALED PRESSURE

ULCER(S) AT EACH STAGE

Item M0300

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New Staging Definitions

Resources:

• www.npuap.org

• Free diagrams of ulcer stages can be downloaded for educational use.

CMS has adapted these definitions.

http://www.npuap.org/

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M0300 Guidelines1

1. Determine deepest anatomical stage of each pressure ulcer.

2. Identify unstageable pressure

ulcers.

3. Determine “present on admission.”

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M0300 Guidelines2

Do not reverse stage.

Consider current and historical levels of tissue involvement.

Do not code lesions not primarily related to pressure.

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NUMBER OF STAGE 1 PRESSURE ULCERS

Item M0300A

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M0300A Number of Stage 1 Pressure Ulcers

Document number of Stage 1 pressure ulcers.

Stage 1 pressure ulcers may deteriorate without adequate intervention.

They are an important risk factor for further tissue damage.

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M0300A Conduct the Assessment1

Perform a head-to-toe, full body skin assessment.

Focus on bony prominences and pressure-bearing areas, such as:

o Sacrum

o Buttocks

o Heels

o Ankles

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M0300A Conduct the Assessment2

• Check any reddened areas for ability to blanch.

• Firmly press finger into tissue then remove

• Non-blanchable: no loss of skin color or pressure-induced pallor at the compressed site

• Search for other areas of skin that differ from surrounding tissue.

• Painful

• Firm

• Soft

• Warmer or cooler

• Color

change

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M0300A Assessment Guidelines

Assessment to determine staging should be holistic.

Stage 1 may be difficult to detect in individuals with dark skin tones.

Determine whether an ulcer is a Stage 1 pressure ulcer or suspected deep tissue injury.

Do not rely on only one descriptor as the descriptors for these two types of ulcers are similar.

Code pressure ulcers with intact skin that are suspected deep tissue injury in M0300G Unstageable Pressure Ulcers Related to Suspected Deep Tissue Injury.

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Category/ Stage 1 Pressure Ulcer

Intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Darkly pigmented skin may not have visible blanching.

Color may differ from the surrounding area.

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Is this a Stage 1 Pressure Ulcer?

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Not a Stage 1 Pressure Ulcer

This is moisture associated skin damage from incontinence.

Do not document in M0300A.

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STAGE 2 PRESSURE ULCERS

Item M0300B

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Category/ Stage 2 Pressure Ulcer1

Partial thickness loss of dermis presenting as:

• Shallow open ulcer

• Red or pink wound bed

• Without slough

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Category/ Stage 2 Pressure Ulcer2

May also present as an intact or open/ ruptured blister.

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M0300B Assessment Guidelines2

Stage 2 ulcers will generally lack the surrounding characteristics found with a deep tissue injury.

Blood-filled blisters related primarily pressure are more likely than serous filled blisters to be associated with a suspected deep tissue injury.

Ensure, again, a complete, and comprehensive, assessment of the resident and the site of injury

Do not code skin tears, tape burns, perineal dermatitis, maceration, excoriation, or suspected deep tissue injury in M0300B.

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M0300B Stage 2 Pressure Ulcers Coding Instructions

1. Number of Stage 2 pressure ulcers

2. Number of Stage 2 pressure ulcers present upon admission/ reentry

• Number of pressure ulcers first noted at time of admission

• Number of pressure ulcers acquired during a hospital stay if being readmitted

3. Date of oldest Stage 2 pressure ulcer

Code suspected deep tissue injury at M0300G.

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Pressure Ulcer Blister?

1. What steps should you take to assess this?

2. How would this be coded?

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Blood - Filled Blister



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Blisters from Burns



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STAGE 3 PRESSURE ULCERS/

STAGE 4 PRESSURE ULCERS

Items M0300C & M0300D

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M0300C Conduct the Assessment

Perform a head-to-toe, full body skin assessment.

Focus on bony prominences and pressure-bearing areas.

Determine if lesion being assessed is primarily related to pressure.

• Rule out other conditions.

• Do not code here if pressure is not the primary cause.

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Full thickness tissue loss.

Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.

Slough may be present but does not obscure the depth of tissue loss.

May include undermining and tunneling.

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M0300C Stage 3 Pressure Ulcers Coding Instructions


• Identify all Stage 3 pressure ulcers currently present.


• Code the number of pressure ulcers first noted at time of admission.

• Code number of pressure ulcers acquired during a hospital stay if being readmitted.

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Full thickness tissue loss with exposed bone, tendon or muscle.

Slough or eschar may be present on some parts of the wound bed.

Often includes undermining and tunneling.

Depth varies by anatomical location (bridge of nose, ear, occiput, and malleous ulcers can be shallow).

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M0300D Stage 4 Pressure Ulcers Coding Instructions



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UNSTAGEABLE

PRESSURE ULCERS

Item M0300E/ M0300F/ M0300G

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Unstageable Pressure Ulcers

Three types to differentiate

Number of these unstageable pressure ulcers present upon admission/ reentry

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M0300E Unstageable Non-Removable Device

Ulcer covered with eschar under plaster cast

Known but not stageable because of the non-removable device

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M0300E Unstageable Non-Removable Dressing

Known but not stageable because of the non-removable dressing

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M0300F Unstageable Slough and/ or Eschar

Known but not stageable related to coverage of wound bed by slough and/ or eschar

Full thickness tissue loss

Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown or black) in the wound bed

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M0300G Unstageable Suspected Deep Tissue Injury1

Localized area of discolored (darker than surrounding tissue) intact skin.

Related to damage of underlying soft tissue from pressure and/ or shear.

Area of discoloration may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Deep tissue injury may be difficult to detect in individuals with dark skin tones.

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Quality health care begins with prevention and risk assessment.

Care planning begins with prevention.

Appropriate care planning is essential in optimizing a resident’s ability to avoid, as well as recover from, pressure (as well as all) wounds.

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Clearly document assessment findings in the resident’s medical record.

Track and document appropriate wound care planning and management.

Deep tissue injuries can indicate severe damage.

Identification and management is imperative.

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M0300E, M0300F, M0300G Coding Instructions

Code number of each type of pressure ulcer.

Code number of each type of ulcer present upon admission/ reentry.

Do not code M0300G when a lesion related to pressure presents with an intact blister and the surrounding or adjacent soft tissue does not have the characteristics of Deep Tissue Injury.

Code under M0300B Unhealed Pressure Ulcers -- Stage 2.

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DIMENSIONS OF UNHEALED STAGE 3 OR 4

PRESSURE ULCERS OR ESCHAR

Item M0610

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Dimensions of a Pressure Ulcer What to Measure

Identify pressure ulcer with the largest surface area from the following:

• Unhealed (nonepithelialized) Stage 3 or 4

• Unstageable pressure ulcer related to slough or eschar

Measure every Stage 3, Stage 4, and unstageable related to slough or eschar pressure ulcer to determine the largest.

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M0610A Length

Measure the longest length from head to toe using a disposable device.

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M0610B Width

Measure widest width of the pressure ulcer side to side perpendicular (90° angle) to length.

The depth of this pressure ulcer is approximately 3.7 cm.

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M0610 Coding Instructions

Enter pressure ulcer dimensions in centimeters.

If depth is unknown, enter a dash in each space.

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M0610C Depth

Moisten a sterile, cotton-tipped applicator with 0.9% sodium chloride (NaCl) solution.

Place applicator tip in deepest aspect of the wound and measure distance to the skin level.

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MOST SEVERE TISSUE TYPE

FOR ANY PRESSURE ULCER

Item M0700

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M0700 Most Severe Tissue Type for Any Pressure Ulcer

Determine type(s) of tissue in the wound bed.

Code for most severe type of tissue present in pressure ulcer wound bed.

Code for most severe type if wound bed is covered with a mix of different types of tissue.

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MO700 Epithelial Tissue

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MO700 Granulation Tissue

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MO700 Slough

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MO700 Necrotic Tissue (Eschar)

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WORSENING IN PRESSURE ULCER STATUS SINCE PRIOR ASSESSMENT (OBRA, PPS,

OR DISCHARGE)

Item M0800

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M0800 Assessment Guidelines

Complete only if this is not the first assessment since the most recent admission (A0310E = 0).

Look-back period is back to the ARD of the prior assessment.

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M0800 Coding Instructions

Enter the number of pressure ulcers that:

• Were not present.

OR

• Were at a lesser stage on prior assessment.

Code 0 if:

• No pressure ulcers have worsened.

OR

• There are no new pressure ulcers.

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HEALED PRESSURE ULCERS

Item M0900

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Healed Pressure Ulcers

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M0900 Healed Pressure Ulcers

Complete only if this is not the first assessment since the most recent admission (A0310E=0).

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OTHER ULCERS, WOUNDS AND SKIN PROBLEMS

SKIN AND ULCER

TREATMENTS

Item M1040 & M1200

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M1040/ M1200 Conduct the Assessment

Review the medical record. • Skin care flow sheet or other skin tracking form

• Treatment records and orders for documented treatments in the look-back period

Speak with direct care staff and treatment nurse. • Confirm conclusions from the medical record review.

Examine the resident. • Determine if ulcers, wounds, or skin problems are present.

• Observe skin treatments.

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M1040B Diabetic Foot Ulcers

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M1040D Open Lesions Other than Ulcers, Rashes, Cuts

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M1040E Surgical Wounds

Failed Flap

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M1040F Burns

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M1200 Skin and Ulcer Treatments1

Must have 2 of these present to affect RUG Score

M1200A and/or B, C,D,E,G, and H *(A&B will count as one if both coded)

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M1200 Skin and Ulcer Treatments2

Pressure-relieving devices do not include: • Egg crate cushions of any type

• Doughnut or ring devices in chairs

Turning/ repositioning program • Specific approaches for changing resident’s position and realigning the

body

• Program should specify intervention and frequency

Nutrition and hydration • High calorie diets with added supplements to prevent skin breakdown

• High protein supplements for wound healing

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Resource Utilization Impact

Categorization under the Resource Utilization Grouper is in the Special Care Category

Wound care is costly and labor intensive; you want to ensure you are getting appropriate payment for services rendered

Clinical indicators for RUG-IV, as well as RUG-III if you are still using this for Medicaid Case Mix in your state

This can result in a loss of over $100/day for a Part A resident if it is coded incorrectly

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Special Care Low

Cerebral Palsy, multiple sclerosis, or Parkinson’s disease with ADL score >=5; respiratory failure and oxygen while a resident; feeding tube (calories>=51% or calories=26-50% and fluid >=501cc); ulcers (2 or more Stage II or 1 or more Stage III or IV pressure ulcers; or 2 or more venous/arterial ulcers; or 1 Stage II pressure ulcer and 1 venous/arterial) with 2 or more skin care treatments; foot infection/diabetic foot ulcer/open lesions of foot with treatment; radiation therapy while a resident; dialysis while a resident

AND

ADL score of 2 or more

WILL DEFAULT TO CLINICALLY COMPLEX IF ADL SCORE LESS THAN 2

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Quality Measures

The new quality measures draft report was updated on 09/29/2011

The updated Quality Measures will be reported via the 5 Star Quality Rating System on Nursing Home Compare beginning April 1st, 2012.

• Sample period has begun.

Helps surveyors create their audit sample

2 Specific Pressure Ulcer Quality Measures

• Percent of residents with pressure ulcers that are new or worsened-Short Stay

• Percent of high-risk residents with pressure ulcers-Long Stay

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Short Stay- SS_0678

Percent of Residents With Pressure Ulcers That Are New or Worsened #0678

• Captures the percentage of short-stay residents with new or worsening Stage 2-4 pressure ulcers

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Pressure Ulcers New or Worsened-Short Stay

Numerator: • Short stay resident for which a look-back scan indicates one or more new or

worsened Stage 2-4 pressure ulcers

• Where on any assessment in the look-back scan:

• 1. Stage 2 -M0800A (worsening in pressure ulcer status since prior assessment) > 0 and M0800A <= M0300B1 (# of Stage II ulcers)

• 2. Stage 3 -M0800B (worsening in pressure ulcer status since prior assessment) > 0 and M0800B <= M0300C1 (# of Stage III ulcers)

• 3. Stage 4 -M0800C (worsening in pressure ulcer status since prior assessment) > 0 and M0800C <= M0300D1 (# of Stage IV ulcers)

Denominator: • All residents with one or more assessments that are eligible for a look-back

scan, except those with exclusions

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Pressure Ulcers New or Worsened-Short Stay (2)

Exclusions: • Residents are excluded if none of the assessments that are included

in the look-back scan has usable response for M0800A, B, or C.

Covariates: • 1. Indicator of requiring limited or more assistance in bed mobility

self-performance on the initial assessment

• 2. Indicator of bowel incontinence at least occasionally on the initial assessment

• 3. Have diabetes or peripheral vascular disease on initial assessment

• 4. Indicator of Low Body Mass Index, based on Height and Weight on the initial assessment

• 5. All covariates are missing if no initial assessment is available

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Long Stay-LS_0679

Percent of High-Risk Residents With Pressure Ulcers #0679

• Captures the percentage of long-stay, high risk residents with Stage II-IV pressure ulcers

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High Risk Pressure Ulcers -Long Stay

Numerator:

• All residents with a selected target assessment that meets both of the following conditions:

• 1. There is a high risk for pressure ulcers, where “high risk” is defined in the denominator definition below.

• 2. Stage II-IV pressure ulcers are present, as indicated by any of the following three conditions: • 2.1 M0300B1 (# of Stage II pressure ulcers) =1,2,3,4,5,6,7,8,9 OR

• 2.2 M0300C1 (# of Stage III pressure ulcers) =1,2,3,4,5,6,7,8,9 OR

• 2.3 M0300D1 (# of Stage IV pressure ulcers) =1,2,3,4,5,6,7,8,9 OR

• 2.4 Any of the additional diagnoses is a Stage II-IV ulcer ICD-9 (I8000= 707.22, 707.23, 707.24)

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Denominator:

• All residents with a selected target assessment that meet the definition of high risk, except those with exclusions. Residents are defined as high-risk if they meet one or more of the following three criteria on the target assessment:

• 1. Impaired bed mobility or transfer indicated, by either or both of the following:

• 1.1 Bed mobility, self performance = 3,4,7,8

• 1.2 Transfer, self performance= 3,4,7,8

• 2. Comatose (B0100=1)

• 3. Malnutrition or risk of malnutrition (I5600 is checked)

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Exclusions:

• 1. Target assessment is an admission assessment or a PPS 5 day or readmission/return assessment

• 2. If the resident is not included in the numerator(the resident did not meet the pressure ulcer conditions for the numerator) AND any of the following conditions are true:

• A. M0300B1 (# of Stage II pressure ulcers) = “-”

• B. M0300C1 (# of Stage III pressure ulcers) = “-”

• C. M0300D1 (# of Stage IV pressure ulcers) = “-”

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Value Based Purchasing

Pay for performance

• Demonstration in process in New York (79 homes), Wisconsin (62 homes) and Arizona (41 homes)

• 3 Year project started July 1st, 2009

• Based upon Quality Measures

• Staffing

• Appropriate hospitalizations

• Outcome measures for the MDS

• Inspection survey deficiencies

• Payment will be directly effected by poor numbers

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Expense Management

Appropriate tracking of wounds and product utilization

Technology as an aid for tighter management and overall tracking

Pricing and product availability -Shop Vendors • Work with a formulary to contain supplies that your team members

can order

Involve clinical team to monitor expenses monthly • This is often done by finance only

About the Sponsors

Post Acute Consulting LLC

• Post Acute Consulting, LLC specializes in Medicare and

Medicaid reimbursement.

• Post Acute Consulting is the “A Team" of Compliance and

Reimbursement.

Dave Rokes

(888) 688-5224

[email protected]

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WoundRounds™ is the point-of-care wound management

& prevention solution that empowers nurses to deliver

better wound care in less time, resulting in:

• Savings of 8-10 hours per week per user

• 50-80% reduction in facility-acquired pressure ulcers

• Lower wound care costs

• Decreased readmissions

• Reduced fines and litigation

WoundRounds™ is the point-of-care wound management & prevention solution that empowers nurses to deliver better wound care in less time, resulting in:

• Automated MDS 3.0 reporting • Savings of 8-10 hours per week per user • 50-80% reduction in facility-acquired pressure ulcers • Lower wound care costs • Decreased readmissions • Reduced fines and litigation

www.woundrounds.com

847.519.3500

About the Sponsors

Upcoming Free Webinar

Technology for Improved Wound Management

• Thursday, December 8th at Noon Central Time

• Speaker: Beth Florczak, MS, RN, WCC, RAC-CT

o Director, Quality & Clinical Excellence at Provena Life Connections

• How can your facility improve wound outcomes while decreasing

costs?

• Learn how long term care facilities are using technology to get more

wound care with fewer resources

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WoundRounds™ is the point-of-care wound management & prevention solution that empowers nurses to deliver better wound care in less time, resulting in:

• Automated MDS 3.0 reporting • Savings of 8-10 hours per week per user • 50-80% reduction in facility-acquired pressure ulcers • Lower wound care costs • Decreased readmissions • Reduced fines and litigation

www.woundrounds.com

847.519.3500

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Health & Medicine

WoundRounds: Clinical Reimbursement and Wound Care webinar slides