WoundRounds: Clinical Reimbursement and Wound Care webinar slides


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Presentation slides for the November 9, 2011 webinar on Clinical Reimbursement & Wound Care presented by Dave Rokes, Post Acute Consulting, sponsored by Wound Rounds

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WoundRounds: Clinical Reimbursement and Wound Care webinar slides

  1. 1. Clinical Reimbursement in Wound CareSponsored by:• WoundRounds• Post Acute Consulting LLC 1
  2. 2. About the SpeakersSpeaker• 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 2
  3. 3. About the SpeakersModerator• 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 3
  5. 5. 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 5
  7. 7. 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 7
  8. 8. Major Changes to Section M2 Pressure ulcer present on admission/ reentry Date of oldest Stage 2 pressure ulcer Dimensions in centimeters Type of tissue 8
  9. 9. Clinical/ Administrative Interface 9
  10. 10. 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 10
  11. 11. Clinician Skills Needed Risk assessment New pressure ulcer staging Ulcer measurement Wound identification 11
  12. 12. 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 12
  14. 14. 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 14
  15. 15. 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 15
  16. 16. Is This Evidence of a Risk Factor? 16
  17. 17. Healed PU = Risk of PUUlcer healed Presented within 3 months Stage 4 ulcer 17
  18. 18. 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 18
  19. 19. M0100A Risk Factors Existing Non - Removable Pressure Dressing UlcerNon - Removable Device Healed (Closed) Pressure Ulcer 19
  20. 20. M0100B Formal Assessment/ Tools Braden Scale©  Norton Scale • www.bradenscale.org • http://www.ncbi.nlm.nih.gov/b • www.hartfordign.org ookshelf/br.fcgi?book=hsahcpr &part=A4521 Other • Institution scales 20
  21. 21. M0100C Clinical Assessment Imperative to determine etiology of all wounds and lesions Consider using mnemonics that capture key risk factors HALT© for example © Ayello 21
  22. 22. 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 22
  23. 23. HALT©2 L – Look at the skin T – Touch the skin • Temperature changes • Exposure to incontinence © Ayello 23
  24. 24. 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. 24
  25. 25. Item M0210 UNHEALEDPRESSURE ULCER(S) 25
  26. 26. M0210 Unhealed Pressure Ulcers Coding Instructions 26
  28. 28. New Staging Definitions Resources: • www.npuap.org • Free diagrams of ulcer stages can be downloaded for educational use. CMS has adapted these definitions. 28
  29. 29. M0300 Guidelines11. Determine deepest anatomical stage of each pressure ulcer.2. Identify unstageable pressure ulcers.3. Determine “present on admission.” 29
  30. 30. M0300 Guidelines2 Do not reverse stage. Consider current and historical levels of tissue involvement. Do not code lesions not primarily related to pressure. 30
  32. 32. 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. 32
  33. 33. 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 Heels o Buttocks o Ankles 33
  34. 34. 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 • Soft • Color • Firm • Warmer or cooler change 34
  35. 35. 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. 35
  36. 36. 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. 36
  37. 37. Is this a Stage 1 Pressure Ulcer? 37
  38. 38. Not a Stage 1 Pressure Ulcer This is moisture associated skin damage from incontinence. Do not document in M0300A. 38
  39. 39. Item M0300BSTAGE 2 PRESSURE ULCERS 39
  40. 40. Category/ Stage 2 Pressure Ulcer1 Partial thickness loss of dermis presenting as: • Shallow open ulcer • Red or pink wound bed • Without slough 40
  41. 41. Category/ Stage 2 Pressure Ulcer2 May also present as an intact or open/ ruptured blister. 41
  42. 42. 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. 42
  43. 43. M0300B Stage 2 Pressure Ulcers Coding Instructions1. Number of Stage 2 pressure ulcers2. 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 readmitted3. Date of oldest Stage 2 pressure ulcer Code suspected deep tissue injury at M0300G. 43
  44. 44. Pressure Ulcer Blister?1. What steps should you take to assess this?2. How would this be coded? 44
  45. 45. Blood - Filled Blister1. What steps should you take to assess this?2. How would this be coded? 45
  46. 46. Blisters from Burns1. What steps should you take to assess this?2. How would this be coded? 46
  48. 48. 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. 48
  49. 49. Category/ Stage 3 Pressure Ulcer 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. 49
  50. 50. M0300C Stage 3 Pressure Ulcers Coding Instructions1. Number of Stage 3 pressure ulcers • Identify all Stage 3 pressure ulcers currently present.2. Number of Stage 3 pressure ulcers present upon admission/ reentry • 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. 50
  51. 51. Category/ Stage 4 Pressure Ulcer 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). 51
  52. 52. M0300D Stage 4 Pressure Ulcers Coding Instructions1. Number of Stage 4 pressure ulcers2. Number of Stage 4 pressure ulcers present upon admission/ reentry 52
  53. 53. Item M0300E/M0300F/ M0300G UNSTAGEABLEPRESSURE ULCERS 53
  54. 54. Unstageable Pressure Ulcers Three types to differentiate Number of these unstageable pressure ulcers present upon admission/ reentry 54
  55. 55. M0300E Unstageable Non-Removable Device Ulcer covered with eschar under plaster cast Known but not stageable because of the non-removable device 55
  56. 56. M0300E Unstageable Non-Removable Dressing Known but not stageable because of the non- removable dressing 56
  57. 57. 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 57
  58. 58. 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. 58
  59. 59. M0300G Unstageable Suspected Deep Tissue Injury2 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. 59
  60. 60. M0300G Unstageable Suspected Deep Tissue Injury3 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. 60
  61. 61. 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. 61
  63. 63. 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. 63
  64. 64. M0610A Length Measure the longest length from head to toe using a disposable device. 64
  65. 65. 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. 65
  66. 66. M0610 Coding Instructions Enter pressure ulcer dimensions in centimeters. If depth is unknown, enter a dash in each space. 66
  67. 67. 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. 67
  69. 69. 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. 69
  70. 70. MO700 Epithelial Tissue 70
  71. 71. MO700 Granulation Tissue 71
  72. 72. MO700 Slough 72
  73. 73. MO700 Necrotic Tissue (Eschar) 73
  75. 75. 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. 75
  76. 76. 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. 76
  77. 77. Item M0900HEALED PRESSURE ULCERS 77
  78. 78. Healed Pressure Ulcers 78
  79. 79. M0900 Healed Pressure Ulcers Complete only if this is not the first assessment since the most recent admission (A0310E=0). 79
  81. 81. 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. 81
  82. 82. M1040B Diabetic Foot Ulcers 82
  83. 83. M1040D Open Lesions Other than Ulcers, Rashes, Cuts 83
  84. 84. M1040E Surgical WoundsFailed Flap 84
  85. 85. M1040F Burns 85
  86. 86. M1200 Skin and Ulcer Treatments1Must 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) 86
  87. 87. 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 87
  88. 88. 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 88
  89. 89. 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 89
  90. 90. 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 90
  91. 91. 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 91
  92. 92. 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 92
  93. 93. 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 93
  94. 94. 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 94
  95. 95. 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) 95
  96. 96. High Risk Pressure Ulcers -Long Stay 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) 96
  97. 97. High Risk Pressure Ulcers -Long Stay 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) = “-” 97
  98. 98. Value Based PurchasingPay 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 98
  99. 99. 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 99
  100. 100. 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 drokes@postacute.com 100
  101. 101. About the Sponsors WoundRounds™ is the point-of-care wound management & prevention solution that empowers nurses to deliver WoundRounds™ is the point-of-care wound better wound care in less time, resulting in: management & prevention solution that empowers • Savings of 8-10 hours per week per user nurses to deliver better wound care in less time, • 50-80% resulting in: reduction in facility-acquired pressure ulcers • Lower wound care costs • Automated MDS 3.0 reporting • Decreased readmissions • Savings of 8-10 hours per week per user • Reduced fines and litigation • 50-80% reduction in facility-acquired pressure ulcers • Lower wound care costs • Decreased readmissions • Reduced fines and litigation www.woundrounds.com 101 847.519.3500
  102. 102. Upcoming Free WebinarTechnology 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 102
  103. 103. WoundRounds™ is the point-of-care woundmanagement & prevention solution that empowersnurses 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 103