Preventing Wounds to Maximize Reimbursement

The Centers for Medicare and Medicaid (CMS) have stopped paying for care associated with “preventable complications,” such as hospital-acquired pressure ulcers. It also began prohibiting healthcare organizations from billing patients for these and certain other preventable conditions, such as surgical site infections.

Now if a patient admitted for pneumonia develops a pressure ulcer, CMS will only reimburse the hospital for treating pneumonia. And if a patient is admitted with a pressure ulcer that progresses to a deeper stage of tissue involvement, the hospital is responsible for the additional cost related to the worsening ulcer. For both of these “never events,” the hospital must absorb the hospitalization and treatment costs.

Fast Facts on Wounds

  • Pressure ulcers affect up to 44% of patients with spinal cord injuries.
  • In 2006, 322,946 cases of pressure ulcers were reported to Medicare as a secondary diagnosis, with an average charge of $40,381 for the hospital stay.
  • Neuropathic wounds occur in 15% of patients with diabetes mellitus in the U.S. Up to 24% of them require lower extremity amputation.
  • Lower extremity vascular wounds affect about 2.5 million Americans. Lifetime treatments costs for venous wounds can exceed $40,000 per patient. 
  • Amputation is required in 2.5 out of every 10,000 patients with arterial insufficiency.

Renowned wound care expert and Director of the Wound Care Program at USC University Hospital, Rose Hamm, PT, DPT, CWS, FCCWS, views this reimbursement change as a powerful motivation to prevent and treat wounds efficaciously.

“It makes all disciplines aware of skin integrity and increases accountability for prevention strategies for patients at increased risk for pressure ulcer formation. When it comes to wound management, we have to be proactive.”

Hamm recommends the following strategies to prevent wounds and promote healing and prevent worsening or existing wounds.

Assessment Strategies:

  • Perform and record a full skin assessment for each patient on admission. If you detect any integumentary impairment, document it objectively. The physician must also assess and document it within 48 hours of admission.
  • Do a risk assessment using a normalized assessment tool, such as the Braden scale. 
  • Address risk factors in the nursing plan of care. For example, if the risk assessment reveals poor nutritional intake, consult the dietician, monitor serum albumin and prealbumin levels, and administer nutritional supplements as prescribed. 
  • Reassess regularly according to facility policy. For example, reassess high-risk patients once a shift in acute-care settings. In long-term care settings, reassess high-risk patients at least once a week; low-risk patients, once a month. Adjust the plan of care based on assessment findings.
  • Document all assessment findings objectively and accurately. Even if a pressure ulcer is present on admission, it must be documented in order for the facility to be reimbursed for care.

Treatment Strategies:

  • Consider why the patient has this wound. Analyze skin integrity, positioning, and other risk factors to determine mechanical and chemical forces that caused the wound. According to Hamm, “This is the most important step because it guides specific interventions.”
  • Provide evidence-based wound care.
  • Avoid common mistakes in wound care. Use staging only for pressure ulcers—not for neuropathic, arterial, venous, or other types of wounds. Use a wound filler, such as alginate or cellulose, to completely fill—not pack—a deep wound, including any undermining and sinuses. Don’t cover a wound with a dressing that leaves dead spaces in the cavity because this allows collection of exudates and increases the risk of infection.

Other Strategies:

  • Develop a wound care team. Put together a team of nurses, nurse assistants, and physical therapists to track problems in skin care and wound management and to educate each other.
  • Use evidence-based knowledge in wound care. Go beyond traditional teaching. According to Hamm, “When organizations provide an online course, such as Wound Management, clinicians become more effective, patients receive quality care, and the hospital maximizes reimbursement. It’s a win-win-win situation.”

For details on the Wound Management online course, call 800-999-6274.

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