Making the Case for Wound Care Reimbursement
Making the Case for Wound Care Reimbursement
PTs should keep education, research and proper documentation in mind
Medicare reimbursement for wound care for all providers has always been a variable commodity, but perhaps more so for physical therapists who work in skilled nursing facilities (SNFs). Because nursing has traditionally headed SNF wound care teams, some Medicare intermediaries may be unaware that therapists' roles have expanded beyond debridement and whirlpool treatments.
For PTs who offer ultrasound (US), electrical stimulation and other, newer forms of wound care to the SNF population, then, the challenge is to not only comply with Medicare's basic documentation guidelines, but to also justify their role on the wound care team and the efficacy of less accepted forms of treatment.
"In the five years or so before the implementation of PPS, there appeared to be a big move within the SNF setting to have therapists be more involved in wound care. Part of that reasoning was due to the reimbursement issue--nurses were not reimbursed for wound care, but appropriate skilled therapy interventions could be billed to Medicare," explained Pauline Watts, MCSP, PT, co-founder of Encompass Education, a consulting company based in Palm Harbor, FL. "But Medicare is not very familiar with [PT wound care], so in documentation, therapists need to be very careful to justify why it is their skills that are needed," by clearly explaining the treatment, establishing measurable goals and documenting patient progress.
That may sound easy enough, but therapists who offer wound care also need to tailor documentation to the specific form of treatment they are offering. With this in mind, ADVANCE recently asked Watts about the basics of documenting wound care for Medicare patients, and how therapists can achieve better reimbursement for both traditional and newer forms of treatment.
The Medicare Basics
When documenting wound care, Watts said, therapists should always begin with the basics of good Medicare documentation for any form of treatment. Because some Medicare intermediaries have only a superficial understanding of physical therapy, their reimbursement decisions frequently hinge on how well the therapist explains the need for treatment and gains. "There are some treatments that Medicare will not pay for, but what reimbursement usually comes down to is quality of documentation," noted Watts. "Medicare lays down the basic rules, but it's up to therapists to justify that their intervention was appropriate."
For this reason, the PT recommended that therapists always answer these four questions when completing any Medicare documentation:
- Does the patient's condition justify the level of care that was used? In some cases, this might go without saying; for example, if the PT performs debridement to remove necrotic tissue from the wound. If treatment includes less-traditional forms of wound care, however, therapists should take extra care to justify those services.
- How is the patient responding to these interventions? "Medicare wants measurements, descriptions and a documented increase in function," Watts explained, "so therapists should explain the patient's response using objective measures."
- How are you proceeding toward the established goals? Therapists should set measurable goals from the onset, and all documentation should explain how the current treatment is moving toward those goals.
- Is the amount of time spent on this course of treatment appropriate based on the amount of progress that has been made? "The rule of thumb in wound care is if there's no change after two weeks, you need to change something, either the modality or the combination of treatments that you're using," said Watts. Therapists who spend an excessive amount of time on a treatment that's only producing minimal results can expect their Medicare claims to be denied.
Wound Care Modalities
With those questions answered, therapists should then consider tailoring their notes to the treatment modalities they've used. Although all documentation should justify the level of care, PTs should explain how the patient is progressing and chart progress toward measurable goals. Since there are subtle differences in the way that Medicare views some wound care treatments, Watts offered ADVANCE documentation tips for the following treatments:
Debridement: Because it's commonly used to remove necrotic tissue from wounds, therapists who use debridement usually won't have problems with reimbursement. Watts noted, however, that debridement will sometimes make a wound worse before it gets better, and therapists should note this possibility on their documentation.
"When the wound is a pressure ulcer over a heel or another bony prominence, it may initially appear as if it is a stubborn Stage 1 pressure ulcer. However, the wound will almost always be a Stage 3 or 4, as the tissues closest to the bone will have already been damaged. Because there will usually be a good amount of necrotic tissue beneath the surface that needs to be removed, the size of the wound will increase after debridement," she explained. "So therapists need to explain in their documentation that this is an expectation, and it doesn't necessarily mean that debridement isn't beneficial."
For example, therapists in this situation might include in their notes, "There is an expectation that the size of the wound, as we debride necrotic tissue beneath the surface area, will increase." By explaining to Medicare that an increase in wound size is an expectation, rather than a bump in the road, therapists are more likely to be reimbursed for continued treatment.
Hydrotherapy: Like debridement, hydrotherapy is frequently used to assist wound care, usually as a primer to prepare the wound for more specific removal of necrotic tissue. And if there is necrotic tissue in the wound, Watts said, Medicare is usually willing to reimburse therapists for that service. "Whether it's appropriate, however, is another question. With whirpool therapy, for example, you have to worry about contamination and damage to granulating tissue and healthy tissue around the wound," she added. Instead, she recommended therapists use power sprays or other more selective and localized forms of hydrotherapy.
Ultrasound: When applied to the periphery of a wound, ultrasound can be a valuable tool to reduce edema and pain by increasing blood circulation to that area. According to Medicare, however, US is a course of treatment used only when a wound is unresponsive to other more conventional treatment methods. For this reason, therapists who use US to treat wounds need to carefully document not only their use of that modality, but also include a description of the modalities or techniques that did not achieve the desired response. "When documenting ultrasound, we should also be careful to provide details--explain the location, whether the US was pulsed or constant, whether it was done with water or with gel, and the patient's response," said Watts.
Electrical Stimulation: Employed for the same wound healing benefits as ultrasound, reduction of pain and edema, e-stim is applied to the wound bed. Treatments are generally either 30 minutes twice a day, or an hour a day three to seven times a week, depending on the severity of the wound. Although the mean healing time reported in the literature ranges from about seven and a half to 10 weeks (Feeder, et al, Physical Therapy, 1991; 71: 639-649), if there is no change within two weeks, the treatment parameters (electrode placement, polarity of current, etc.) should be changed. Again, e-stim is only instigated when a wound has been documented unresponsive to more conventional treatment protocols.
Although research has shown e-stim to accelerate wound healing, in May of 1997, HCFA announced a policy in which Medicare would no longer reimburse PTs using the modality for the treatment of wounds. Due in large part to efforts by the APTA, that decision has since been overturned, but Medicare intermediaries still carefully scrutinize e-stim. Therapists who use the modality for wound care should, therefore, be particularly careful with their documentation.
An Expanding Role?
While therapists' role in wound care has become much more accepted among the medical community in recent years, the Prospective Payment System (PPS) has likely reduced the use of some modalities in SNFs. "I don't have the figures, but I'm sure there's been a change in the application of therapy in skilled nursing facilities because of PPS," Watts noted. "My personal feeling is that therapists can maximize their [efforts] by working on functional treatments while using certain wound care modalities. But daily hydrotherapy or e-stim can add up to a lot of minutes, and facilities may decide to limit PTs' role in debridement to avoid putting patients into what they might believe to be too high a RUGs category."
For therapists to continue to expand their role, she continued, they'll need to continually demonstrate their skill in wound care by attending educational seminars, producing research that proves the efficacy of their treatments, and most importantly, writing good documentation. "Our documentation does not always justify our knowledge, and I think that's one reason therapists were hit so hard by the Balanced Budge Act," Watts concluded. "But when we document well and provide good care, I think we can adequately demonstrate our value for the amount of money being spent."
Mike Le Postollec is on staff at ADVANCE and can be reached at firstname.lastname@example.org.