APWCA News

The APWCA contributed to a successful effort to reverse a dangerous policy that limited ulcer debridements. Wisconsin Physician Services (WPS) is a Medicare Contractor responsible for six states. They released a Local Coverage Determination (LCD) for ulcer debridement that did not include stage II pressure ulcers or diabetic foot ulcers in its list of covered conditions. The APWCA is a proud member of the Alliance of Wound Care Stakeholders and contributed to their fight against this policy. After many letters and in-person testimony, WPS revised this LCD to include stage II pressure ulcers and diabetic foot ulcers in the list of covered conditions. Advocacy for both you and your patients is part of your APWCA member benefits!

Your APWCA recently collaborated with the Alliance of Wound Care Stakeholders and others in an effort to combat an unfair policy from WPS Government Health Administrators. WPS is the Part B Medicare Administrative Contractor (MAC) for Nebraska, Kansas, Iowa, Missouri, Michigan, and Indiana. WPS released the Local Coverage Article, "A55909: Wound Care Coding Companion for Wound Care L37228”. This article excluded coverage for CPT 97597 (Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) when the depth of the ulcer debrided is limited to breakdown of skin. A letter was written to WPS challenging this exclusion and requesting that WPS provide peer-reviewed literature that supports this exclusion.

APWCA contributed to the effort by the Alliance of Would Care Stakeholders over the last couple months to oppose Noridian’s new policy article governing use of skin substitutes. This article dictates coverage in the absence of a Local Coverage Determination and limits the indication of skin substitute use.

See the full article here.

This year APWCA contributed to the effort by the Alliance of Wound Care Stakeholders to oppose United Healthcare’s policy which limits the use of skin substitute products.

See the full article and read United Healthcare’s Response here.

Last year, on behalf of its members, the APWCA submitted a comment letter to CMS regarding the 2019 Medicare Part B Physician Fee Schedule. A copy of the full letter is attached below.

The APWCA argued against:

• Consolidation of payment for levels 2-5 office and other outpatient E/M services
• New E/M codes for “podiatry services”
• The application of the MPPR concept to E/M coding
• The raise to 30 of the score needed to avoid a MIPS penalty
• Change to the small practice MIPS bonus

The APWCA commented on some specific RVUs and responded to their request for information regarding postoperative visits following 10 day global procedures.

Final APWCA 19 MPFS Comment Letter.pdf

The APWCA contributed to the comments recently contributed by the Alliance of Wound Care Stakeholders to the Physician- Focused Payment Model Technical Advisory Committee (PTAC) regarding a proposal regarding “Bundled Payment for All Inclusive Outpatient Wound Care Services in Non Hospital Based Setting” that was submitted by Seha Medical. The comment letter expressed concern regarding one all-inclusive payment as it would negatively affect the care that providers would be able to deliver. The fear that one all-inclusive payment could also limit the care that patients receive was shared. The letter pointed out that the proposal did not require the provider to adhere to a particular care model, follow a particular set of national guidelines or established protocols in order to achieve the desired cost and utilization objectives. Furthermore, the point was made that chronic ulcer patients often have multiple co-morbidities requiring treatment to optimize ulcer care, and this proposal did not account for that. The Alliance letter concluded with a request to not implement the proposal as written and an offer to serve as a resource to the PTAC if it wants to consider a bundled payment for wound care services.

Last year, on behalf of its members, the APWCA submitted comments to CMS regarding the electronic clinical quality measure titled, “Hospital Harm – Hospital- Acquired Pressure Injury.” We expressed concern that the denominator had no exclusions and suggested that certain exclusions be included. A cope of that letter is below:

The American Professional Wound Care Association® (APWCA) is a non-profit medical association welcoming medical providers from all disciplines involved in prevention and treatment of difficult wounds. Through a synergy of disciplines, APWCA has been a worldwide leader in clinician advocacy and education for the prevention and treatment of acute and chronic wounds since 2001. This association provides an informational and educational forum for healthcare providers, while promoting excellence in wound healing and patient advocacy.

On behalf of the APWCA we appreciate the opportunity to comment on the electronic clinical quality measure titled, “Hospital Harm – Hospital- Acquired Pressure Injury.” We are concerned that the denominator has no exclusions. All hospitalized patients ages 18 years and older are included. We agree that pressure ulcers should be avoided in all patients when possible, but contend that all pressure injuries are not preventable. We agree with your statement in question #7 that “practices may change for end- of-life or hospice patients who have a comfort care-only order.” Comfort care-only orders can be captured in some EHR systems, but not all. There are also some hospitals still not using a fully functional EHR. Therefore, we do suggest denominator exclusions in this measure.

We suggest that the following exclusions be considered:
Palliative care
End of life care
Metastatic malignancies
Septic shock

As you know, the same critical pathologies that compromise perfusion to critical organs such as the heart, lungs, and brain also compromise perfusion to the skin!

Thank you for the opportunity to provide this feedback and for considering our suggestion

Robert Skerker, MD, FAPWCA
Medical Director, Morristown Wound Healing Center
APWCA liaison to the Alliance of Wound Care Stakeholders

Jeffrey D Lehrman, DPM, FASPS, MAPWCA
Medical Director, Center for Wound Healing and Hyperbaric Medicine at
Crozer-Chester Medical Center
APWCA Board of Directors

NEW THIS YEAR! Special APWCA discounted rate of $299 (Enter code: APWCA-2019) to attend the 20th Anniversary NCVH 2019 Annual Conference, which now includes a day-long educational track focused on the interdisciplinary integrated team approach to wound care - Save hundreds of dollars!

Register Here!

APWCA will be presenting a full day didactic session on May 31st! See schedule of the day below:

10:00 - 11:20AM NCVH/APWCA Session IV: Reconstruction of Complex Tissue Defects in the Lower Extremities
10:00 - 10:10AM The Importance and Goals of Wound Healing in Limb Preservations, Charles Andersen, MD
10:10 - 10:20AM When to get a Vascular Consult and the Limitation of Non-Invasive Vascular Studies, Craig Walker, MD
10:20 - 10:30AM Identifying the Etiology of the Wound, Charles Andersen, MD
10:30 - 10:40AM Debridement of the Complex Wound: Extent, Tools and Frequency Stephanie Wu, DPM
10:40 - 10:50AM Controlling the Bacteria in the Wound: Topical vs. Systemic Treatment, Charles Southerland, DPM
10:50 - 11:00AM Venous Ablation for the Venous Leg Ulcers: Indications and Timing, Robert Coronado, MD
11:00 - 11:10AM THat is the Role of Cellular and or Tissue Based Products in Dermal Reconstruction: Evidence Based Medicine, Steven Kavros, DPM

11:20 - 1:30PM Lunch/Lunch Symposia/Exhibits

1:30 - 3:00PM [Podiatry and Wound Care] Session V: Reconstruction of Complex Tissue Defects in the Lower Extremities
1:30 - 1:40PM Hyperbaric Oxygen Therapy: What is the Evidence? Jeffrey Niezgoda, MD
1:40 - 1:50PM Vascular Imaging: Evidence to Improve Outcomes, Jeffrey Ross, DPM, MD
1:50 - 2:00PM When to Consider Flaps vs. Split Thickness Skin Grafts, Charles Southerland, DPM
2:00 - 2:10PM Taking the Mystery Out of Offloading: It is more than a Simple Insert, Steven Kavros, DPM
2:10 - 2:20PM Compression Therapy for Chronic Venous Insufficiency: Compression Wraps vs. Gradient Support Hose, Cheryl Bongiovanni, PhD
2:20 - 2:30PM Topical Oxygen: Hocus or Evidence Based, Stephanie Wu, DPM
2:30 - 2:40PM What is Feasible for Complex Would Healing in the Changing Economic and Reimbursement Environment, Steven Kavros, DPM
2:40 - 2:50PM Questions and Answers/Panel Discussion
2:50 - 3:00PM Closing Remarks, Frank Tursi, DPM 

3:00PM Adjourn

Recent research demonstrates the effectiveness of various foam dressings for pressure redistribution. Jeffrey Niezgoda, MD (APWCA Vice-President) recently published his findings in a poster presentation (SAWC 2018).  His results demonstrated that all foams are not equivalent in the ability to provide pressure relief in patients at risk for developing pressure ulcers.  OxyBand Rescue out performed all other foam dressings currently on the market, providing superior reduction in average pressures and peak pressures, while at the same time maximizing contact area.  The NPUAP has recently published recommendations advocating the use of foam dressings to provide pressure redistribution in an attempt to reduce the risk of pressure ulcer formation in at risk patients.  A copy of the Poster is provided.  

The Centers for Medicare and Medicaid Services (CMS) recently released an announcement seeking input from stakeholders on a new electronic clinical quality measure under development titled, “Hospital Harm – Hospital-Acquired Pressure Injury.”

This measure assesses the proportion of hospitalized patients 18 years and older who develop a new stage 2-4 pressure ulcer, deep tissue injury, unstageable pressure ulcer, or experience worsening of any of the above during their hospitalization.

We read the full description of the measure and provided the following feedback on behalf of APWCA membership:

• Concern that the denominator has no exclusions; made the point all pressure ulcers are not preventable
• Responded to one of the questions posed by the measure authors by explaining protocols may change for end-of-life or hospice patients who have comfort care-only orders

-- Clarified this could be difficult to track because comfort care-only orders may not be captured in some EHR systems and some hospitals are still not using a fully functional EHR

• Suggested denominator exclusions be added to this measure, including:
  

-- Palliative care
-- End-of-life care
-- Metastatic malignancies
-- Septic shock

This is just one example of how APWCA advocates for our members.  To learn more about your membership and benefits visit www.apwca.org.

If you would like to submit comments on your own, follow these instructions provided by the Alliance of Wound Care Stakeholders:

• Current JIRA users with an active account select “Log In” at top right corner at http://jira.oncprojectracking.org

• If you do not have a JIRA account, select “Sign up” at http://jira.oncprojectracking.org/login.jsp

              1. Select “Projects” at top middle on home screen
              2. Select “View All Projects”
              3. Select “Quality-Measures” on left-side of screen
              4. Select “Comments on eCQMs under development” project
              5. To enter comments, select “Create” (orange button) at the top middle of the screen
              6. Select the type of issue from the “Issue Type” drop-down menu
              7. In “Summary” field, type the following title: 
                  Hospital Harm – Hospital Acquired Pressure Injury
              8. Select the measure name for comment on from the “Draft Measures” drop-down: 
                  Hospital Harm – Hospital Acquired Pressure Injury
              9. Fill out fields labeled “Contact name,” “Contact email,” and “Contact phone”
            10. Enter comments in the “Description ”field or upload an attachment under the “attachment” field
            11. Select “Create” at the bottom left to submit comments
            12. For additional comments, select “Create another” and then “Create”