APWCA News

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”

Immediate Medicare Changes That May Affect You

The Medicare Administrative Contractor (MAC) for Jurisdiction J (Tennessee, Alabama, and Georgia) is transitioning from Cahaba to Palmetto. The Part A transition went into effect January 26, 2018 and Part A providers should already be submitting claims to Palmetto GBA. Cahaba has discontinued the receipt of Part A redetermination, reopening, and ADR submissions via the InSite Web Portal. 

Any of your Part A Redeterminations, Reopenings or ADR responses should now be sent to:

Cahaba Medicare Part A
Post Office Box 6168
Indianapolis, IN 46206

If you have been communicating with Cahaba via FAX, you may find that some of those FAX lines are no longer functioning, including some that deal with Part B. If you need to communicate Part B information to Cahaba after January 26, 2018 they ask that you use this mailing address:  

Cahaba Medicare Part B
Post Office Box 6169
Indianapolis, IN  46206

The Part B transition goes into effect February 26, 2018.  Providers should note that their Local Coverage Determinations (LCDs) will transition from Cahaba to Palmetto. A listing of Palmetto LCDs can be found here: Software vendors should update their software to send claims to:

Part A:
Palmetto GBA
Attn: JJ Medicare Part A PO Box 100305
Columbia, SC 29202-3305 

Part B:
Palmetto GBA
Attn: JJ Medicare Part B PO Box 100306
Columbia, SC 29202-3306 

More information can be found at the Jurisdiction J Transition website:  https://www.palmettogba.com/JJTransition

President, Dr. Steven Kavros, and member, Dr. Robert Coronado have been published in the February issue of Advances in Skin and Wound Care. ‘Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review’ can be read online now.

In August 2017, the APWCA distributed a survey to its members to collect their perceptions about change in the pressure ulcer staging system as proposed by the National Pressure Ulcer Advisory Panel (NPUAP). The proposed change was centered around the use of the term 'pressure injury' to replace 'pressure ulcer'.

An invitation email was sent to the APWCA's 1020 members. About 190 members accessed the survey and about 150 responses were submitted. This results in a response rate of 15% and provides a Confidence Interval of ± 7%. The survey consisted of 6 items. Each item and its results are appended in this report.

Results

• A plurality of respondents (40%) felt that 'pressure ulcer' was the most acceptable term with 30% of respondents deeming both 'ulcer' and 'injury' to be acceptable.
• A slight majority of respondents (58%) felt that Stage 1 and Deep Tissue Injury (DTI) should be included in the staging system despite the drawback of including lesion that occur in the absence of broken skin
• A plurality of respondents preferred to keep the term 'stages' (43%) as opposed to 'categories' (28%) in describing the continuum of ulcerations included in the classification scheme.
• An equal number of respondents felt that pressure ulcer (38%) or both pressure ulcer or injury (37%) were reflective of etiology.
• A plurality of respondents (43%) felt that a change in terminology should be first addressed by entities charged with nomenclature and policy before changes are implemented. This indicates a desire for a procedural sequence to be undertaken before adopting new terminology.
• A significant majority of respondents (70%) felt that 'injury' reflects an implication of harm even if it is unintended. This is an important finding as it reflects the fact that some respondents preferring 'injury' and those accepting of both 'ulcer' and 'injury' expressed this concern.

Conclusion

Taken together, the results indicate that while a plurality of APWCA respondents would prefer to keep the term ulcer, many would be accepting of the term 'injury'. That being said, if a change in terminology is to be pursued, the results indicate that two issues be addressed: 1) the implication of harm associated with the term 'injury' should be addressed and mitigated in some manner and, 2) a terminology change should be first addressed by entities charged with nomenclature and policy.

View Detailed Responses

The Quality Payment Program (QPP) Final Rule was released last night. We are still reviewing every detail and considering comments to submit, but below you will find some of the big points we have pulled out so far.

• Threshold to avoid a penalty moves from 3 to 15 MIPS points
• 2014 and/or 2015 CEHRT allowed but bonus ACI points available if use only 2015 CEHRT
• Eligible clinicians or groups with <= $90K Part B allowable or <= 200 Part B beneficiaries excluded
• Cost category counts for 10% of MIPS score
• Cost category score will be calculated by Medicare Spending per Beneficiary (MSPB) and total per capita cost measures
• CMS will calculate Cost measure “performance” - nothing for us to report for that category
• Clinicians affected by Harvey, Irma, or Maria that do not submit 2017 MIPS data will not have a negative adjustment in 2019
• Clinicians affected by Harvey, Irma, or Maria can file a hardship exception application for Quality, ACI, and CPIA categories for 2018 performance period
• Still only allowed one submission method per category
• Quality category moves from 60% of MIPS score in 2017 to 50% in 2018
• Clinical Practice Improvement Activity category still counts 15% - can still avoid penalty with just a perfect CPIA score
• Clinicians in practices of 15 or less are exempt from ACI category and that 25% moves to Quality category
• Exceptional performance threshold remains 70 MIPS points
• Option to participate as a Virtual Group
• 2018 QPP Final Rule Reporting Periods: Cost - 12 mos, Quality - 12 mos, ACI - 90 days, CPIA - 90 days

Links: Full Release / CMS Summary Sheet

Nothing discussed in this communication guarantees coverage or payment. This is our interpretation of the Final Rule. Coverage and payment policies of governmental and private payers may vary from time to time and in different parts of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APWCA does not claim responsibility for any consequences or liability attributable to the use of any of the information discussed in this communication.

With quality measure-based payment models now driving Medicare reimbursement under MACRA (the Medicare Access and CHIP Reauthorization Act), wound care practitioners have faced a unique challenge: few reportable quality measures relevant to wound care.

A study recently published in the International Society For Pharmacoeconomics and Outcomes Research's Value in Health journal shows the full burden and cost of wound care in the US Medicare population, highlighting the need for CMS health policy makers to develop more appropriate quality measures, episode of care measures and reimbursement models for wound care. The findings - particularly the insights regarding the costs of diabetic foot ulcers and diabetic infections - are of particular interest to the podiatry community.

The study "An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds" analyzed 2014 Medicare data and determined the cost of chronic wound care for Medicare beneficiaries in aggregate, by wound type, and by setting. The findings are compelling:

• Chronic nonhealing wounds impact nearly 15% of Medicare beneficiaries (8.2 million).
• A conservative estimate of the annual cost is $28 billion when the wound is the primary diagnosis on the claim. When the analysis included wounds as a secondary diagnosis, the cost for wounds is conservatively estimated at $31.7 billion.
• • Surgical wounds and diabetic foot ulcers drove the highest total wound care costs (including cost of infections).
  • On an individual wound basis, the most expensive mean Medicare spending per beneficiary was for arterial ulcers followed by pressure ulcers.
  • Hospital outpatient services drove the greatest proportion of costs - demonstrating a major shift in site-of-service costs from hospital inpatient to outpatient settings.
  • Surgical infections were the largest prevalence category, followed by diabetic wound infections.

This documentation of the economic impact of nonhealing wounds can be meaningful from a policy perspective moving forward. "The true burden of wound care to Medicare has remained relatively hidden and have not been a focus from a public policy standpoint in the U.S. We are hopeful that documenting the significant economic cost and impact of chronic wounds can influence priorities for Federal research funding in this space and for innovative payment approaches by the CMS, including quality and performance measures within MACRA," noted lead study author Dr. Samuel Nussbaum, Schaeffer Center for Health Policy and Economics, University of Southern California.

National quality measures have not been developed for use under MACRA's Merit-based Incentive Payment System (MIPS) that are relevant to the broad spectrum of wound care. With quality measure-based payment models driving Medicare reimbursement under MACRA, this is a problem for practitioners. "CMS needs to recognize the cost and prevalence of chronic wounds in the development of chronic care models and episodes of care. Chronic wounds can't be forgotten about if we want to drive better health outcomes and smarter wound care spending," said co-author Caroline Fife, MD, Medical Director, CHI St. Luke's Hospital (The Woodlands, Texas) and Executive Director, U.S. Wound Registry.

The study was funded by the Alliance of Wound Care Stakeholders, an association of clinician associations and medical specialty societies focused on promoting quality care and access to products and services for people with wounds and the providers who treat them. The Alliance has been leading advocacy initiatives to educate policy makers and regulators about the importance of more meaningful quality measures for the wound care space. The American Professional Wound Care Association is a member of the Alliance.

The full study is available online; the Alliance's comments to CMS seeking performance measures more relevant to wound care are posted on www.woundcarestakeholders.org.

Downloads: Full Article (PDF) / Fact Sheet / News Release

Novitas Solutions, Inc. is the Medicare contractor (MAC) for the following states and district:

Arkansas
Colorado
Delaware
District of Columbia
Louisiana
Maryland
Mississippi
New Jersey
New Mexico
Oklahoma
Pennsylvania
Texas

In January 2017, Novitas published a proposed rule for payment of wound care treatments to their beneficiaries which we thought was filled with many inconsistencies and confusion with aspects that did not seem to be based on the current state of wound care delivery by the wound care industry (many of whom are members of the APWCA). This proposed rule was subject to a 60 day comment period. APWCA, in conjunction with the Alliance of Wound Care Stakeholders, spoke on behalf of its Novitas members and submitted comments. Our voice was heard!

Novitas has just published their recently finalized LCD (Local Coverage Determination) L35125 entitled "Wound Care" which is due to go into effect on November 11, 2017. A copy of the entire LCD L35125 is available here. This update to membership is meant to review key points of the finalized LCD.

1. Surgical/excisional debridement of dermis, subcutaneous tissues, and fascia: There is no limit to the number of surgical debridements a patient may receive in a 360 day time frame. However, Novitas feels that greater than 8 debridements at any depth is "excessive". Therefore, the LCD states that should the patient require greater than 8 total debridements, "meticulous" documentation is necessary to explain why this "excessive" amount of debridement is indicated. Please keep in mind that providers should already be documenting medical necessity with each and every debridement. Please take this opportunity to review your documentation habits.
2. Surgical/excisional Muscle/fascia and bone debridement: Novitas feels that more than 5 total debridements that include muscle/fascia or bone in a 360 day period is "excessive" but will not place an "a priori" limit. Instead the LCD requires that more than 5 total debridements that include muscle/fascia or bone in a 360 day period be accompanied by "meticulous" documentation illustrating that the service is both medically reasonable and necessary.
3. Non-contact non-thermal Ultrasound for wound treatment (MIST): The LCD states it should be offered a minimum of 2-3 times per week. But, if no observable wound improvement is noted after 2 weeks (4-6 treatments), then this wound treatment is not reasonable or necessary. Furthermore, no more than 18 treatments in a 6 week period will be considered reasonable or necessary.
4. Negative Pressure Wound Therapy (NPWT): Two types are considered: a) that done with DME, and b) that done with disposable systems as an outpatient or homecare patient. Both are covered given proper indications and usage. The LCD states, "…the beneficiaries who undergo treatment utilizing negative pressure wound therapy, only a minority appears to require more than 6 NPWT services in a 120 day period to accomplish the desired objective of the treatment plan of the wound. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the NPWT treatment already provided, should NPWT services be continued beyond this frequency or time frame."

There were numerous changes from the proposed LCD to the final LCD which was just published. The changes relevant to our comments include:

1. No frequency limit on total number of debridements in a year
2. No frequency limit on the total number of debridements including muscle / fascia and bone in a year
3. Disposable NPWT coverage was not removed as was proposed
4. Wound photography not required as proposed (but it is suggested especially when more than 8 total debridements or 5 debridements including muscle / fascia and bone are performed in a year)
5. Palliative wound care is covered
6. The statement in the proposed LCD that a wound needs to show a documented improvement of 10% per month or granulation tissue progression of 1 mm per month was removed

ICD-10 codes that start with L97- are used for non-pressure chronic ulcers of the lower limb. These codes are used for diabetic foot ulcers, stasis ulcers, and others. Since the onset of ICD-10, there were only five 6^th character options for these L97- codes. These were:

1 – limited to breakdown of skin
2 – with fat layer exposed
3 – with necrosis of muscle
4 – with necrosis of bone
9 – with unspecified severity

These did not leave the option to indicate with our codes that an ulcer had muscle exposed without necrosis of muscle or bone exposed without necrosis of bone. The APWCA worked with the Alliance of Wound Care Stakeholders to write to the World Health Organization (WHO) and explain this gap in code options and request that more options be created that would allow us to code these scenarios accurately.

Our efforts have been recognized! The WHO has announced new 6^th character options that can be used with all L97- codes. These go into effect October 1, 2017.

The following 6^th character options are being added:

5 – with muscle involvement without evidence of necrosis
6 – with bone involvement without evidence of necrosis
8 – with specified severity NEC

These new 6^th characters of “5” and “6” allow the option to indicate the ulcer is to the depth of muscle or bone without necrosis at that depth. The new 6^th character of “8” should be used if the severity of the ulcer is specified in the documentation, but none of the 6^th character options of 1-6 are appropriate.

These new 6^th characters can be used with any code that begins with L97-.

Note: Any ICD-10 code listed above that ends with a “-“ is not complete and requires more characters to complete the code.

Nothing discussed in this communication guarantees coverage or payment. The existence of an ICD-10 code does not ensure payment if it used. Coverage and payment policies of governmental and private payers may vary from time to time and in different parts of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APWCA does not claim responsibility for any consequences or liability attributable to the use of any of the codes discussed in this communication.

Thank you to all participants of the APWCA 2017 National Clinical Conference for helping make this year’s educational program a huge success! With almost 400 in attendance, 75+ presentations, standing room only review course, and a sold-out exhibit hall, this year’s meeting exceeded all expectations.

Presentations are available online for public viewing until September 30 http://www.apwca.org/2017-Presentations. Beginning October 1, educational content will be available to members only.

SAVE THE DATE and join us September 6-8, 2018 in Baltimore, MD for next year’s conference.

Masters Award (MAPWCA) Recipients: E. Cuauhtémoc Sánchez, MD; Cheryl M. Bongiovanni, PhD; Charles Andersen, MD; Tyler Sexton, MD; Randall Cook, MD; Steven Sprigle, PhD, PT along with President (L) Steven Kavros, DPM; Vice President (R) Jeff Niezgoda, MD and Conference Chairs Kathya Zinszer, DPM and Barbara Delmore, PhD, RN

APWCA was well-represented at the recent New Cardiovascular Horizons (NCVH) Annual Conference held in New Orleans on May 31-June 2. Steven Kavros, DPM, MAPWCA, FACCWS, CWS, APWCA President, presented excellent content during the Podiatry and Wound Care sessions including "Treatment of Ischemic Wounds with Non-Contact, Low-Frequency Ultrasound: The Mayo Clinic Experience" (View PDF) and "Improving Wound Healing Outcomes Using Hypocholorous Solution as a Therapy" (View PDF). He also participated in the NCVH Interview Arena to promote the upcoming APWCA National Clinical Conference, September 7-9, in Philadelphia, PA.