1. Schaum, Kathleen D. MS

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Happy 30th anniversary Advances in Skin & Wound Care!


This author is honored to have participated in the success of this journal for the last 17 years-that's a lot of reimbursement information! Most of that reimbursement information pertains to the Medicare program, which is the major payer for patients with chronic wounds. You may be surprised to learn that the Medicare program celebrated its 50th anniversary on July 30, 2015. Even though the environment (political, financial, and medical) was very different when Medicare was enacted than it is today, the goals of better care, smarter spending, and healthier people are still the same.


Like Medicare, this author is celebrating her 50th year of learning about the ever-changing Medicare program and of educating medical professionals and manufacturers how their services, procedures, and products are reimbursed by Medicare. Per the request of the journal's editorial team, this column will highlight the top 10 Medicare reimbursement regulations that are currently impacting wound care practices. As you read these new regulations, please keep in mind that all wound care professionals still have to follow the coding, payment, and coverage regulations for submitting claims to traditional Medicare. All of the new Medicare quality payment programs will determine if you receive Medicare payment adjustments (positive or negative) to your traditional Medicare payments. In addition, quality ratings may determine if an individual, agency, or facility is invited to participate in the various payment models based on quality.



Codes for products (Healthcare Common Procedure Coding System), procedures/services (CPT(R)*), and diagnoses are typically updated on an annual basis, although some codes for drugs/biologics and coding edits (see below) may be modified on a quarterly basis. Two major coding regulations are impacting the wound care industry and deserve special attention from wound care professionals:


* ICD-9-CM and ICD-9-PCS were replaced by ICD-10-CM and ICD-10-PCS on October 1, 2015. The change to ICD-10 allows wound care professionals to capture more details about the health status of their patients and sets the stage for improved patient care and public health surveillance across our country. ICD-10 will help move the nation's healthcare system to smarter care by helping physicians and other healthcare providers to better


* define patients' clinical status and to treat their complex medical conditions,


* coordinate care among providers, and


* support new payment methods that drive quality of care.



Just like ICD-9, the key to successful ICD-10 diagnosis coding is knowing the descriptions of the codes and documenting the patient's condition accurately, specifically, and thoroughly.




* National Correct Coding Initiative (NCCI) Edits were created in 1996 but are typically updated every quarter. These edits determine whether 2 outpatient wound care procedures performed during the same encounter will be reimbursed by Medicare. The NCCI edits pertain to many wound care procedures, such as evaluation and management and debridement; application of cellular and/or tissue-based products for skin wounds; total contact casts; Unna boots; multilayer compression bandage systems; negative-pressure wound therapy utilizing durable medical equipment; negative-pressure wound therapy utilizing disposable equipment and fluid management systems; low frequency, noncontact, nonthermal ultrasound, and so on. Wound care professionals should pay close attention to the annual update of the NCCI manual and the quarterly updates of the NCCI edits.






The Sustainable Growth Rate payment system was repealed in April 2015 and was replaced by the 2016 Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act Quality Payment Program. The Quality Payment Program makes Medicare better by helping physicians and other qualified healthcare professionals (QHPs) focus on care quality and the one thing that matters most: making patients healthier. The Quality Payment Program provides new tools, models, and resources to help physicians and other QHPs give their patients the best possible care. In addition, physicians and other QHPs can choose how they want to take part based on their practice size, specialty, location, or patient population. The Quality Payment Program has 2 tracks to choose from:


* the Merit-based Incentive Payment System


* Advanced Alternative Payment Models






The Hospital Readmission Reduction Program improves healthcare for people with Medicare by linking what Medicare pays hospitals to the quality of the care they provide and not only the quantity of services they provide in a given performance period. The Program provides financial incentives to hospitals to reduce costly and unnecessary readmissions by better coordinating transitions of care and improving the quality of care given to patients with Medicare. The current readmission rates that are measured are for patients with acute myocardial infarction, heart failure, pneumonia, chronic obstructive pulmonary disease, elective total hip and/or total knee replacement, and coronary artery bypass graft surgery. In order to lower the rate of readmissions, hospitals are


* focusing on better coordination of care and communications between providers and patients and their caregivers;


* improving discharge planning, education, and follow-up for discharged patients; and


* using electronic medical records to share information and provide continuity of care.






The Centers for Medicare & Medicaid Services (CMS) has begun packaging the items and services that they consider integral, ancillary, supportive, dependent, and adjunctive to a primary service. Payments for these services, which CMS refers to as "adjunctive services," are packaged into the payments for the primary services. Cellular and/or tissue-based products for skin wounds were the first major wound care items to be packaged into their application codes. The CMS continues to remind hospital outpatient departments that they should properly code and charge for the packaged items in order for CMS to build the appropriate costs into the payment for the primary service.





The Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP) will start in fiscal year 2019 and will reward skilled nursing facilities with incentive payments for the quality of care they give to Medicare beneficiaries. The SNFVBP promotes better clinical outcomes for skilled nursing facility patients and makes their care experience better during facility stays. Medicare will pay participating skilled nursing facilities for their services based on the quality of care, not only the quantity of services they provide in a given performance period. Medicare currently sends skilled nursing facilities confidential quality feedback reports on their measure performance and posts the skilled nursing home performance on Nursing Home Compare.


The current quality measures in the SNFVBP are the following:


* Skilled Nursing Facility 30-Day All-Cause Readmission Measure that estimates the risk-standardized rate of unexpected readmissions within 30 days for


* people with fee-for-service Medicare who were inpatients at Prospective Payment System (PPS), critical access, or psychiatric hospitals, and


* any cause or condition.


* Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure that estimates the risk-standardized rate of unexpected, potentially preventable readmissions within 30 days for people with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals






The instrument/data collection tool used to collect and report performance data by home health agencies is called the Outcome and Assessment Information Set (OASIS). Since 1999, CMS has required Medicare-certified home health agencies to collect and transmit OASIS data for all adult patients whose care is reimbursed by Medicare and Medicaid with the exception of patients receiving prenatal or postnatal services only. The OASIS data are used for multiple purposes, including calculating several types of quality reports, which are provided to home health agencies to help guide quality and performance improvement efforts.


Beginning in January 2010, home health agencies have been required to collect a revised version of the OASIS data set (OASIS-C). The OASIS-C includes data items supporting measurement of rates for use of specific evidence-based care processes. From a national policy perspective, CMS anticipates that these process measures will promote the use of best practices across the home health industry.


Since fall 2003, CMS has posted a subset of OASIS-based quality performance information on the website "Home Health Compare." These publicly reported measures include outcome measures that indicate how well home health agencies assist their patients in regaining or maintaining their ability to function and process measures that evaluate the rate of home health agency use of specific evidence-based processes of care.


Home Health Compare uses a star rating between 1 and 5 to show people how a home health agency compares with other home health agencies on measurements of their performance. The star ratings are based on 9 measures of quality that give a general overview of performance.





Medicare's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program changes the amount Medicare pays for certain DMEPOS items. Under this program, suppliers submit bids to provide certain medical equipment and supplies to people with Medicare living in, or visiting, competitive bidding areas. Medicare uses these bids to set the amount it pays for each DMEPOS item. All suppliers are thoroughly screened to ensure they meet Medicare requirements (such as eligibility and financial, quality, and accreditation standards) before they are awarded contracts.


If Medicare beneficiaries have original Medicare insurance, the Competitive Bidding Program requires them to obtain competitive bidding items in competitive bidding areas from a contract supplier, unless an exception applies. Items that are commonly used by chronic wound care patients include the following:


* enteral nutrient equipment and supplies


* external infusion pumps and supplies


* hospital beds and related accessories


* negative-pressure wound therapy pumps (durable medical equipment) and related supplies


* oxygen and related equipment and supplies


* scooter and related accessories


* seat lifts


* support surfaces (groups 1 and 2)


* walkers


* wheelchairs (standard power or manual) and related accessories






The CMS has implemented a prior authorization demonstration model for nonemergent hyperbaric oxygen therapy in Illinois, Michigan, and New Jersey. The demonstration project began on March 1, 2015, and will end on February 28, 2018. The CMS is testing whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. The CMS believes using a prior authorization process will help confirm that services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid. If the Medicare beneficiary has 1 of the following 5 conditions and wishes to receive their hyperbaric oxygen treatments in Illinois, Michigan, or New Jersey, prior authorization is now required by CMS:


* chronic refractory osteomyelitis (unresponsive to conventional medical and surgical management)


* osteoradionecrosis (as an adjunct to conventional treatment)


* soft tissue radionecrosis (as an adjunct to conventional treatment)


* actinomycosis (only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment)


* diabetic wounds of the lower extremities in people who meet the following conditions:


* They have type 1 or type 2 diabetes and a lower-extremity wound that is due to diabetes.


* They have a wound classified as Wagner grade III or higher.


* They have failed an adequate course of wound therapy (as defined in the National Coverage Determination).



Prior authorization does not create new clinical documentation requirements. Instead, it requires the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services and to avoid an appeal process.





The Center for Medicare & Medicaid Innovation (CMMI) supports the development and testing of innovative healthcare payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or CHIP benefits. A CMMI model must either reduce spending without reducing the quality of care or improve the quality of care without increasing spending, and must not deny or limit the coverage or provision of any benefits. The CMMI is currently focused on the following priorities:


* testing new payment and service delivery models,


* evaluating results and advancing best practices, and


* engaging a broad range of stakeholders to develop additional models for testing.



Currently, CMMI has 7 categories of models:


1. Accountable Care Organizations are groups of physicians, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, receive the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an accountable care organization succeeds in both delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.


2. Episode-Based Payment Initiatives, commonly referred to as the Bundled Payments for Care Improvement initiative, is composed of 4 broadly defined models of care, which link payments for multiple services beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.


3. Primary Care Transformation is developing initiatives to test innovations in primary care, particularly mechanisms to encourage more comprehensiveness in primary care delivery; to improve the care of complex patients; to facilitate robust connections to the medical neighborhood and community-based services; and to move reimbursement from encounter-based toward value-driven, population-based care.


4. Initiatives Focused on the Medicaid and CHIP Population are going on throughout the country in 6 different programs; for example, the Medicaid Incentives for the Prevention of Chronic Diseases Model provides incentives to Medicaid beneficiaries of all ages who participate in prevention programs and demonstrate changes in health risk and outcomes, including the adoption of healthy behaviors. The program must address 1 or more of the following prevention goals: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, and avoiding the onset of diabetes or, in the case of a diabetic, improving the management of the condition.


5. Initiatives Focused on the Medicare-Medicaid Enrollees are going on throughout the country in 3 different programs; for example, the Financial Alignment Initiative is designed to provide Medicare-Medicaid enrollees with a better care experience and to better align the financial incentives of the Medicare and Medicaid programs.


6. Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models are planned and/or going on throughout the country in 22 different programs; for example, the Frontier Community Health Integration Project Demonstration aims to develop and test new models of integrated, coordinated healthcare in the most sparsely populated rural counties with the goal of improving health outcomes and reducing Medicare expenditures.


7. Initiatives to Speed the Adoption of Best Practices are testing different models intended to increase the engagement of Medicare beneficiaries, Medicaid beneficiaries, Medicare-Medicaid enrollees, and/or CHIP beneficiaries in modifiable aspects of their health and healthcare. Currently, 11 models are going on throughout the country; for example, the Community-based Care Transitions Program tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the Community-based Care Transitions Program are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high-risk beneficiaries, and to document measurable savings to the Medicare program.






The IMPACT Act pertains to long-term-care hospitals, skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities. It requires these providers to


* report standardized and interoperable patient assessment data with regard to quality measures, and patient assessment instrument categories, and


* exchange the data among post-acute care providers and other providers.



Standardized data (eg, the post-acute care clinical assessment, patient's preferences and goals, quality measures, resource use, hospitalization, and discharge to the community) will be captured and compared. Please note the first item in the IMPACT Act's quality measures domains pertains to wound care professionals in long-term-care hospitals, skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities:


* skin integrity and changes in skin integrity


* functional status, cognitive function, and changes in function and cognitive function


* medication reconciliation


* incidence of major falls


* transfer of health information and care preferences when an individual transitions



The use of standardized quality measures and data will enable interoperability and access to longitudinal information for these providers to facilitate coordinated care, improved outcomes, and overall quality comparisons. See


*CPT is a registered trademark of the American Medical Association.