Presentation slides for the November 9, 2011 webinar on Clinical Reimbursement & Wound Care presented by Dave Rokes, Post Acute Consulting, sponsored by Wound Rounds

1. Clinical Reimbursement
in Wound Care
Sponsored by:
• WoundRounds
• Post Acute Consulting LLC
1

2. About the Speakers
Speaker
• David Rokes, RN, is COO of Post
Acute Consulting and has 19 years
experience in skilled nursing and
home health settings, specializing
in the clinical and financial
management.
• He has extensive experience
driving reimbursement results while
maintaining the utmost compliance.
• Dave is President of the American
Association of Clinical
Reimbursement Specialists
2

3. About the Speakers
Moderator
• Debra Kurtz is the moderator of
the event and industry expert. She
is the president of Kurtz
Consulting Inc. which provides
healthcare organizations with
sales and marketing solutions.
• www.DebraKurtz.com
3

4. CLINICAL
REIMBURSEMENT
AND WOUND CARE
P R ES E N T E D BY DAV I D RO K ES , R N
C .O.O. P O ST AC U T E CO N S U LT I NG , L LC
44

5. Objectives
 Discuss the pressure ulcer staging.
 Describe how to measure pressure ulcers.
 Discuss importance of interdisciplinary collaboration
for wound differentiation.
 Code Section M correctly and accurately.
 Impact on RUG-III/RUG-IV
 Effects on Quality Measures, P4P & 5 Star Reporting
 Expense Management
5

6. SECTION M AND
THE MDS 3.0
SKIN CONDITIONS
66

7. Major Changes to Section M1
 Risk assessment
 Staging
• No more “reverse” staging
• Deepest pressure ulcer
• Worsening pressure ulcer
• Separate items for unstageable and suspected deep tissue
injury pressure ulcers
7

8. Major Changes to Section M2
 Pressure ulcer present on admission/ reentry
 Date of oldest Stage 2 pressure ulcer
 Dimensions in centimeters
 Type of tissue
8

9. Clinical/ Administrative Interface
9

10. Organizational Assessment
 Look at your systems
• Clinical/ administrative intersection
• Who does the data collection and how does it flow?
• How is documentation done? Who is responsible? Is it
consistent?
 Review your current:
• Pressure ulcer policies and guidelines
• Process for pressure ulcer risk
• Process for developing and implementing a care
plan for at risk residents
10

11. Clinician Skills Needed
 Risk assessment
 New pressure ulcer staging
 Ulcer measurement
 Wound identification
11

12. NPUAP Pressure
Ulcer Definition
 CMS has adapted the NPUAP 2007 definition of a
pressure ulcer as well as categories/ staging.
 A pressure ulcer is a localized injury to the skin
and/ or underlying tissue usually over a bony
prominence, as a result of pressure or pressure
in combination with shear and/ or friction.
http://www.npuap.org
12

13. Items M0100 & M0150
DETERMINATION OF
PRESSURE ULCER RISK
RISK OF PRESSURE ULCERS
13

14. Pressure Ulcer Risk Factors1
 Immobility and decreased functional ability
 Co-morbid conditions (ESRD, thyroid, diabetes)
 Drugs such as steroids
 Impaired diffuse or localized blood flow
 Resident refusal of care and treatment
14

15. Pressure Ulcer Risk Factors2
 Cognitive impairment
 Exposure of skin to urinary and fecal
incontinence
 Undernutrition, malnutrition, and hydration
deficits
 Healed pressure ulcer that has closed
• Higher risk of opening up due to damage, injury, or
pressure
• Due to loss of tensile strength of the overlying tissue
• Tensile strength of skin overlaying a closed pressure
ulcer only 80% of normal skin
15

16. Is This Evidence of a Risk Factor?
16

17. Healed PU = Risk of PU
Ulcer healed Presented with
in 3 months Stage 4 ulcer
17

18. M0100 Determination
of Pressure Ulcer Risk
 Reflects multiple approaches for determining
a resident’s risk for developing a pressure ulcer.
• Presence or indicators of pressure ulcers
• Assessment using a formal tool
• Physical examination of skin and/ or medical record
18

19. M0100A Risk Factors
Existing Non - Removable
Pressure Dressing
Ulcer
Non - Removable Device
Healed (Closed) Pressure Ulcer
19

20. M0100B Formal Assessment/ Tools
 Braden Scale©  Norton Scale
• www.bradenscale.org • http://www.ncbi.nlm.nih.gov/b
• www.hartfordign.org ookshelf/br.fcgi?book=hsahcpr
&part=A4521
 Other
• Institution scales
20

21. M0100C Clinical Assessment
 Imperative to determine etiology of all wounds and lesions
 Consider using mnemonics that capture key risk factors
 HALT© for example
© Ayello
21

22. HALT©1
 H – History of pressure ulcer/ patient events
• Immobility
• Decreased functional ability
• Undernutrition, malnutrition hydration deficits
 A – Associated diagnoses/ co-morbidities
• Advancing age
• Medications (e.g. steroids)
• Hemodynamic instability, blood flow impairment
• ESRD, thyroid disease
• Diastolic pressure below 60
© Ayello
22

23. HALT©2
 L – Look at the skin
 T – Touch the skin
• Temperature changes
• Exposure to incontinence
© Ayello
23

24. M0150 Risk of Pressure Ulcers
 Recognize and evaluate each resident’s risk factors.
 Identify and evaluate all areas at risk of constant pressure.
 Determine if resident is at risk.
24

25. Item M0210
UNHEALED
PRESSURE ULCER(S)
25

26. M0210 Unhealed Pressure Ulcers
Coding Instructions
26

27. Item M0300
CURRENT NUMBER OF
UNHEALED PRESSURE
ULCER(S) AT EACH STAGE
27

28. New Staging Definitions
 Resources:
• www.npuap.org
• Free diagrams of ulcer stages can be downloaded
for educational use.
 CMS has adapted these definitions.
28

29. M0300 Guidelines1
1. Determine deepest anatomical stage of each
pressure ulcer.
2. Identify unstageable pressure
ulcers.
3. Determine “present on admission.”
29

30. M0300 Guidelines2
 Do not reverse stage.
 Consider current and historical levels of tissue
involvement.
 Do not code lesions
not primarily related
to pressure.
30

31. Item M0300A
NUMBER OF STAGE 1
PRESSURE ULCERS
31

32. M0300A Number of
Stage 1 Pressure Ulcers
 Document number of Stage 1 pressure ulcers.
 Stage 1 pressure ulcers may deteriorate without adequate
intervention.
 They are an important risk factor for further tissue damage.
32

33. M0300A Conduct the Assessment1
 Perform a head-to-toe, full body skin
assessment.
 Focus on bony prominences and pressure-bearing
areas, such as:
o Sacrum o Heels
o Buttocks o Ankles
33

34. M0300A Conduct the Assessment2
• Check any reddened areas for ability to
blanch.
• Firmly press finger into tissue then remove
• Non-blanchable: no loss of skin color or pressure-
induced pallor at the compressed site
• Search for other areas of skin that differ from
surrounding tissue.
• Painful • Soft • Color
• Firm • Warmer or cooler change
34

35. M0300A Assessment Guidelines
 Assessment to determine staging should be holistic.
 Stage 1 may be difficult to detect in individuals with dark skin
tones.
 Determine whether an ulcer is a Stage 1 pressure ulcer or
suspected deep tissue injury.
 Do not rely on only one descriptor as the descriptors for these
two types of ulcers are similar.
 Code pressure ulcers with intact skin that are suspected deep
tissue injury in M0300G Unstageable Pressure Ulcers Related
to Suspected Deep Tissue Injury.
35

36. Category/ Stage 1 Pressure Ulcer
 Intact skin with non-blanchable redness of a localized area
usually over a bony prominence.
 Darkly pigmented skin may not have visible blanching.
 Color may differ from the surrounding area.
36

37. Is this a Stage 1 Pressure Ulcer?
37

38. Not a Stage 1 Pressure Ulcer
 This is moisture associated
skin damage from
incontinence.
 Do not document
in M0300A.
38

39. Item M0300B
STAGE 2 PRESSURE
ULCERS
39

40. Category/ Stage 2 Pressure Ulcer1
 Partial thickness loss of dermis presenting as:
• Shallow open ulcer
• Red or pink
wound bed
• Without
slough
40

41. Category/ Stage 2 Pressure Ulcer2
 May also present
as an intact or open/ ruptured blister.
41

42. M0300B Assessment Guidelines2
 Stage 2 ulcers will generally lack the surrounding
characteristics found with a deep tissue injury.
 Blood-filled blisters related primarily pressure are more likely
than serous filled blisters to be associated with a suspected
deep tissue injury.
 Ensure, again, a complete, and comprehensive, assessment of
the resident and the site of injury
 Do not code skin tears, tape burns, perineal dermatitis,
maceration, excoriation, or suspected deep tissue injury in
M0300B.
42

43. M0300B Stage 2 Pressure Ulcers
Coding Instructions
1. Number of Stage 2 pressure ulcers
2. Number of Stage 2 pressure ulcers present upon
admission/ reentry
• Number of pressure ulcers first noted at time of admission
• Number of pressure ulcers acquired during a hospital stay if
being readmitted
3. Date of oldest Stage 2 pressure ulcer
 Code suspected deep tissue injury at M0300G.
43

44. Pressure Ulcer Blister?
1. What steps should you take to assess this?
2. How would this be coded?
44

45. Blood - Filled Blister
1. What steps should you take to assess this?
2. How would this be coded?
45

46. Blisters from Burns
1. What steps should you take to assess this?
2. How would this be coded?
46

47. Items M0300C
& M0300D
STAGE 3 PRESSURE ULCERS/
STAGE 4 PRESSURE ULCERS
47

48. M0300C Conduct the Assessment
 Perform a head-to-toe, full body skin
assessment.
 Focus on bony prominences and pressure-bearing
areas.
 Determine if lesion being assessed is primarily related
to pressure.
• Rule out other conditions.
• Do not code here if pressure is not the primary cause.
48

49. Category/ Stage 3 Pressure Ulcer
 Full thickness tissue loss.
 Subcutaneous fat may
be visible but bone,
tendon or muscle
are not exposed.
 Slough may be present
but does not obscure the
depth of tissue loss.
 May include undermining and tunneling.
49

50. M0300C Stage 3 Pressure Ulcers
Coding Instructions
1. Number of Stage 3 pressure ulcers
• Identify all Stage 3 pressure ulcers currently present.
2. Number of Stage 3 pressure ulcers present upon
admission/ reentry
• Code the number of pressure ulcers first noted at time of
admission.
• Code number of pressure ulcers acquired during a hospital stay if
being readmitted.
50

51. Category/ Stage 4 Pressure Ulcer
 Full thickness tissue
loss with exposed bone, tendon
or
muscle.
 Slough or eschar may be present
on
some parts of the wound bed.
 Often includes undermining and
tunneling.
 Depth varies by anatomical
location (bridge of nose, ear,
occiput, and malleous ulcers can
be shallow).
51

52. M0300D Stage 4 Pressure Ulcers
Coding Instructions
1. Number of Stage 4 pressure ulcers
2. Number of Stage 4 pressure ulcers present upon
admission/ reentry
52

53. Item M0300E/
M0300F/ M0300G
UNSTAGEABLE
PRESSURE ULCERS
53

54. Unstageable Pressure Ulcers
 Three types to differentiate
 Number of these unstageable pressure ulcers present upon
admission/ reentry
54

55. M0300E Unstageable
Non-Removable Device
 Ulcer covered with eschar under plaster cast
 Known but not stageable because of the non-removable device
55

56. M0300E Unstageable
Non-Removable Dressing
 Known but not stageable because of the non-
removable dressing
56

57. M0300F Unstageable
Slough and/ or Eschar
 Known but not stageable related to coverage of wound bed by
slough and/ or eschar
 Full thickness tissue loss
 Base of ulcer covered
by slough (yellow, tan,
gray, green or brown)
and/ or eschar (tan,
brown or black) in the
wound bed
57

58. M0300G Unstageable
Suspected Deep Tissue Injury1
 Localized area of discolored (darker than surrounding tissue)
intact skin.
 Related to damage of
underlying soft tissue from
pressure and/ or shear.
 Area of discoloration may
be preceded by tissue that
is painful, firm, mushy,
boggy, warmer or cooler as
compared to adjacent tissue.
 Deep tissue injury may be difficult to detect in individuals with
dark skin tones.
58

59. M0300G Unstageable
Suspected Deep Tissue Injury2
 Quality health care begins with prevention and risk
assessment.
 Care planning begins with prevention.
 Appropriate care planning is essential in optimizing a
resident’s ability to avoid, as well as recover from,
pressure (as well as all) wounds.
59

60. M0300G Unstageable
Suspected Deep Tissue Injury3
 Clearly document assessment findings
in the resident’s medical record.
 Track and document appropriate wound care planning
and management.
 Deep tissue injuries can indicate severe damage.
 Identification and management is imperative.
60

61. M0300E, M0300F, M0300G
Coding Instructions
 Code number of each type of pressure ulcer.
 Code number of each type of ulcer present upon
admission/ reentry.
 Do not code M0300G when a lesion related to
pressure presents with an intact blister and the
surrounding or adjacent soft tissue does not have the
characteristics of Deep Tissue Injury.
 Code under M0300B Unhealed Pressure Ulcers --
Stage 2.
61

62. Item M0610
DIMENSIONS OF
UNHEALED STAGE 3 OR 4
PRESSURE ULCERS OR ESCHAR
62

63. Dimensions of a Pressure Ulcer
What to Measure
 Identify pressure ulcer with the largest surface
area from the following:
• Unhealed (nonepithelialized) Stage 3 or 4
• Unstageable pressure ulcer related to slough or eschar
 Measure every Stage 3, Stage 4, and
unstageable related to slough or eschar
pressure ulcer to determine the largest.
63

64. M0610A Length
 Measure the longest length from head to toe using a
disposable device.
64

65. M0610B Width
 Measure widest width of the pressure ulcer
side to side perpendicular (90° angle) to length.
 The depth of this
pressure ulcer
is approximately
3.7 cm.
65

66. M0610 Coding Instructions
 Enter pressure ulcer dimensions in
centimeters.
 If depth is unknown, enter a dash in each space.
66

67. M0610C Depth
 Moisten a sterile, cotton-tipped applicator
with 0.9% sodium chloride (NaCl) solution.
 Place applicator tip in deepest aspect of the
wound and measure distance to the skin level.
67

68. Item M0700
MOST SEVERE TISSUE TYPE
FOR ANY PRESSURE ULCER
68

69. M0700 Most Severe Tissue Type
for Any Pressure Ulcer
 Determine type(s) of tissue in the wound bed.
 Code for most severe type of tissue present in pressure ulcer
wound bed.
 Code for most severe type if wound bed is covered with a mix
of different types of tissue.
69

70. MO700 Epithelial Tissue
70

71. MO700 Granulation Tissue
71

72. MO700 Slough
72

73. MO700 Necrotic Tissue (Eschar)
73

74. Item M0800
WORSENING IN PRESSURE
ULCER STATUS SINCE PRIOR
ASSESSMENT (OBRA, PPS,
OR DISCHARGE)
74

75. M0800 Assessment Guidelines
 Complete only if this is not the first
assessment since the most recent admission (A0310E = 0).
 Look-back period is back to the ARD of the prior assessment.
75

76. M0800 Coding Instructions
 Enter the number of pressure ulcers that:
• Were not present.
OR
• Were at a lesser stage on prior assessment.
 Code 0 if:
• No pressure ulcers have worsened.
OR
• There are no new pressure ulcers.
76

77. Item M0900
HEALED PRESSURE
ULCERS
77

78. Healed Pressure Ulcers
78

79. M0900 Healed Pressure Ulcers
 Complete only if this is not the first
assessment since the most recent admission (A0310E=0).
79

80. Item M1040 & M1200
OTHER ULCERS, WOUNDS
AND SKIN PROBLEMS
SKIN AND ULCER
TREATMENTS
80

81. M1040/ M1200
Conduct the Assessment
 Review the medical record.
• Skin care flow sheet or other skin tracking form
• Treatment records and orders for documented treatments in the look-
back period
 Speak with direct care staff and treatment nurse.
• Confirm conclusions from the medical record review.
 Examine the resident.
• Determine if ulcers, wounds, or skin problems are present.
• Observe skin treatments.
81

82. M1040B Diabetic Foot Ulcers
82

83. M1040D Open Lesions Other
than Ulcers, Rashes, Cuts
83

84. M1040E Surgical Wounds
Failed Flap
84

85. M1040F Burns
85

86. M1200 Skin and Ulcer Treatments1
Must have 2 of these present to affect RUG Score
M1200A and/or B, C,D,E,G, and H *(A&B will count as one if both coded)
86

87. M1200 Skin and Ulcer Treatments2
 Pressure-relieving devices do not include:
• Egg crate cushions of any type
• Doughnut or ring devices in chairs
 Turning/ repositioning program
• Specific approaches for changing resident’s position and realigning the
body
• Program should specify intervention and frequency
 Nutrition and hydration
• High calorie diets with added supplements to prevent skin breakdown
• High protein supplements for wound healing
87

88. Resource Utilization Impact
 Categorization under the Resource Utilization Grouper is
in the Special Care Category
 Wound care is costly and labor intensive; you want to
ensure you are getting appropriate payment for services
rendered
 Clinical indicators for RUG-IV, as well as RUG-III if you
are still using this for Medicaid Case Mix in your state
 This can result in a loss of over $100/day for a Part A
resident if it is coded incorrectly
88

89. Special Care Low
 Cerebral Palsy, multiple sclerosis, or Parkinson’s disease with
ADL score >=5; respiratory failure and oxygen while a resident;
feeding tube (calories>=51% or calories=26-50% and fluid
>=501cc); ulcers (2 or more Stage II or 1 or more Stage III or
IV pressure ulcers; or 2 or more venous/arterial ulcers; or 1
Stage II pressure ulcer and 1 venous/arterial) with 2 or more
skin care treatments; foot infection/diabetic foot ulcer/open
lesions of foot with treatment; radiation therapy while a
resident; dialysis while a resident
AND
 ADL score of 2 or more
 WILL DEFAULT TO CLINICALLY COMPLEX IF ADL SCORE LESS
THAN 2
89

90. Quality Measures
 The new quality measures draft report was updated on
09/29/2011
 The updated Quality Measures will be reported via the
5 Star Quality Rating System on Nursing Home
Compare beginning April 1st, 2012.
• Sample period has begun.
 Helps surveyors create their audit sample
 2 Specific Pressure Ulcer Quality Measures
• Percent of residents with pressure ulcers that are new or
worsened-Short Stay
• Percent of high-risk residents with pressure ulcers-Long Stay
90

91. Short Stay- SS_0678
 Percent of Residents With Pressure Ulcers
That Are New or Worsened #0678
• Captures the percentage of short-stay
residents with new or worsening Stage 2-4
pressure ulcers
91

92. Pressure Ulcers New or Worsened-Short Stay
 Numerator:
• Short stay resident for which a look-back scan indicates one or more new or
worsened Stage 2-4 pressure ulcers
• Where on any assessment in the look-back scan:
• 1. Stage 2 -M0800A (worsening in pressure ulcer status since prior
assessment) > 0 and M0800A <= M0300B1 (# of Stage II ulcers)
• 2. Stage 3 -M0800B (worsening in pressure ulcer status since prior
assessment) > 0 and M0800B <= M0300C1 (# of Stage III ulcers)
• 3. Stage 4 -M0800C (worsening in pressure ulcer status since prior
assessment) > 0 and M0800C <= M0300D1 (# of Stage IV ulcers)
 Denominator:
• All residents with one or more assessments that are eligible for a look-back
scan, except those with exclusions
92

93. Pressure Ulcers New or Worsened-Short Stay (2)
 Exclusions:
• Residents are excluded if none of the assessments that are included
in the look-back scan has usable response for M0800A, B, or C.
 Covariates:
• 1. Indicator of requiring limited or more assistance in bed mobility
self-performance on the initial assessment
• 2. Indicator of bowel incontinence at least occasionally on the initial
assessment
• 3. Have diabetes or peripheral vascular disease on initial assessment
• 4. Indicator of Low Body Mass Index, based on Height and Weight
on the initial assessment
• 5. All covariates are missing if no initial assessment is available
93

94. Long Stay-LS_0679
 Percent of High-Risk Residents With
Pressure Ulcers #0679
• Captures the percentage of long-stay, high risk
residents with Stage II-IV pressure ulcers
94

95. High Risk Pressure Ulcers -Long Stay
 Numerator:
• All residents with a selected target assessment that meets both
of the following conditions:
• 1. There is a high risk for pressure ulcers, where “high risk” is
defined in the denominator definition below.
• 2. Stage II-IV pressure ulcers are present, as indicated by any of
the following three conditions:
• 2.1 M0300B1 (# of Stage II pressure ulcers) =1,2,3,4,5,6,7,8,9 OR
• 2.2 M0300C1 (# of Stage III pressure ulcers) =1,2,3,4,5,6,7,8,9 OR
• 2.3 M0300D1 (# of Stage IV pressure ulcers) =1,2,3,4,5,6,7,8,9 OR
• 2.4 Any of the additional diagnoses is a Stage II-IV ulcer ICD-9 (I8000=
707.22, 707.23, 707.24)
95

96. High Risk Pressure Ulcers -Long Stay
 Denominator:
• All residents with a selected target assessment that meet the
definition of high risk, except those with exclusions. Residents
are defined as high-risk if they meet one or more of the
following three criteria on the target assessment:
• 1. Impaired bed mobility or transfer indicated, by either or
both of the following:
• 1.1 Bed mobility, self performance = 3,4,7,8
• 1.2 Transfer, self performance= 3,4,7,8
• 2. Comatose (B0100=1)
• 3. Malnutrition or risk of malnutrition (I5600 is checked)
96

97. High Risk Pressure Ulcers -Long Stay
 Exclusions:
• 1. Target assessment is an admission assessment or a PPS 5
day or readmission/return assessment
• 2. If the resident is not included in the numerator(the resident
did not meet the pressure ulcer conditions for the numerator)
AND any of the following conditions are true:
• A. M0300B1 (# of Stage II pressure ulcers) = “-”
• B. M0300C1 (# of Stage III pressure ulcers) = “-”
• C. M0300D1 (# of Stage IV pressure ulcers) = “-”
97

98. Value Based Purchasing
Pay for performance
• Demonstration in process in New York (79 homes),
Wisconsin (62 homes) and Arizona (41 homes)
• 3 Year project started July 1st, 2009
• Based upon Quality Measures
• Staffing
• Appropriate hospitalizations
• Outcome measures for the MDS
• Inspection survey deficiencies
• Payment will be directly effected by poor numbers
98

99. Expense Management
 Appropriate tracking of wounds and product utilization
 Technology as an aid for tighter management and overall
tracking
 Pricing and product availability -Shop Vendors
• Work with a formulary to contain supplies that your team members
can order
 Involve clinical team to monitor expenses monthly
• This is often done by finance only
99

100. About the Sponsors
Post Acute Consulting LLC
• Post Acute Consulting, LLC specializes in Medicare and
Medicaid reimbursement.
• Post Acute Consulting is the “A Team" of Compliance and
Reimbursement.
Dave Rokes
(888) 688-5224
drokes@postacute.com
100

101. About the Sponsors
WoundRounds™ is the point-of-care wound management
& prevention solution that empowers nurses to deliver
WoundRounds™ is the point-of-care wound
better wound care in less time, resulting in:
management & prevention solution that empowers
• Savings of 8-10 hours per week per user
nurses to deliver better wound care in less time,
• 50-80%
resulting in: reduction in facility-acquired pressure ulcers
• Lower wound care costs
• Automated MDS 3.0 reporting
• Decreased readmissions
• Savings of 8-10 hours per week per user
• Reduced fines and litigation
• 50-80% reduction in facility-acquired pressure ulcers
• Lower wound care costs
• Decreased readmissions
• Reduced fines and litigation
www.woundrounds.com 101
847.519.3500

102. Upcoming Free Webinar
Technology for Improved Wound Management
• Thursday, December 8th at Noon Central Time
• Speaker: Beth Florczak, MS, RN, WCC, RAC-CT
o Director, Quality & Clinical Excellence at Provena Life Connections
• How can your facility improve wound outcomes while decreasing
costs?
• Learn how long term care facilities are using technology to get more
wound care with fewer resources
102

103. WoundRounds™ is the point-of-care wound
management & prevention solution that empowers
nurses to deliver better wound care in less time,
resulting in:
• Automated MDS 3.0 reporting
• Savings of 8-10 hours per week per user
• 50-80% reduction in facility-acquired pressure ulcers
• Lower wound care costs
• Decreased readmissions
• Reduced fines and litigation
www.woundrounds.com
847.519.3500 103