(WARNING! This Blog Entry Includes Incredibly Technical Billing InformationWhich May Lead To Your Eyes Rolling Into The Back Of Your Head!)
A new proposed rule comes out today from Medicare just in time for the the Federal Register that will be published on May 5th. Although most of the items in the new proposed rule are for inpatient care, there are two areas that will ultimately effect reimbursement for outpatient wound care.
The first proposed new rule is the creation of three new MS-DRG's for Excisional Debridement and a revision to the current MS-DRG. This was prompted by a request to move the procedural code for excisional debridement from a surgical code to a nonsurgical code. The justification for this move was that most excisional debridement is done bedside and therefore should not be included in the surgical codes. Fortunately, when Medicare reviewed their data, they found that they would be underpaying providers by moving that procedural code and therefore kept the procedural code in the surgical section. By drawing attention to the Inpatient excisional debridement, they did find a path to reduce their payments though. The proposed charges are as follows;
- MS-DRG 570 (skin debridement with MCC) relative weight 2.5217
- MS-DRG 571 (skin debridement with CC) relative weight 1.5531
- MS-DRG 572 (skin debridement without CC/MCC) relative weight 0.9928
- MS-DRG 573 (skin graft for skin ulcer or cellulitis with MCC) relative weight 3.4604
- MS-DRG 574 (skin graft for skin ulcer or cellulitis with CC) relative weight 2.7057
- MS-DRG 575 (skin graft for skin ulcer or cellulitis without CC/MCC) relative weight 1.2322
Although these codes are only used in the inpatient billing, it does bring to light the benefits of having an outpatient wound care center that can not only handle the majority of the excisional debridements outside the operating room but also function as a feeder for the surgical department.
The second proposed rule is in regards to readmission rates. CMS is now defining what the readmission is based on the National Quality Forum and is focusing on three readmission conditions of AMI, Heart Failure and Pneumonia. They are working on developing their Excess Readmission Ratio. CMS stated in the new proposed rule, “We are proposing to use the risk-standardized ratio calculated for the NQF-endorsed measures for AMI, HF, and PN as the “excess readmission ratio.” This risk-standardized ratio (excess readmission ratio), as required by statute, is a ratio of ‘risk adjusted readmission based on actual’ to ‘risk adjusted expected readmissions.’ Moreover, use of this ratio meets the statutory requirement that the numerator and denominator of the ratio be determined in a manner that is “consistent with” an NQF- endorsed readmission measure methodology. CMS-1518-P481 The proposed ratio is a measure of relative performance. If a hospital performs better than an average hospital that admitted similar patients (that is, patients with the same risk factors for readmission such as age and comorbidities), the ratio will be less than one. If a hospital performs worse than average, the ratio will be greater than one. Hospitals with a ratio greater than one have excess readmissions relative to average quality hospitals with similar types of patients.” This is the groundwork for reducing payments based on quality measures. The initial focus is on AMI, Heart Failure and Pneumonia.
We also know that chronic wounds are a contributing factor to hospital readmissions. Having a comprehensive outpatient wound care department will help to maintain the integrity of the continuum of care. These patients will be followed up on weekly helping to ensure compliance with home care treatment plans and ultimately stay out of the hospital.
Enjoy your Margarita!