Government Affairs update June 2007
Marilyn Magoffin G/A Chair
The Public Policy committee for WOCN has been very busy this past 2 months responding to several rule changes proposed by CMS, which if implemented, would affect the practice of WOC nurses. The following is a summary of those actions:
Compression Therapy for Venous Insufficiency
In the past year, there have been changes on reimbursement for various types of compression therapy by some of the Medicare fiscal intermediaries. In Feb 2007, Noridian, the fiscal intermediary for Nevada, issued a billing clarification re: high compression multiplayer wraps. Their ruling stated that these products would not be covered under the Unna boot CPT code because they could be applied independently by patients or families/caregivers. This in a nutshell is the issue: The Unna boot CPT code is a widely used code that includes strapping, casting, and lymphedema wraps in addition to treating venous stasis wounds. There has been a huge increase in the use of this code (multiplayer wraps are probably one of the reasons.) When Medicare sees such an increase, they tend to think this is a source of fraud and abuse and take efforts to try to curb the use of it. This effort by Noridian is just one of many different attempts by a number of the fiscal intermediaries to limit the use of this code. The current Unna boot CPT code does not, nor has it ever included any specific language about multiplayer compression wraps. While we are reacting strongly to Noridian's rationale, the fact is that they do not need any rationale to deny coverage. They just need to point to the fact that multiplayer compression wraps are not Unna boots, and will not be reimbursed as such. LCD (Local Coverage Determination) Additionally, Unna's boots are not described in the current CMS product list as being used for compression therapy but are specifically for casting. This has been a very complicated issue that the Public Policy Committee has been monitoring. A sample letter was sent out on the forums for affected members to write their fiscal intermediary (Please see appendix A) and a copy was forwarded to Betty Razor to forward to the Nevada WOC nurses
Competitive Bidding of Electric Wheelchairs and Scooters
The Public Policy Committee prepared a letter of comment (see Appendix B) to CMS when CMS decided wheelchair cushions were an accessory item eligible for competitive bidding. WOCN believed that wheelchair cushions should remain a covered item as these cushions are essential for the prevention of pressure ulcers in our patients. CMS is now reviewing this decision and hopefully is reconsidering their position.
Mutual of Omaha Coverage Policy on Wound Care
The Public Policy Committee prepared an organizational comment (see appendix C) to this draft policy which was using the Wagner system for grading pressure ulcers, the term "Enterostomal Therapist" and other out dated or inappropriate terminology
CMS Proposed Rule for Inpatient Prospective Payment
The Public Policy Committee is prepared a comment (see Appendix D) to CMS as they propose to penalize hospitals for facility acquired pressure ulcers. While we are supportive of hospitals having accountability in failing to use preventative measures tp protect patients from pressure ulcers ee were concerned that hospitals would be unfairly burdened as there was no recourse for unavoidable pressure ulcers and the current ICD 9 codes used for determining
And from our advance practice colleagues:
National Government Relations Update
Highlights for Advocacy Action
1. Home Care Bill: "The Home Health Care Planning Improvement Act of 2007" to be sponsored by Senator Collins of Maine has been drafted with input from ACNP and other professional organizations. The bill would amend Title XVIII of the Social Security Act to allow NPs, CNSs, CNMs, and PAs, as Medicare providers, to order home care for patients.
2. Medicaid Bills: (a) Medicaid Advance Practice Nurses & Physician Assistants Access Act (S. 59), introduced by Senator Daniel Inouye (D-HI) in January 2007, allows NPs, CNSs, and PAs, to deliver services to Medicaid patients as primary care providers. (b) H.R. 2066, the House companion bill to S.59, was introduced by Congressman John W. Olver (D-MA) with 17 co-sponsors.
ACNP requests that you WRITE a brief note (only 3-4 sentences) and FAX it to your Members of Congress ASAP, to ask that they sign-on as co-sponsors of S. 59 and H.R. 2066, the companion Medicaid bills which would allow NPs, CNSs, and PAs to provide services as primary care providers under Medicaid's fee-for-service programs. To find your Members of Congress, go directly to www.Congress.org and insert your home zip code. The website will provide the names, addresses, phones and fax numbers for your two US Senators and your US Representative.
3. Nursing Workforce: ACNP continues to support a $200 million allocation in Fiscal Year 2008 appropriations for Nursing Workforce Development Programs. This includes $76 million for Advanced Education Nursing Programs in Title VIII of the Public Health Service Act. The "Nursing Community" a coalition of 30+ national nursing organizations supports this funding. Committee hearings have not yet been scheduled to consider this appropriation.
CMS Provides Opportunity for NPs to Demonstrate Quality
NPs may avail themselves of the opportunity to demonstrate quality using the mechanism provided by The Centers for Medicare and Medicaid Services (CMS) by participating in a voluntary quality reporting system: the Physician Quality Reporting Initiative (PQRI). This program establishes a financial incentive for eligible professionals (including nurse practitioners) to participate and is a means to ensure that NP quality data is on record with CMS.
Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.
Access all the facts about the PQRI on the CMS' website, http://www.cms.hhs.gov/PQRI/. Check out "Eligible Professionals" and "Frequently Asked Questions" to better know how to respond to issues in your practice setting.
Media Campaign for Provider-Neutral Language in Direct-to-Consumer Advertising
ACNP asks all nurse practitioners to participate in our media campaign to impact Direct-to-Consumer (DTC) advertising for both patients and NPs. Every time you hear or read an advertisement for a pharmaceutical product, note whether the phrase "Ask your doctor" or "Ask your healthcare provider" is used. To facilitate ACNP's data collection efforts, please e-mail that information including the name of the drug and the name of the pharmaceutical company that placed the ad to dtc@acnpweb.org.
ACNP will publicly acknowledge those companies using provider-neutral language and encourage others to do so. We ask all members and nonmembers to join us as we gather data to address this issue of misrepresentation to consumers about prescriptive privileges in the United States.
For Nevada Members:
This message was submitted by: "Lee Ann Krapfl" <krapflla@mercyhealth.com>
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Noridian is the fiscal intermediary for most states west of the Mississippi River. Effective Feb 21, 2007 they published a clarification stating that multilayer compression wraps were not to be billed using the CPT Code for Unna Boots because, in their opinion, these multilayer wraps could be applied independently by patients and families.
The actual ruling can be read in its entirety by going to:
Obviously, most WOC nurses who actually use these products would disagree with this rationale. There is concern that this ruling clarification will be adopted by other fiscal intermediaries as well.
We are asking members to respond to Noridian and ask them to reconsider this ruling. Following is a sample letter with talking points that members can use to draft their response.
Thanks to all members in advance who take the time and effort to respond to Noridian on behalf of your patients.
Lee Ann Krapfl, RN, CWOCN
Chair, WOCN Public Policy Committee
Noridian Administrative Services
Medicare B
P.O. Box 6711
Fargo, N.D. 58108-6711
To Whom It May Concern:
I am writing in response to your recent billing clarification regarding high compression bandage systems. I am a certified wound nurse and have clinical experience with these multiplayer wraps. From my personal experience in caring for patients with venous stasis leg ulcers, the suggestion that the patient and/or caregiver can safely apply these products independently is simply unfounded.
Sustained, graduated compression delivered by the multiplayer wraps is more therapeutic. The disadvantage is that the application of them is actually more complex than an Unna boot and requires advanced skill, training and experience of a health care professional. My rationale is as follows:
An Unna boot delivers a pressure range between 12-18 mmHg. When applied to a leg with a venous ulcer, the main function is the protection of the wound with the application of minimal compression.
Ideally, the most effective therapeutic compression to treat venous ulcers requires 25-45 mmHg at the ankle reducing to 15-20 mmHg at the knee.
Sustained, graduated compression delivered by a multiplayer-wrap is a more complex procedure than the application of an Unna boot. There is an application of multiple layers, usually 3-4 layers. Each layer is applied with a different technique and pressure such as spiral or figure-eight. Additionally, each layer must be applied in a specific order as instructed per the manufacturer's recommendations. Evidence has shown that the effectiveness of these wraps is dependent upon the training, skill and experience of the health care professional applying the compression. Application of this system requires more time, skill and training when compared to the application of an Unna boot.
Because the sustained, graduated compression wrap delivers a high amount of pressure, confirmation of adequate circulation is required before and after application. This is more critical than with the Unna boot application and requires more advanced assessment skills of a health care practitioner.
Because venous insufficiency can result in very delicate skin, maceration and dermatitis, additional skin preparation is usually needed with emollient lotions, steroid creams or barrier ointments prior to the application of a sustained, graduated compression wrap. The clinical judgments of the health care professional in this regard are necessary to prevent further skin injury.
The decision by Noridian to deny reimbursement for these wraps as not medically reasonable and necessary because patients and/ or their caregivers can independently apply them is not based in fact. I am asking for a reconsideration of this ruling.
April 18, 2007
Leslie V. Norwalk
Acting Administrator, Centers for Medicare & Medicaid Services
Hubert H. Humphrey Building
200 IndependenceAvenue SW
Washington, DC 20201
Dear Ms. Norwalk:
We are writing on behalf of the Wound, Ostomy and Continence Nurses' Society. This professional organization provides care for the many Medicare beneficiaries that are afflicted with chronic wounds. On April 10th the Centers for Medicare & Medicaid Services (CMS) published "Competitive Acquisition for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other Issues; Final Rule" (42 CFR 411 and 414) in the Federal Register. Additional information on the subject has been released in public forums, guidance documents and via the websites of CMS and its contractors. There is one issue of this Final Rule that gives our organization cause for deep concern. Two of the product categories to be included in the first round of bidding are:
- Standard Power Wheelchairs, Scooters and Related Accessories
- Complex Rehabilitative Power Wheelchairs and Related Accessories
The issue regarding these two product categories pertains to the "Related Accessories" and specifically to the inclusion of wheelchair seat cushions in the list of HCPCS codes to be bid. Our concern is based on the fact that wheelchair cushions are part of a therapeutic treatment plan to manage or prevent a wide variety of skin and wound care conditions. Powered wheelchairs are used to manage mobility issues. While people with mobility issues may also need a wheelchair cushion, the cushion is intended to treat or prevent a separate medical condition, such as pressure ulcers. Most persons requiring the use of a wheelchair spend much of their day in the chair, and are at extremely high risk for the development of pressure ulcers. The wheelchair cushion is designed to decrease the risk of pressure ulcer development, and is usually necessary to treat an existing pressure ulcer. We do not consider these pressure redistributing cushions to be accessory items, but rather a separate item used to address a costly and debilitating complication of immobility.
Our request is that wheelchair cushions not be considered accessory items and should therefore not be included in the competitive bidding for powered wheelchairs or scooters. Including this item will restrict the clinician's ability to treat or prevent the skin or wound care condition that the wheelchair cushion is designed to help.
Respectfully submitted,
Margaret Goldberg, MSN, RN, CWOCN
President, WOCN
Lee Ann Krapfl, BSN, RN, CWOCN
Chair, WOCN Public Policy
May 9, 2007
Lisa Hiykel
Mutual of Omaha Insurance Company
Medicare Division
P.O. Box 1602
Omaha, NE 68101
Dear Ms Hiykel:
We are commenting on the Draft LCD for Wound Care #DL15700. We represent the Wound, Ostomy and Continence Nursing Society, an organization of credentialed wound care nurses that specialize in the care of patients with a wide variety of acute and chronic wounds. Thank you for forwarding this LCD to our attention. We welcome this opportunity to comment.
Page 6 E. Definitions 4. Standard Wound Care
"Patients with grade 3 through 5 wounds should have vascular and/or orthopedic surgery consultations in their documentation."
We would recommend the following language substitution: Patients with wound involvement of deep structures to include bone, tendon, muscle, joint or internal organs should have a specialist consultation to include vascular surgery, orthopedic surgery, general surgery, podiatry, plastic surgery or infection specialist in their documentation.
Page 6 E. Definitions 5. Wound Staging
"Information for staging/grading of wounds is a modified Wagner grading system"
We would recommend the following language substitution:
Pressure Ulcers should be staged according to the National Pressure Ulcer Advisory Panel's Pressure Ulcer Staging Definitions:
Deep Tissue Injury: Purple or maroon localized area of intact skin or blood-filled blister.
Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Stage III: Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle.
Unstageable: Full thickness tissue loss in which the base of the ulcer is covered with slough and/or eschar in the wound bed.
The Wagner grading system is an acceptable staging tool for neuropathic foot ulcers, but it is not a proven tool to be used for wounds of other etiologies.
Page 7 II General Indications C. Visits...
The use of the title "enterostomal nurse" and "enterostomal therapist" are no longer valid titles. We recommend substituting the title "credentialed wound care nurse specialist" throughout the document.
Page 10 G. Negative Pressure Therapy 3. Documentation of wound characteristics
ii. "The wound has been debrided and is free of nonviable or necrotic tissue..."
We wound recommend the following language substitution:
The wound has been debrided and has less than 20% nonviable or necrotic tissue in the base... This language is more consistent with national practice guidelines and manufacturer's recommendations for this treatment modality.
Page 13 IV. Supporting Reasonable and Necessary Wound Care
3. "Evidence of increased granulation tissue must be documented weekly."
We wound recommend the following language substitution:
Evidence of wound healing must be documented weekly, or on a regular basis based on the patient's clinical condition. Evidence of wound healing can be measured by a decrease in wound dimensions, a decrease in wound drainage and odor, a decrease in the amount of nonviable or necrotic tissue, an increase in granulation tissue, a decrease in redness, induration or swelling or an improvement in pain.
Thank you again for the opportunity to comment on this draft.
Sincerely,
Margaret Goldberg, MSN, RN, CWOCN
President, WOCN
Lee Ann Krapfl, BSN, RN, CWOCN
Chair, WOCN Public Policy Committee
June 5, 2007
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Room 445-G
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201
Dear CMS Officials:
We are writing to comment on the Proposed Changes to the Hospital Prospective Payment Systems and Fiscal Year 2008 Rates, CMS-1533-P. We represent the Wound, Ostomy and Continence Nurses' Society (WOCN.) This is an organization of certified nurses specializing in the care of chronic wounds, including pressure ulcers. While our members practice in every setting, the majority are employed by hospitals. In addition to providing direct care, many also monitor pressure ulcer data, participate in benchmarking and coordinate quality improvement efforts targeted at the reduction of facility acquired pressure ulcers.
We thank the Centers for Medicare and Medicaid Services (CMS) for the opportunity to comment on this proposed rule. Specifically, we would like to comment on Section II, "Proposed Changes to DRG Classifications and Relative Weight", Sub-Section 7, "F. Hospital Acquired Conditions, Including Infections." In this section, pressure ulcers are included as one of six hospital-acquired conditions that will result in lower MS-DRG payments. If a pressure ulcer is not present on admission, and develops during the patient's hospital stay, then the case will not be assigned to the 258 higher-paying MS-DRGs that reflect the increased costs of care for patients with complications and co-morbidities. While we are supportive of this provision in principle, we have several concerns about how this provision will be implemented by hospitals in practice.
Not All Pressure Ulcers are Avoidable
The skin is a body organ that can sometimes fail, in spite of our very best efforts. While many pressure ulcers are avoidable by using evidenced-based interventions that reduce the patient's risk, there are circumstances where the medical condition prevents us from implementing all of the preventive interventions desirable. Unstable spinal and pelvic fractures, intractable pain and end-of-life care are examples where certain interventions are inappropriate, and even medically contraindicated.
In "Guidance to Surveyors for Long Term Care Facilities' (CMS Manual System Pub. 100-07 State Operations Provider Certification issued November 2004, page 5) CMS acknowledges that some pressure ulcers are "unavoidable." In the Guidance, CMS directs surveyors to avoid citing Long Term Care Facilities with a F-314 deficiency when a pressure ulcer develops on a resident despite application of clinically appropriate prevention interventions.
The proposed rule does not contain provisions for an appeal process or other recourse for a hospital with a patient that develops an unavoidable pressure ulcer. Given the variability and instability of many acute care patients, we believe the final rule should include provisions to accommodate this situation.
ICD-CM Codes Have Limitations
The ICD-9-CM diagnosis codes 707.00-707.07 & 707.09 have severe limitations. We have concerns about using them to document a pressure ulcer present on admission and as a quality reporting measure. These codes do not reflect the variability in pressure ulcers such as the stage of the ulcer, the size, the presence of necrotic tissue, the presence of infection, etc. The cost of treating a Stage IV pressure ulcer with bone involvement is significantly higher than the cost of managing a Stage II partial thickness ulcer, yet the ICD-9-CM codes for pressure ulcers would not differentiate between these two wound types and would score both the same for payment.
We recommend CMS supplement ICD-9-CM codes for pressure ulcers with severity adjustments for complications and co-morbidities that are present on admission. We believe this will better allow hospitals to be appropriately compensated for the care that they deliver to the sickest and most vulnerable Medicare beneficiaries.
Accurate Identification of Pressure Ulcers Requires Education and Expertise
The proposed rule requires hospitals to identify all pressure ulcers present on admission in order to qualify for a higher DRG payment. This requires the bedside clinician to perform a thorough skin inspection as soon as is reasonably possible on admission to the facility. We support this intervention. Conversely, there is wide variability in the assessment skills of clinicians and a wide variety of wounds and skin conditions that can be mistaken for pressure ulcers. Such things as incontinence dermatitis, skin rashes, abrasions, skin tears, neuropathic and vascular ulcers can all resemble a pressure ulcer. It often takes the advanced education and assessment skills of a wound specialist in order to distinguish the true etiology of wounds. The National Databank for Nursing Quality Indicators (NDNQI) has validated that pressure ulcers can be mislabeled and that pressure ulcer data is most accurate when collected by credentialed wound nurses. Additionally, the proposed rule may have the unintended consequence of providing hospitals a financial incentive to misdiagnose the etiology of some wounds.
We commend CMS for including provisions in the proposed rule to reduce of pressure ulcer incidence in hospitals. Our organization has been a long time supporter of including pressure ulcer reduction as a National Patient Safety Goal of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) across all settings where healthcare is delivered. We support efforts to incentivize healthcare facilities to take pressure ulcer prevention seriously. Financially rewarding facilities that deliver poor care or do not follow nationally accepted clinical practice guidelines for pressure ulcer prevention and treatment is not in the best interests of patients or payers.
We would like to thank CMS once again for the opportunity to provide comments and offer the WOCN Clinical Practice Guidelines for the Prevention and Management of Pressure Ulcers, as well as our website www.wocn.org as a resource for evidence-based interventions for pressure ulcer prevention.
Sincerely,
Margaret Goldberg, MSN, RN, CWOCN
President, WOCN
Lee Ann Krapfl, BSN, RN, CWOCN
Chair, WOCN Public Policy Committee