How Podiatrists Can Navigate The Shifting Model Of Wound Care During The COVID-19 Pandemic

Podiatry has a very large role in the COVID-19 pandemic. We are going to be operating under pandemic medicine protocols for at least the next 18 months. That does not mean that your local restaurants and movie theaters will not reopen. However, until we see the development and full distribution of a vaccine, hospitals and, frankly, all settings of healthcare services, will be operating under this pandemic model of care for the foreseeable future. We need to understand that while there is an end in sight, it is not short-term. So where can podiatrists make the biggest difference? 

The podiatrist’s role as a diabetic foot and wound care expert is even more important now during the pandemic. Several studies have illustrated the contribution of podiatry in reducing diabetic foot and wound-related ER visits, hospitalizations, amputations, and length of stay. Hospitals are expecting an influx of patients with the COVID-19 virus in the coming weeks and months, and are taking action to limit other services so they can surge to meet the demand. Podiatrists are well-positioned to help relieve the burden on hospitals. By providing expert care to patients with diabetic foot complications and lower extremity wounds, we can help keep them out of the hospital and reduce their risk to contract the novel coronavirus.

In my opinion, the pre-pandemic goal of wound care seemed to be “wound healing at any cost.” However, during the pandemic, the goal is shifting to “avoiding hospitalization at all cost.” It is obvious by all the waivers for providers to perform telemedicine and in-home care that The Centers for Medicare and Medicaid Services (CMS) is pushing for more services to be performed in the home environment. That is difficult to do in wound care since best practices are heavily dependent upon providing procedures. Accordingly, we have to modify our goals. There are triage and escalation schematics that can guide providers in this process.^1,2

The Alliance of Wound Care Stakeholders recently submitted a request for emergency relief to CMS, asking for certain provisions to help providers taking care of wounds by telemedicine and in the home environment. The Alliance represents a broad group of parties interested in wound care in Washington DC, including the American Podiatric Medical Association (APMA). The Alliance advocates on behalf of providers, allied health, management companies, manufacturers and distributors to lawmakers and policymakers.

Astonishingly, we are seeing wound care centers around the country closing their doors or limiting their hours in response to direction from CMS, government bodies and the United States Surgeon General to postpone or cancel appointments. Based on my discussions with industry leaders, up to half of wound care centers in the U.S. are at risk of temporary closure. That is because wound centers are frequently located inside the physical space of a hospital. Hospitals are limiting visitors and not allowing outpatient services in the building. Accordingly, wound care, which is getting misclassified as a non-essential service, is being closed by hospital administrators.

We are also finding that even in the wound care centers that are open, there are podiatrists working, but other doctors that typically work there, such as ER or infectious disease physicians, are being repurposed away from the wound center. The result is a workforce shortage in wound care. CMS recognizes this and is asking for guidance on rules and policies that could be temporarily relieved in order to provide better care for patients.

One thing the Alliance is proposing is that the site of service for house calls (place of service 12) be reimbursed at the same rate and have the same policies apply as they do to place of service 11 (a provider’s office). In other words, if a podiatrist goes to a patient’s house, anything he or she normally does in the office, the DPM could then do in the house. As per our proposed emergency relief request, podiatrists could conceivably apply a cellular or tissue-based product, perform a debridement or a total contact cast in the home. 

Right now, there is significant disruption in the delivery of care for patients with diabetic foot ulcers and other wounds. This request for emergency relief to CMS will hopefully mitigate some of the damage occurring in wound care. It is happening in a lot of other areas of health care as well.

Where Things Currently Stand With Telemedicine

Another area of medicine where we are seeing changes on an almost hourly basis is telemedicine.

It is important to stay current. Rules and regulations are rapidly evolving. All information in this blog is current as of April 2, 2020. There are many more services we will be able to do with telemedicine moving forward. In the meantime, here are several important points to consider.

• One must understand how telemedicine is governed, both by the billing side and the licensure side. Just because Medicare says you can do something, that does not mean a given state agrees. You have to weigh those two things simultaneously. Some states are waiving licensure requirements, allowing, for example, a DPM in California to see a patient via telemedicine that is sitting in Virginia. 
• Check with your state and any other state in which you anticipate seeing patients. The Federation of State Medical Boards has an online document you may consult to see which states are waiving licensure requirements and under what circumstances.³
• The provider is governed by the scope of practice in the patient’s state, the one that is waiving the license. Although it may be legal for that DPM in California to see the Virginia patient via telemedicine, the provider is working under Virginia’s laws. 
• As a result, one must also understand if your malpractice policy will cover you to see patients by telemedicine. You must notify your carrier of any anticipated or current telemedicine activities. I discussed the issue with the largest podiatric malpractice insurance carrier and the company will not be charging more to include telemedicine on policies, but the carrier does require the doctor to notify the carrier of the telemedicine activities.⁴ 
• As it stands today, any potential liability would be under the jurisdiction of the patient’s state and that’s where the lawsuit will be filed. This makes it even more important to consult with your malpractice company on coverage for telemedicine visits.

Billing And Telemedicine: What You Should Know

Some recent developments on the billing side of telemedicine are reflecting the shift in how CMS wants care to be rendered during the pandemic.

• You can see new patients via telemedicine. 
• CMS is directing providers to use the codes for office visits (992xx) for telemedicine services. If the patient is on a hospital floor or in the ER, but you are seeing him or her via telemedicine, you can use the hospital or ER consultation codes. This is a benefit for doctors as they are higher reimbursement codes.
• Previously, there could not be a physician encounter and a home health encounter on the same day. Now a home health nurse can see a patient, support two-way audio/video communication on site, and you can provide direction, and now the physician can bill the visit as an office visit.
• The Office of the National Coordinator for Health Information Technology (ONC) relaxed HIPAA requirements for telemedicine as long as one is operating in good faith. You may use whatever is on your phone and at the patient’s disposal. You may not use public broadcasts such as Facebook Live but you can use FaceTime, WhatsApp, Zoom, Facebook Messenger, etc. It must have both audio and video capabilities. Telephone-only visits have separate codes and are reimbursed at a much lower rate. 
• When you bill for telemedicine, you bill by time only, since there is obviously no way to perform certain elements of a full exam. 

Podiatrists are having trouble finding their place in this pandemic. We have the opportunity to play a vital role, especially with vulnerable populations such as those with wounds. We can and do help reduce hospitalization, ER utilization and length of stay. We can help support hospital systems that, if not already overwhelmed, may reach that critical point during to the COVID-19 outbreak. Podiatry can and will make a difference during this time.

Dr. Rogers is the Chief Medical Officer of the Amputation Prevention Experts (APEx) Health Network and is an advisor to the Alliance of Wound Care Stakeholders. Dr. Rogers is also a member of the Board of Directors of the American Board of Podiatric Medicine (ABPM).

References

1. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck – the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. 2020 Mar 25 [online ahead of print]. DOI: 10:7547/20-051. Available at: https://www.japmaonline.org/doi/pdf/10.7547/20-051 . Published March 15, 2020. Accessed April 1, 2020.
2. Alliance of Wound Care Stakeholders. Wound care is an essential – not elective – service that prevents hospital admissions and ED visits among a fragile cohort of patients at high risk of COVID-19. Available at: https://www.woundcarestakeholders.org/images/Final2_Statement_-_Wound_Care_as_Essential.pdf . Published March 20, 2020. Accessed April 2, 2020.
3. Federation of State Medical Boards. States waiving licensure requirements/renewals in response to COVID-19. Available at: https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declarations-licensures-requirementscovid-19.pdf . Published March 31, 2020. Accessed April 2, 2020.
4. PICA. PICA COVID-19 updates. Available at: https://picagroup-5900118.hs-sites.com/pica-covid-19-info-page . Updated April 1, 2020. Accessed April 2, 2020.