Will Reimbursement Changes Adversely Affect Preventative Wound Care?

This author details recent changes to the CMS physician fee schedule and what lower reimbursement may mean for wound care centers and the high-risk patients they treat.

The 2011 update in the Centers for Medicare and Medicaid Services (CMS) physician fee schedule can be projected to reduce reimbursement for wound care services in facilities by 22 percent. While Congress called for a 0 percent update in the fee schedule for 2011, the CMS cut the conversion factor from $36.8729 to $33.9764, which is an approximate -7.8 percent reduction. The conversion factor cut is designed to help keep the relative value unit (RVU) changes budget neutral.

   Physicians who specialize in wound healing have a unique practice and represent a heterogeneous group of physician specialties, including general surgery, podiatry, vascular surgery, plastic surgery, infectious diseases, endocrinology, pulmonology and general surgery. Some practice in private offices but given the nature of the work, many practice in hospital-based wound centers.

   Updates in the 2011 fee schedule particularly impact codes that are used by wound specialists. Wound debridement codes were completely revised both in definition and value, and some common skin substitute application codes were drastically reduced. Changes in RVU and fee schedule for common codes from 2010 to 2011 for facility sites are illustrated in the tables below.

A Closer Look At The Coding Changes

Debridement reimbursement (1104x) is no longer based on the number of wounds debrided but rather on the total area of the debridement in increments of 20 cm2. Partial (11040) and full thickness (11041) skin debridement codes were deleted and replaced with removal of devitalized tissue (97597). There are now add-on codes to report additional increments of 20 cm2. The add-on codes are inherently reduced in value and should not be modified by -59.

   Why the drastic impact in wound services? It is all about the requirement to bill by surface area and not number of wounds. Under 2010 guidelines, if there were two wounds that each measured 9 cm2 and were debrided into the subcutaneous tissue, one would bill 11042 and 11042-59. The -59 modifier results in a 50 percent reduction of reimbursement for the second code.

   In the 2011 guidelines, one only bills 11042, adding the surface areas together to total <20 cm2. Even if adding the surface areas together is sufficient to bill another unit, the RVU of the add-on code is 40 percent of the value of the first code.

   The debridement of subcutaneous tissue (11042) code was the only frequently used wound care code that increased in value from 1.17 RVU to 1.4 RVU. This increase is offset by the requirement to code by area and not number of wounds. If this were debridement of muscle, the reduction would be even greater. The RVU of the parent code for muscle debridement (11043) dropped 42 percent and the add-on code for muscle debridement (11046) is 31 percent of the parent code. It is difficult to directly calculate the impact on reimbursement since it depends on the 2011 square area scenarios and the number of wounds debrided in the 2010 scenarios.

   In our wound center, 67 percent of the patients have more than one wound. The average number of wounds in those patients is 2.35.

   The skin substitute policy has also undergone drastic changes. Both Apligraf (15340) and Dermagraft (15365) were replaced by a CMS G code (G0440). The service was also revalued. In 2010, Apligraf had an RVU of 7.00 and Dermagraft had a RVU of 7.72. In 2011, G0440 is valued at 3.51. While the products are still reimbursed, the reimbursement for the physician service dropped by more than $150 in all scenarios.

Understanding The Impact Of The CMS Changes On Wound Care Clinics

To determine how this will affect physician revenue in the clinic, we sampled two consecutive days of patients (55) and calculated the reimbursement for the services delivered under the 2010 guidelines compared with the 2011 guidelines. The 55 patients in 2010 would have generated $5,643.87 and now the same services coded in 2011 would generate $4,419.61, a reduction of 22 percent.

   Our calculations were based on a doctor delivering services in a facility with the 2010 and 2011 fee schedules from CMS Palmetto, Los Angeles County.

Final Notes

Every year in the United States, there are nearly 100,000 amputations, a majority of which are on those with diabetes.1 There are 25.8 million people in the U.S. with diabetes and 79 million adults over age 20 with pre-diabetes.2 Amputations are a dreaded complication of diabetes. A chronic wound is present on nearly 85 percent of limbs that are amputated, making it the one of most common reasons for amputation.3

   During the 2008 presidential election, many candidates campaigned on increasing revenue and access to preventative services, and used the “diabetes-related amputation” as an example to illustrate their point.4 This update in the CMS fee schedule for wound care is the antithesis of that ideology. The substantial reduction creates a disincentive for physicians to treat patients with chronic wounds. As a result, this may leave Medicare patients experiencing delays in treatment or cause them to seek treatment by non-specialists. Just as the epidemic of diabetes continues to get worse, we may see an increase in the rate of amputations.

   Dr. Rogers is the Associate Medical Director for the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles. He is the Medical Director for the Amputation Prevention Centers of America, a national network of wound centers and limb salvage centers.

References

1.Centers for Disease Control and Prevention. Hospital discharge rates for nontraumatic lower extremity amputations by diabetes status - United States, 1997. MMWR Morb Mortal Wkly Rep. 2001;50(43):954–958.

2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet 2011. https://www.cdc.gov/diabetes/pubs/factsheet11.htm .

3. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13(5):513–521.

4. American Podiatric Medical Association. Presidential candidates stump podiatry reimbursement plight to make a case for health reform. Available at: https://bit.ly/h7tZvx .