From The Editor

"All Gaul is divided into three parts,” is the famous first line of Julius Caesar’s history of the Gallic wars. He then methodically describes the inhabitants of each region, analyzing the traits of each culture that made them either brave or vulnerable. This 2,000-year-old text is still required reading for military strategists. Caesar knew that to subdue an enemy you first had to understand that enemy. For those who read this journal, our world is divided into two parts: wounds and ulcers. This dichotomy can be frustrating because real patients often refuse to stay neatly on one side of the divide. However, there’s a reason the divide exists. Philosophically, these problems are different. Ulcers are chronic problems in some way related to an underlying medical condition. Wounds are problems specifically resulting from an accident or surgery.  The Centers for Medicare & Medicaid Services (CMS) uses this paradigm of our world to craft coverage policy while manufacturers use it to design products and clinical trials. Clinicians use this view of the world as a way to approach clinical care. When a problem is classified as a “wound,” correct coding requires that we identify exactly which surgery or accident the wound is “related to.” For anyone suffering from insomnia or in need of a good laugh, spend a few hours scrolling through this ICD-10-CM code set and ponder the fact that these codes must have been developed because someone actually needed to use them.  According to the code set, it’s possible to be injured by a kite-carrying person, a macaw (an engendered bird), falling space debris, or sucked into a jet engine (there is also a follow-up visit code for this injury). Remember, we do not have an ICD-10 code set adequate to depict the clinical spectrum of diabetic foot ulcers (DFUs), no matter which classification scheme you want to use. Why then do we have an injury code set broad enough to cover the entire spectrum of “Looney Tunes” escapades? If you guessed it’s because these codes are used in litigation, you guessed right. 

Here’s my point: Until April 9, 2016, pressure ulcers were problems that were at least potentially related to an underlying patient medical condition. On April 9, 2016, per the National Pressure Ulcer Advisory Panel, our world entirely changed and pressure ulcers were suddenly reclassified as wounds due to injuries, opening the door to very specific ICD-10 injury codes such as, “pressure injury due to inadequate nursing care” or “pressure injury due to [name of medical device].” Changing the terminology to “injury” will almost certainly increase litigation against hospitals and medical device manufacturers. Even worse, it may hasten the trend towards the criminalization of pressure ulcers. This is not just because the word “injury” carries with it the connotation of intentional harm. The problem has to do with changing the entire paradigm of pressure ulcers from a problem that occurs primarily in vulnerable patients to a problem that results from an injury that is caused by something, whether it is a healthcare practice, a healthcare provider, or a medical device. Caesar did conquer Gaul, but there were massive casualties on both sides. Changing the world is messy business.

The world is changing in another way. In December, CMS will post the quality data for just about every eligible provider on its Physician Compare website. Wound care providers around the United States will be able to demonstrate their expertise in recording hemoglobin A1c and body mass index values, as well as in performing tasks such as medication reconciliation. The U.S. Wound Registry (USWR) will post the performance results of eligible providers who reported quality data using the USWR wound- and hyperbaric-specific quality measures. Those clinicians will be reporting their performance rate with measures such as DFU offloading, venous ulcer compression, and vascular screening. I’d like to think this is the way to change our world for the better – by improving the quality of care provided to patients rather than by improving the chances of frivolous litigation over a problem we understand with less clarity than Caesar understood 1st-century Gaul. 

Caroline E. Fife, MD, FAAFP, CWS, FUHM, is chief medical officer at Intellicure Inc.; executive director of US Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands, TX; and co-chair of the Alliance of Wound Care Stakeholders.