No Good Deed Goes Unpunished: Life in the Crosshairs of CMS

  Wound care and limb preservation are my life’s work.

  As a teenager, I volunteered at a local hospital. When I turned 17, I was offered a position as an orderly, and worked in that capacity until I graduated from college.

  My first encounter with a chronic stage 4 sacral ulcer occurred one summer as I assisted in changing the packing on the unfortunate soul who endured a year’s hospitalization as a result. Yes, you read correctly—a year’s hospitalization with a stage 4 sacral ulcer!

Fast Forward to 2008

  The years flew by as I immersed myself in my career, proud of the many successful outcomes of patients who were previously offered no hope. Imagine pouring your heart and soul into making the lives of your patients better, all the while building a reputation within the community among providers and the public.

  Most satisfying is the fact that my practice had the humble beginnings of a 600 square-foot office. Over time, my wife, De Anna—a nurse practitioner and fellow wound specialist— and I had created a simple model that was serving the needs of the “sickest of the sick,” while ensuring continuity of care in multiple settings.

  The end of each long day usually brought a mixture of satisfaction and fatigue, and knowing that tomorrow would be much of the same. That is, until the letters began coming, and coming, and coming. What followed was multiple letters, seemingly every day, from the Centers for Medicare & Medicaid Services, requesting copies of charts of our patients, indicating that Medicare was scrutinizing our services.

  We had been through this before, as our practice evolved from general podiatry to a freestanding (physician owned and operated) wound center. With nothing to hide, things always came out favorably. Comply with the request, send in some graphic, nasty wound photos, and the case managers will understand what we do each day. We often joked that it was a shame we didn’t have “scratch-and-sniff” technology to use for our photo submissions!

  I have even gone before CMS to present cases, explaining why skin substitutes should be included as a treatment modality for diabetics with heel ulcers (a prior exclusion, despite inclusion for diabetic foot ulcers--isn’t the heel part of the foot?). A number of case managers there were friends who were previously employed by Blue Cross/Blue Shield and now worked for CMS. I even treated some of their colleagues. Surely, this latest focused medical review must be a misunderstanding, perhaps fueled by the further evolution of our practice to a mobile service.

  Mobile service? As a quick aside, our practice purchased a 30-foot mobile mammography unit from a local hospital, with the idea of traveling to underserved areas or making care more accessible to those who were unable to travel to our wound center/office. We never treated a single patient on the mobile unit, as rising fuel costs, obtaining insurance, and hiring a driver with a special license to drive the unit, among others, became quite tricky. As the mobile unit was being renovated (actually, more like gutted), our signage and phone number went on the outside: “Wound Care on Wheels.” The mobile unit was parked in an industrial park that had lots of traffic, and as a result, the mobile unit inadvertently became a billboard for “Wound Care on Wheels,” and patients soon began calling. Although the mobile unit was not ready to be utilized in its planned capacity, we realized that a need for our service not only existed, but was in real demand. We realized that a mobile service could still be created, using my wife’s automobile and my pick-up truck instead of the old 30-foot mobile mammography unit. We also realized that the mobile unit would have reduced our efficiency as a limiting factor of sorts. We could see patients in a greater variety of settings without the issues associated with the mobile unit.

  Within a year, we tracked our numbers and observed several things. Most importantly, not only was our mobile service filling a need, but also, that a greater continuity of care for our patients was achieved. We followed our patients in our office, hospitals, homes, and eventually with hesitation, into long- term facilities.

  Additionally, our overhead was reduced dramatically as we found ourselves spending less time in the office. Our success continued, and an additional Nurse practitioner was hired. Then another part-time nurse practitioner was hired. Next a Podiatrist out of Residency was hired.

  Things were going well, and then the letters from CMS began. Complying with the requests, we promptly submitted records as requested, photos, measurements included. Then came the notification that payments would be held and that we were making repeated errors. Please, how are we making errors when we are helping to heal the majority of our patients and helping to keep them out of the hospitals?

  Not only was I being challenged, but so was my wife. Who was passing judgment on us? Was it an accountant or financial officer, who was only concerned with quantification? Why was fraud being implied by CMS? We had been told by some entity that we were wrong! We figured, “No good deed goes unpunished!”

  Eventually, we were both contacted by CMS nurses and our case managers, who I warmly referred to as our “P.O.s” (as in Parole Officers). No matter how stressful a situation, a sense of humor always helps, especially when innocence will be found.

  I knew it would be an uphill battle when one of the questions I was asked by my case manager was, “Dr. Bell, why do you make house calls?” Followed up with, “Do you do a lot of wound care in your practice?”

  Was my case manager serious? Did she not see the name of my practice? At this moment, I knew we were in for a long battle, and one that ensued for over a year. It was finally resolved in the spring of 2010.

  Thanksgiving of 2008 is burned in my mind as a time that went from one of thanks to one of incredible stress. This is when the letter first arrived, and for months thereafter, things did not get much better. Weekly requests for charts, which meant more of my already precious time spent reviewing records, printing photos, checking every detail.

  Further dialogue with my case manager revealed several other concerns that made me question things even more. An area that brought my practice to the attention of CMS centered on the code 99233 versus 99232. These are Evaluation and Management codes for follow-up with hospital patients. Many of my patients are seen in a long-term acute care (LTAC) hospital, specifically created for chronic wound care and ventilator patients. Apparently, by documenting “improvement” in a specific wound’s assessment, no matter how severe, and no matter how much time was spent at bedside or coordinating care, an error on my part was the net result.

  An example here would be a case where I had done a bedside surgical debridement of necrotic tissue on a stage 4 heel ulcer. Documented as sharp surgical excisional debridement, the wound often appeared cleaner, with fewer odors during the follow up visits. An assessment documented as “ulcer of left heel stage 4, clinically improved, without sign of infection” resulted in an automatic reduction of from a 99233 to a 99232. It did not matter that the patient could still be presenting with bone exposed or still be at extremely high risk for amputation. My efforts, despite following the rules as outlined, were being trivialized. My case manager explained that if a wound was showing improvement, I needed to downgrade the code! I was being penalized for doing my job correctly! The incentive or flaw built into the system as such is to not show any improvement (or to at least not document it) and to avoid any description showing a positive trend.

  The other code I was encouraged to use was during visits to step down or nursing facilities. “Dr. Bell, you should be using Active Wound Care Management codes on these patients.” “Why?” I began to explain. “First of all, I do not just observe or instruct a nurse to put a dressing on a patient. I make rounds with staff of the facilities. I “gown and glove up” and have worked around the limited mobility of many patients, often hunched over beds, positioning patients, or kneeling on the floor for a wheelchair patient to examine a heel ulcer.” All to assess and debride, as well as to dress and off load a wound. I am involved in not only performing sharp excisional debridement of wounds in the facilities as a podiatric surgeon, but I am also involved in the coordination of care with their attending physicians and other consultants, such as interventional cardiologists, vascular surgeons, infectious disease specialists and physical therapists. “Secondly, aren’t the codes you are suggesting I use intended for Physical Medicine and Therapy? I do not practice either. I am paying malpractice insurance for the privilege of performing podiatric surgery, the specialty I was trained in, no matter the setting.”

  Another aside: since my practice was established in 1998, we have used several excellent Electronic Medical Record systems. For a variety of reasons, we needed to change from Medinotes, then to Leonardo MD, an excellent web-based EMR, but not wound care specific.

  Weeks turned into months, and payments delayed sometimes for months, frustrations were growing, and then one day, it all came to a head. In the midst of our periodic re-evaluations, we were found to still be “deficient” in our charting. Deficiency, it turned out, had nothing to do with the quality of work, the efficiency of our practice, or anything other than the fact that despite our thorough charting, we were not capturing time spent with our patients, and several seemingly minor details.

  Tired of what I perceived to be implied guilt, I finally had enough, and placed a call to my case manager (who turned out to be not only sympathetic, but a good resource, once my meltdown ensued).

  I had some questions of my own for her, and finally, feeling as if there was nothing left to lose, I unloaded in a 15 minute, profanity-free tirade—all the years of trying to do my best, the hours spent agonizing over patients, and the frustrations now led me to a willingness to move on to another career if that was what needed to happen.

   “Where is your accountability? What is your level of expertise? All we have done is try to help people who have been kicked to the curb, and thanks to you and CMS what little time I have each weekend is spent reviewing and submitting charts to defend myself! You should be ashamed of yourselves! I invite you to spend a week with me and make rounds, see firsthand some of the issues and nonsense our patients and my fellow providers put up with. You treat us like we are frauds and criminals!” Nervous laughter ensued from my case manager, followed by a polite decline of my sincere invitation. “We run a small practice and I know that every penny counts. We are trying to be good stewards of Medicare money (the majority of our patients are Medicare), so why would we be trying to hurt the system that helps us? Our model is far more efficient, as we provide a continuity of care that is not found in other systems. Why are you penalizing us for doing a good job when you should be examining what we are doing and learning from us?”

  Somewhere in the midst of all this, I realized that our first web-based EMR system, Leonardo MD, although excellent, was not capturing the nuances of the wound care we were providing our patients. I had researched several systems during our review, and eventually selected Intellicure. It wasn’t long after we began using Intellicure that we realized not only were we not doing anything drastically wrong, but also, that we were inadvertently grossly under-billing!

  Imagine the feeling of submitting notes generated with a “wound care specific EMR”: the decreased stress, increased confidence, and knowledge that we now had the tool to capture the time and effort we never realized we should have been getting credit for. Bottom line: we were ultimately exonerated and our accounts receivable increased as a result!

  My wife’s encounter with her case manager was more intense. Unfortunately, De Anna had finally had enough. In one of her conference calls, she explained some of the circumstances she had encountered during home and nursing home visits, to the point that her case manager was in tears. My wife also explained that all the joy had been taken from her professionally, and that she would no longer provide mobile service to anyone. Despite objections by her case manager to not make such a decision, she stopped doing the mobile service in 2009 and stopped practicing at the end of 2010.

  There is one last area to consider where De Anna was involved. She had served on a Florida Medicare committee for 2 years and was an active member when we were first placed on review. Initially, her case manager suggested that CMS was only studying our practice as a model for future consideration. We soon realized is that they had a funny way of showing their interest, and that they could have asked for our help in a more warm and fuzzy way! Some thanks for volunteering with CMS, as well!

  Several things have become apparent to me, having been through such a trying ordeal. Our roles as wound care providers are hard enough without having to endure the accusatory implications of any focused review. How do you get past the emotional aspect, especially when you have done noting wrong?

  Protect yourself. If you do not use a specialized EMR for wound care, you are tempting the fates. Wound care is in the crosshairs of CMS and other payors. They assume you are guilty and you must support your innocence. The only way to do this objectively is to support your case through your documentation. I always prided myself on my documentation. Blue Cross/Blue Shield originally recruited me as a wound care provider, in part, because of my documentation! If you do not have an EMR that is wound care specific, not only are you taking chances, but you are also missing out on being reimbursed for its use, by way of the federal government’s incentive program.

  In going through the audit process, I not only learned much about “the system,” but about myself. I am a firm believer that we are all patient advocates and that we must speak up for our patients. I also believe that we need to be “provider advocates” as well. As the medical specialty of wound care evolves, we find not only our professions being questioned, but many unsung heroes are being scrutinized. My “eruption” at the expense of my CMS case manager was, in part, me being a voice for my fellow wound care providers and years of frustration, long hours, fighting for our patients, and being perceived as less than specialists, or nothing more than “bandage changers.”

  Use wound care EMRs to prove that without debate, wound care providers are not fraudulent by design, but are “angels among us.” Practice wisely, be proactive, and do not be bullied for doing a great job!

Desmond Bell, DPM, CWS is the Co-Founder and Executive Director of Save A Leg, Save A Life Foundation. Contact him at drbell@savealegsavealife.org.