You Are in the Wound/Ulcer Management Business, Not the CTP Application Business!

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This author/consultant just left the 2024 Symposium on Advanced Wound Care (SAWC) Spring in Orlando, FL. For those of you who attended, I am sure you will agree this was one of the best SAWC events you ever attended. If an attendee wanted to learn about a certain service, procedure, or product, the SAWC faculty for the multiple venues and the vast number of exhibitors delivered high quality information and education on about every major topic.

This author/consultant was honored to be one of the faculty for this impressive symposium. When I was invited to present the session entitled “CTPs/Skin Substitutes: Reimbursement Facts, and Nothing but the Facts!” I quickly accepted because I wanted to educate the attendees that the numerous claim denials and repayments that they are experiencing are preventable.

Because most denials and repayments of cellular and/or tissue-based products (CTPs) for skin wounds are due to lack of thorough wound/ulcer management documentation, which is required for every encounter, I was excited to have this opportunity to remind the attendees that they are in the wound/ulcer management business, not the CTP application business.

Even though clinical evidence shows us that most wounds/ulcers will heal once diagnosed properly/debrided as needed/dressed with the appropriate primary and secondary dressings and offloaded or compressed, internal and external audits continue to reveal that wound/ulcer management professionals and facilities do not consistently “paint the picture” of the status of the wound/ulcer and their conservative management at every encounter. Then if the wound/ulcer does not progress as planned, and some type of advanced care (such as hyperbaric oxygen therapy or application of CTPs) is needed, the medical record does not consistently support the medical necessity of the advanced therapy. Because wound/ulcer management stakeholders are totally in control of changing this paradigm, I wanted to provide them with checklists that they could use as soon as they returned to their offices, to evaluate their own documentation and to immediately make required improvements.

After I had submitted my presentation to HMP, and shortly before the SAWC, the 7 Medicare Administrative Contractors (MACs) released proposed Local Coverage Determinations (LCDs) and Local Coding Articles (LCAs) pertaining to the application of CTPs for skin wounds. Like all other wound/ulcer management LCDs and LCAs, these proposed policies clearly require thorough documentation of conservative wound/ulcer management at every encounter to show that the application of specific CTPs are medically necessary and reasonable. After reviewing these proposed LCDs and LCAs, and after answering hundreds of questions about the required documentation, I knew that sharing the documentation checklists, appropriate coding, and Medicare payment regulations was even more vital.

After completing my presentation in a packed SAWC seminar room, I answered questions for an additional hour. From the questions that were asked, I could tell that many of these professionals were working in CTP application business models rather than in wound/ulcer management business models, and that many attendees were not thoroughly documenting at each encounter. By the time the last question was answered, I was so glad I had the honor to share this reimbursement information and to help re-focus the professionals to their wound/ulcer management business of which only a small segment of patients typically qualify for advanced therapy such as CTPs.

For readers who did not have the opportunity to attend SAWC, following are the documentation checklists that we discussed:

Summary

Just like I challenged the SAWC attendees, I am challenging all readers to audit their own medical records of 5–10 patients who have received CTP applications. Start by printing every patient encounter from the first time they were seen for the wound/ulcer through every CTP application. Compare your documentation with the required documentation for conservative care, assessment, and plan of care, which is required for each encounter—even when CTPs are applied. Then compare your documentation to the additional documentation required to justify the medical necessity for the CTP application and to fully describe the application procedure from start to finish. CAUTION: Look for cloned notes—wounds/ulcers morph from encounter-to-encounter; so should your documentation!

If your documentation clearly addresses all the items on the checklists, congratulate yourself and the rest of your clinical team. If your documentation is missing some of the items, immediately 1) take the necessary steps to educate yourself and your team how to incorporate any missing details, and 2) request changes that are needed in your electronic health record.

Inadequate and incomplete documentation causes the most CTP application claim denials and repayments. This is preventable by remembering that you are in the wound/ulcer management business. Other advanced treatments like hyperbaric oxygen therapy and application of CTPs are adjunctive to conservative care, and when performed, must be documented in addition to conservative care at each encounter.

Last Month’s Quiz Results

Thank you to everyone who completed the Coding Challenge quiz in last month’s Business Briefs. Here is a breakdown of the results:
 
Score (%)
12/12 (4%)
11/12 (4%)
10/12 (4%)
9/12 (13%)
8/12 (9%)
7/12 (17%)
6/12 (22%)
5/12 (0%)
4/12 (9%)
3/12 (9%)
2/12 (4%)
1/12 (4%)
0/12 (0%)

A plurality of readers, or 22%, got 6 of the 12 answers correct. Only 4% got all 12 correct. Although the workshop participants scored better than the readers (the ones with more success no one answered all 12 questions correctly, but 40% answered 6 of the 12 questions correctly), this author/consultant was disappointed that all participants did not score 100%.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.