The Non-Pressure Ulcer Episode-Based Cost Measure "Field Test" Began Feb. 1

What the Heck Is That?

For years I have been explaining how the Quality Payment Program (QPP) could be the end of wound care practitioners. The reason is that the entire QPP is designed around recognized medical specialties and since there is no recognized specialty for wound care, we are all in trouble.
 
As you know, under the Merit Based Incentive Payment Program (MIPS), clinicians—and please, can I use the word “doctors” without making anyone angry?—receive a score from 0–100 based on four weighted components. The weights of each of these components change each year. Right now, I am going to ignore “promoting interoperability” (using your electronic health record [EHR] to exchange data) and practice improvement activities. Right now, I am going to focus on Quality and Cost—which, in 2024, each represent 30% of the score for most practitioners.
 
In 2024, it’s still possible for doctors to pick the quality measures they report—but trust me, the days of picking any quality measures are numbered. It’s getting harder and harder to find generic, “easy” measures because the Centers for Medicare and Medicaid Services (CMS) get rid of the “easy” ones over time. When clinicians across the country start to have almost universally high-performance rate for things like “recording the medications in the EHR,” those measures gradually get phased out. (I can explain the way that CMS gets rid of “topped out” measures at a later time).
 
There’s another reason that it’s going to get harder and harder to find measures to report if you are a wound care practitioner: CMS is gradually moving all doctors to reporting the measure set associated with their primary specialty.
 
That will be a big problem for me as a family practice doctor since I do not perform screen for breast cancer or do any other typical “FP” type activities. However, for a few more years, wound care practitioners can continue to muddle through quality reporting by doing fall assessments, depression screening, recording blood pressure measurement (remember that the patient’s blood pressure has to be <140/90 to “pass”!) and hemoglobin A_1c measurements (remember that the A_1c has to be less than 9% to “pass”!).
 
Here's the bottom line on the quality measure problem for wound care practitioners: we will gradually run out of measures we can report, and there are almost no relevant measures. (The measure to check patients with diabetes for peripheral neuropathy is not very helpful to wound care practitioners since the patients with diagnosed neuropathy are excluded from the measure, and that is 100% of patients with diabetic foot ulcers—but I digress.)

Cost Measures in the QPP

An even bigger threat to wound care practitioners is the issue of CMS’ cost calculations. As I have discussed before, CMS thinks I practice family medicine. Since nearly half the patients with chronic nonhealing wounds have heart failure, CMS thinks I am their primary care physician (PCP) because those patients see me more than anyone else and CMS holds me accountable for all their readmissions for heart failure. The “episode-based” cost measures that have been applied to me in the past were primarily looking at the cost of heart failure treatment and “all cause” readmission for patients with chronic diseases. That’s why I changed my specialty code to undersea and hyperbaric medicine—although I still haven’t figured out if that is going to help me.
 
Not only am I held accountable for hospital admissions caused by medical conditions that I do not treat, but CMS has noted that I spend far more Medicare dollars than the typical FP. My “Medicare spending per beneficiary” (MSPB) is crazy high. Remember, CMS uses primary specialty to create a comparison group for MSPB—and I will always be an outlier if I am compared to other FPs.
 
That means the “episode based” measure for “non-pressure ulcers” could be really good news for wound care practitioners.
 
CMS has contracted with Acumen, LLC to develop episode-based cost measure for potential use in MIPS that is focused on any type of chronic ulcer that is not a pressure ulcer. That means this cost measure includes a diverse group of problems that includes diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), arterial ulcers, and generic “chronic ulcers” that don’t have a specific name (and which outnumber the other types). If this cost measure “works” in field testing (and I have no idea how CMS/Acumen decides whether it “worked”) at least the cost part of MIPS would judge me on problems that I actually treat.

An Attempt to Explain This in Plain English

Here’s my best stab at explaining the cost measure. A group of “clinician experts” in wound care (of which I was one) were shown a lot of data from Medicare claims and asked to identify what type of clinical encounters would likely identify a wound care practitioner’s involvement with a patient. That’s what they call a “trigger” code. Then we were asked to identify what kind of clinical encounter or procedure would “confirm” that a clinician was providing wound care. The start of a clinician or a group’s management of a patient’s “non-pressure ulcer” is identified by the appearance of a pair of services within 180 days of one another: a trigger code followed by a confirming code. A trigger code is any code from a specific set of CPT/HCPCS codes for outpatient services (outpatient evaluation and management codes (E&M), accompanied by an ICD-10 diagnosis code indicating one of the relevant ulcer types.
 
The expert panel also was asked to decide what kinds of patients should be excluded from the measure (eg, we excluded those with pyoderma gangrenosum, vasculitis and a variety of other conditions). We were also asked what kind of comorbid conditions ought to be used to “risk stratify” patients in order to create groupings of patients/ulcers based on how complicated they are. Time will tell how good a job we did. It was a daunting project and involved looking at a lot of Excel spreadsheets.
 
The measurement period for these Field Test Reports is January 1 to December 31, 2022. Any podiatrist or wound care practitioner of any specialty, including NPs, who has 20 of these “episodes” will get a field test report. The non-pressure ulcer (NPU) episode-based cost measure will be attributed to any group practice tax ID number (TIN) when the trigger and confirmatory codes are met. An individual clinician (TIN-NPI) within that group can be attributed an episode if they bill at least 30% of the trigger or confirmatory services during an episode of care.

What Is the Purpose of Field Testing?

Field testing is a process that includes distributing informational reports to clinicians and soliciting comments from the public via an online survey. During this time, anyone can provide feedback on the draft measure specifications and testing results. The clinician expert workgroup will then review and consider refinements to the measures. Anyone can provide feedback on the draft measure specifications through the general 2024 Field Testing Feedback Survey, which opened at the start of field testing on February 1. A document containing specific questions from this survey will be available on the QPP Cost Measure Information page. There will also be a specific Person and Family Engagement Field Testing Survey for patients or caregivers with lived experience with non-pressure ulcers. The survey questions will be optional. If you prefer, you can attach a comment letter (as a PDF or Word document) in addition or as an alternative to the survey questions. All feedback may be submitted anonymously.
 
Caroline E. Fife is Chief Medical Officer at Intellicure Inc., The Woodlands, TX; executive director of the U.S. Wound Registry; medical director of St. Luke’s Wound Clinic, The Woodlands; and co-chair of the Alliance of Wound Care Stakeholders.