Putting Salt in My Wound Center: Lower Reimbursements for Preventative Services Will Mean More Amputations

From the Amputation Prevention Center at Valley Presbyterian Hospital, Los Angeles, California Address correspondence to: Lee C. Rogers, DPM 15107 Vanowen St. Van Nuys, CA 91405 Phone: 818-902-5755 Email: lee.c.rogers@gmail.com   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%. While Congress called for a 0% update in the fee schedule for 2011, CMS cut the conversion factor from $36.8729 to $33.9764, approximately -7.8%. 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, plastics, infectious diseases, endocrinologists, pulmonologists, and generalists. 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 Tables 1 and 2. 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). Add-on codes were added to report additional increments of 20 cm². The add-on codes are inherently reduced in value and should not by modified by -59.   Why the drastic impact in wound services? It’s all about the requirement to bill by surface area and not number of wounds. Under 2010 guidelines if there were 2 wounds that each measured 3 x 3 cm (9 cm²) and were debrided into the subcutaneous tissue, one would bill 11042 and 11042-59; the -59 modifier results in 50% reduction of reimbursement for the second code. The 2011 guidelines are based on surface area in increments of 20 cm². In this example, 2 wounds that are 9 cm² each would be less than 20 cm², so one only bills 11042 once. Even if adding the surface areas together sufficient to bill another unit, the RVU of the add-on code is 40% 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 a debridement of muscle, the reduction is even greater. The RVU of the parent code for muscle debridement (11043) dropped 42% and add-on code for muscle debridement (11046) is 31% of that of the parent code. It is difficult to directly calculate the impact on reimbursement since it depends on the square area 2011 scenarios and the number of wound debrided in the 2010 scenarios. In our wound center, 67% of the patients have more than one wound. The average number of wounds for 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 7.72. In 2011, G0440 is valued at 3.51. While the product is still reimbursed, the reimbursement for the physician service dropped by more than $150 in all scenarios.   To determine how this will affect physician revenue in the clinic, we sampled 2 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 $5643.87 and now in 2011 the same services coded would generate $4419.61, a reduction of 22%.   Nearly 100,000 amputations are performed in the United States each year as a result of diabetes.¹ Twenty-four million people in the United States have diabetes and 57 million are prediabetic.² Amputations are a dreaded complication of diabetes. A chronic wound is present on nearly 85% of amputated limbs 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 citing “diabetes-related amputation” as an example to illustrate their point.⁴This 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, which may leave Medicare patients experiencing delays in treatment or cause them to seek treatment by non-specialists. Just as the epidemic of diabetes is worsening, we may see an increase in the rate of amputations. Note: 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. About the Author   Dr. Rogers is the associate medical director of the Amputation Prevention Center at Valley Presbyterian Hospital in Los Angeles, CA and 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. https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed: July 30, 2008. 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://www.apma.org/MainMenu/News/NewsReleases/NewsReleaseArchives/2008/NR_01-07-08.aspx. Accessed: January 23, 2011.