Cellular and Tissue-Based Products: Continued Observations on Changes in Reimbursement

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By Thomas E. Serena MD, FACS, FACHM, FAPWCA

The Black OPPS continues unchecked. My last blog addressed the recent Centers for Medicare Services (CMS) outpatient prospective payment system (OPPS) in regards to cellular and tissue-based products (CTPs). In the blog, I bemoaned the fact that CMS ignored the prevailing evidence for CTPs in assigning reimbursement for the various products pricing a couple of the living tissues with the most robust evidence on the market. Many of you requested our policies on CTPs, however the algorithm has changed almost daily since the beginning of the year. You will have to wait I'm afraid. In the interim, this month we will examine the change in facility payments.

The Impact of the CMS OPPS Changes on Delivering Wound Care

This morning, I watched three nurses struggle for an hour to dress a dozen lower extremity wounds on a morbidly obese patient with diabetes who had venous and arterial disease. In addition to diabetes, the patient suffered from congestive heart failure, chronic obstructive pulmonary disease and end stage renal failure. Prior to coming to the wound center, this gentleman had been admitted to the hospital three times for cellulitis associated with his extensive skin breakdown. Weekly visits to the wound center have kept him infection-free and out of the hospital at a tremendous savings to the health care system.

In 2013, the wound center charged the highest acuity level for his visits, but even then most of his visits resulted in a loss of income. This year we have no acuity score to help us with these complex patients. We have a G code. I am not sure exactly what "G" stands for: "gigantic mess," "God-forsaken billing code," "Good for nothing code," or "Government's latest attempt to practice medicine without medical training." The editors assure me that the rest of the "G" list will never see print.

Acuity Scores No More: Implementing the G-Code

For years we have struggled to develop acuity scores for patients seen in wound care centers without much guidance from CMS. We purchased at some expense a tool to calculate acuity. This month CMS removed acuity scoring and replaced it with the above mentioned single G-code. The Black OPPS strike again. The reimbursement for the gentleman described above will barely cover the cost of his dressings. How do we continue to keep the wound center above water? Should I constantly berate physicians in the centers to debride every wound at every chance? I cannot.

I dream that CMS will one day simply give us a lump sum of money to care for our wounded. We will choose the most clinically efficacious and cost-effective treatments. Our patients will heal faster and patient satisfaction will improve.

About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2013 Dr. Serena was elected vice president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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