by Samantha Kuplicki, MSN, APRN-CNS, ACNS-BC, CWS, CWCN, CFCN
In the last installment of my blog, we discussed a brief overview of billing for wound care products and dressings (durable medical equipment or DME) in several common care settings. Let's talk about the Hospital Outpatient Department (HOPD) a little more in-depth. Again, we will use Medicare as the standard for payment policy, as many payors use them as a model for policy-making.
How Do Dressings Get Dispensed in the HOPD?
Some institutions choose to send "take home" dressings with the patient in addition to the dressing(s) used during the outpatient visit, which can surmount a huge monetary loss. Using a DME company, whether it be hospital-based, one that is close to the patient's home or the facility, or one that will ship directly to the patient's home, is the best way to utilize the patient’s insurance benefits and contain costs in the HOPD.
As discussed in my previous post on dressing reimbursement, many wound care procedures "bundle" the dressing or product cost into the procedure code (save for total contact casting, cellular and/or tissue based products, etc). This impacts the type of dressing the clinician may decide to use at the time of the visit. For example, some HOPDs will apply a moist gauze dressing after the outpatient visit, and instruct the patient or caregiver to replace the gauze with a dressing the patient has received from DME which was billed through insurance.
There are also other common practices for managing dressings applied at the time of the visit. Products can be stocked in various sizes to accommodate wound size, so that there is little to no waste after the wound is dressed. Or, if limited sizes of products are stocked, the remainder of the dressing can be placed into a sealed container or bag (keeping the bag and dressing package clean, of course), and affixed with a patient label and kept until the next visit. This all may sound very contrary – why don't we just send them home with the rest of what we don't use? In the majority of situations, due to a technicality, the HOPD is unable to provide the patient with supplies for home use if they are not billed as DME (this is considered inducement to treat under Medicare).
What is the Best Practice to get the Desired Wound Dressing Supplies to My Patient?
In the HOPD, the best kept secrets of patient, provider, and facility satisfaction (i.e. cost containment), are to:
1. Know the tricks of the trade for ordering dressings.
Did you know that many times a patient's order never arrives or is delayed due to errors in documentation? Does your documentation contain all the necessary components to successfully order supplies for your patient? Ensure all orders contain:
- Proof of debridement (it is called a "surgical dressing policy" after all – this is the biggest pitfall to utilization of insurance for wound supplies!),
- Wound measurements and assessment date,
- Exudate level,
- Frequency of dressing change and products desired,
- Diagnosis code for the wound, and
- Provider signature.
Don't forget to keep a "cheat sheet" of Medicare's surgical dressing coverage policy and categories (HCPCS codes) with corresponding wound assessment requirements for size, drainage, allowed frequency of change, etc. This will prevent inappropriate supply ordering and subsequent delay in the patient receiving supplies. It is also helpful to add a generic note or disclaimer to the documentation that substitutions are allowed unless specified, and that a 30 day supply of products may be issued. This allows the DME company to serve the patient most efficiently.
2. Partner with an experienced DME company.
Part of working with a DME company is trialing their services and asking for feedback from patients. A reliable company will notify the ordering provider when the order is accepted/sent to the patient, promptly request more information if it is missing or incomplete, and also follow up with the provider if the supplies were unable to be delivered, or the patient declined to be serviced. Sometimes, the patient has a very high deductible or no surgical dressing coverage, and chooses to pay for supplies out of pocket. This is another attribute to consider when working with a DME company – the ability of the company to "wholesale" products to patients in these situations.
One of the best things a DME can do for both the patient and provider is have an extensive knowledge of HCPCS categories allowables. Again—the provider can become familiar with this as well and ensure the patient does not run low on supplies!
A pertinent example: absorbent foam dressings come in various sizes and accordingly have different HCPCS codes. Let's look at a patient who has copious exudate, and unfortunately requires more than daily dressing changes (tsk, tsk – I know!). If we order him non-bordered 6x6 foam and kerlix daily for a nearly circumferential lower extremity wound, how long do you see this supply lasting the patient? Conversely, if we have spent enough time with the HCPCS cheat sheet and our wonderfully experienced DME provider, we will see that we can order: two sizes of absorbent alginate, two or more sizes of foam, two or more sizes of specialty absorptive dressing (such as sorbion sachet), and also abdominal pads in addition to gauze squares and roll gauze! This can also come in handy when antimicrobial versions of common dressings are desired, as these are more costly, but unfortunately not recognized as a separate category and therefore are not reimbursed at a higher rate. This leads to many DME companies providing limited supplies of silver or iodinated products. When in doubt, or when you have a supply conundrum or difficult patient situation, a good DME will have a representative dedicated to your clinic or facility to troubleshoot the case with you.
3. Keep caregivers in the loop.
Ensuring the patient, lay caregiver, or home health agency is up to date on the plan of care will benefit everyone involved. If everyone is aware of the appropriate care regimen, supplies are less likely to be used inappropriately or wasted altogether. Treatment orders change, and sometimes certain supplies are no longer required. Keeping open communication and notifying the patient or the home health agency that a specific treatment may only be utilized for a specific period of time can alert them to only order a specific quantity and reduce waste or over-ordering. And again, it is important that the HOPD work with home health agencies to ensure the patient’s encounter, including cost of supplies, is feasible for the home health entity.
As we discussed in the previous blog, being familiar with the particular dressing categories is most advantageous to developing a solid foundation of familiarity with various wound dressings. It is one thing to understand how a specific dressing best suits the wound environment, but another thing entirely to understand how best to get it in the hands of the patient and on the wound!
I thank you for taking the time to read my blog. I enjoy learning through the feedback of others, so please feel encouraged to share your thoughts, ideas, and experiences! Until we blog again…I leave you with this quote:
"If you want the best, you’ve got to be the best and work at it."
-Bill Molesley, Downton Abbey
About the Author
Samantha Kuplicki is board certified in wound care by both the American Board of Wound Management as a Certified Wound Specialist (CWS) and by the Wound, Ostomy and Continence Certification Board as a Certified Wound Care Nurse (CWCN) and Certified Foot Care Nurse (CFCN). She serves on the American Board of Wound Management (ABWM) Examination Committee and also volunteers for the Association for the Advancement of Wound Care.
Disclaimer: Information regarding coding, coverage and payment is provide as a service to users. Every effort has been made to ensure the accuracy of the information. However, Kestrel Health Information, Inc. and its subsidiaries do not represent, guarantee or warranty that the coding, coverage and payment information is error-free or that payment will be received. Users should always verify coverage policy, medical necessity requirements and coding instructions, and should review bulletins issued by the specific payor.
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.