Dispensing wound care products in the office can facilitate patient convenience, patient adherence and a better continuity of care that fosters improved outcomes. Accordingly, this author provides an overview of products that could be dispensed to patients in the office as well as insights on inventory management, coding and reimbursement.
The coming pandemic of diabetes and the monumental impact that it will have on the delivery of health services should be well known to any podiatrist. In addition to the epidemic of obesity, the aging population and the massive increase in patients with peripheral arterial disease (PAD), podiatrists are on the cusp of a tsunami of increasing lower extremity pathology.
Given these factors, the most interdisciplinary impact will arguably occur with the management of wounds. For lower extremity experts, it is a true opportunity to cement a place in the world’s consciousness of the importance of the specialty. We need to ensure that we are ready to step up to the challenge, raise the bar of excellence and prove that every lower extremity wound, regardless of etiology, should have a podiatrist as an integral part of the team managing the wound.
While the management of lower extremity wounds in high-risk populations may require involvement at every level of healthcare, such as hospitals, wound centers, nursing homes, homes and research, let us take a closer look at the office setting and how to sort through the jungle of wound care products, their basic categories and applications. In addition, it is important to understand proper documentation and protocols on dispensing these products in the office setting and billing for them.
Why should a podiatrist dispense wound products from the office? The most important reason is that it will lead to better outcomes. This will subsequently lead to more referrals. When a DPM writes a prescription for dressings and sends the patient to a pharmacy or arranges for a home delivery company to mail the patient the products, there is much less likelihood of the patient following your instructions accurately. In addition, the care may not start immediately.
When patients receive a large, intimidating box with a whole bunch of instructions, it is obviously no substitute for the doctor and staff giving them the dressings and demonstrating their use. This is the best method for facilitating better continuity of care.
Pertinent Pointers On Inventory Management
Take advantage of the fierce competition among distributors to negotiate better prices and better perks for wound care products. Ask for rapid delivery free of charge. That will allow you to keep a small inventory with minimal risk.
Make sure you carry a few proven products in inventory. For example, a good way to start out would be to have one or two types of alginates, foams, hydrogels, hydrocolloids and collagens. These will be able to satisfy the initial needs for a wide variety of wounds. Although there is a myriad of choices of categories and dressings to delve into, this will provide a good foundation for any practice.
What You Should Know About Dressing Selection And Appropriate Coding
There are many factors to consider when evaluating the appropriateness of a specific dressing. Some of the factors influencing dressing choice are as follows:
• Anatomical site
• Amount of exudate
• Dead space
• Surrounding skin
• Caregiver ability
• Wound status
• Aggressive therapy versus palliative care
Calcium alginates (HCPCS codes A6196-A6199). These are made from brown seaweed and are extremely absorbent. The patient must have moderate to heavy drainage and your note must reflect this.
Calcium alginates are available in ropes for filling and flat pads for open wounds. They interact with wound exudates to form a moist gel. One may use calcium alginates in infected wounds but you should not combine them with hydrogels. Up to 30 pieces per wound per month are allowed for reimbursement.
Calcium alginate products include Silvercel™ (Systagenix Wound Management) and Melgisorb® Ag (Molnlycke Health Care).
Foams (HCPCS codes A6209-A6214). Foams are also very absorbent and semi-occlusive. The outer surface can have film, adhesive or no backing. Foams do not adhere to the wound bed.
When using foams, the notes need to reflect moderate to heavy drainage. Foam can be a filler in dead space but is not always useful for dry eschar. Do not use foam with hydrogels. Up to 12 pieces per month are allowed.
Examples of foam include Mepilex® (Molnlycke Health Care) and PolyMem® (Ferris Manufacturing).
Collagens (HCPCS codes A6010-A6024). Collagen provides matrix for tissue and vessel growth. Collagen products accelerate wound repair. Wounds must be moist and free of necrotic tissue prior to application of the product. Collagens are absorbent, comfortable and non-adherent. They may be composed of bovine material so one should watch for sensitivities. They are available in pads, particles, powders, paste and ribbons/ strips.
The note should indicate some drainage, such as mild, moderate or heavy drainage. Collagen use is inappropriate in patients with no drainage. One can use collagen in infected wounds and tunneling wounds. However, the use of collagen is not recommended for third-degree burns, dry eschar or necrotic wounds. Up to 30 pieces per wound per month are permitted.
Collagen products include Prisma™ (Systagenix Wound Management), SilvaKollagen (DermaRite) and Puracol® Plus Ag (Medline Industries).
Hydrogel gauze (HCPCS codes A6231-A6233), hydrogel dressing (HCPCS codes A6242-A6247) and hydrogel gel (HCPCS code A6248). Hydrogels help maintain a moist wound healing environment and are available in amorphous gels, sheets or impregnated in gauze. The gauze form can fill wounds.
When using hydrogels, make sure the notes reflect no drainage to light drainage. When infection is present, one can use hydrogels with topical antibiotics but do not use them with abdominal (ABD) pads, foams or calcium alginates. Hydrogels may cause maceration if exudates increase. Gels are permitted up to 3 oz per month while gauze sheets are permitted up to 30 pieces per wound per month.
Hydrogel products include AmeriGel® Hydrogel Saturated Gauze Dressing (AmerX Health Care) and Silvasorb (Medline Industries).
Hydrocolloids (HCPCS codes A6234-6241). These consist of a variety of ingredients including gelatin, pectin, adhesives, polymers, carboxymethylcellulose and gelling agents. Hydrocolloids manage drainage by particle swelling and exudate management is primarily based on dressing thickness. Upon absorption, the matrix materials form a soft gel over the wound bed.
For hydrocolloid use, notes need to indicate light to moderate drainage. These dressings are available as pads (in both thin and thick versions), sheets, gels, fibers, powders and pastes. Although they are effective over bony prominences, do not use hydrocolloids with ABD pads, foams or calcium alginates. Up to 12 pieces per wound per month are permitted.
Examples of hydrocolloids include DuoDerm® Extra Thin (ConvaTec) and Exuderm Odorshield™ (Medline Industries).
Pertinent Pointers On Reimbursement
An important thing to remember is that wound supplies are a covered benefit under Medicare Part B if they are medically necessary and they are used in the treatment of a wound caused by or treated by a surgical procedure. In general, for wound supplies to be a covered benefit, the wound must be full thickness and needs to have undergone debridement.
Submit the bills to the appropriate durable medical equipment (DME) Medicare equipment contractor (MAC) or private insurance with the appropriate diagnoses, the HCPCS code for the product and the number of units dispensed. Finally, submit the modifier A*, where * is the total number of wounds being treated.
It is important to remember that the patient cannot already be on hospice or home healthcare (for any reason), or on a Part A stay in a nursing facility (place of service 31). If that is the case, you cannot bill surgical dressings to the DME MAC. Also, you cannot bill for the dressings you apply in the office. Those are considered part of your office visit charge.
As with any DME, the place of service code is the one where the patient will be using the product, such as 12, 32, 33 and so on.
Check DME HCPCS codes for surgical dressings and pricing, data analysis and coding (PDAC) product listings for the most appropriate code for the product being dispensed at www.dmepdac.com.
Keys To Effective Documentation
For each claim submitted, there are six essential documents you need to provide.
Progress note. This is the most obvious and important one. This justifies the medical necessity for the product you have dispensed. It must be a detailed assessment of the wound(s) with medical decision making leading to the ultimate decision to prescribe and dispense the product appropriate for the wound.
The description must include the type of wound, location, size, depth, amount and type of drainage, debridement method and depth of tissue removed. It must also include the appearance of the wound bed, stage or grade and presence of infection. Wound measurements must be documented at least monthly. The wound must be full thickness — at least Wagner Grade 2 or NPUAP Stage 3 — and must be debrided at some point but not necessarily on the day of dispensing.
Prescription. This must be a separate form on file with the name or type of product, size of dressing, amount needed, frequency of change and expected duration of need. A new order is necessary if the quantity or frequency of the dressing increases, if you start using a new dressing or in three months, whichever comes first.
Patient acknowledgement of receipt of goods form. This form should have warranty and complaint resolution information in it. The form must include the name of dressing, size, number given and frequency of change. One can easily create such forms, listing only the particular items in stock at the office with easy check-off boxes. The patient or responsible party must sign this form. You must offer a copy of this to patients if they want one.
It is important to be aware of the amount of dressings the DME MAC allows to be dispensed per month for each category of dressing. You must also only dispense a maximum of a month’s supply at a time and no more than this.
The “26 supplier standards” form. This is a list of standards, which each DME supplier has to comply with and give a printed copy to the patient. The form could be printed on the back of the aforementioned goods receipt form and one could provide a one page double-sided copy to the patient. Rigorously implementing the numerous requirements of these 26 standards is obviously the first step to dispensing any DME.
Instructions. One must provide written instructions on the use of the product. Again, this is a matter of a one-time effort of making an instruction form for every product in the office intended for dispensing. Keep it simple and short.
Purchase receipt. One must be able to provide receipts showing the purchase of the products supplied.
Granted, this may seem like a tall order to have in place for every single claim. However, it is just a matter of making the initial effort to create the forms needed and setting the system in place with one dedicated staff member who understands the requirements and follows through each time.
Establish Protocols For Common Wound Types
Set up basic protocols for the most common types of wounds. This will ensure consistent and efficient delivery of care. The protocols must be comprehensive apart from regular debridement. Here are some points to keep in mind.
• Biopsy wounds that are chronic and have an unusual appearance.
• Treat infection aggressively.
• Do vascular testing in the office and refer patients for revascularization
• Use diagnostic ultrasound to assess wound depth.
• As far as offloading goes, use walkers, “wound boots” and custom molded shoes.
• Use compression therapy for venous wounds.
• When using dressings, strive to maintain a moist wound environment and absorb drainage.
• Take X-rays.
• Get a nutrition consult.
• Perform complete blood work (ESR, CRP, prealbumin, albumin, HbA1C, etc.).
• Keep advanced treatments in mind if there is slow progress. Products include Apligraf (Organogenesis), Dermagraft (Advanced BioHealing) and Oasis (Healthpoint).
Once the product dispensing process is in place, the benefits will be immediately obvious. Patients leave your office with exactly what you want them to have right away. There is the convenience factor. For the patient, there are no trips to the pharmacy, no waiting for it to arrive in the mail and no delays. They also have a clear understanding of what they need to do and they are more likely to be adherent. Dispensing products also makes your practice look more comprehensive and can subsequently lead to more referrals.
You can keep inventory concerns to a minimum by stocking a few nationally used products in each category. The shelf lives these days are in the range of two years. Follow this with a little training of the staff to learn the function and appropriate use of these products, get the paperwork in order, follow the billing guidelines, and you are ready to go.
Dr. Bhatia is in private practice as the CEO of Columbus Podiatry and Surgery in Columbus, Ohio. He is the Assistant Medical Director and an attending physician for lower extremity wounds at Fairfield Medical Center in Lancaster, Ohio. Dr. Bhatia is a Fellow of the American Professional Wound Care Association and a Fellow of the American Academy of Podiatric Practice Management.
Editor’s note: The author notes that the aforementioned information is as accurate as possible to be applicable nationally. He urges physicians to check with the local coverage decision requirements of the respective DME MAC and private insurances in their states for specific guidelines.
For further reading, see “Current Concepts And Controversies With In-Office Dispensing” in the November 2008 issue of Podiatry Today.