Avoiding medicare overutilization

[Creflo]

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As a former military pod, I didn't have to worry about this. Now I find myself treating patients with chronic ulcers with comorbid conditions such as diabetes, renal disease, vascular disease, etc. I have been advised that if an ulcer does not reduce in size after one month, to change therapy or refer the patient to a wound care center. Can anyone give input on how to balance not overutilizing medicare vs. not getting sued? I want to follow up on stable ulcers that aren't healing every 2-3 weeks with a low level e&m code or debridement code, but in the back of my mind if it isn't getting smaller am I risking getting into trouble with medicare and find myself being reluctant to book follow up visits. Yet at the same time if an ulcer goes south, I'm liable. I can offer wound care center referral, or vascular referral, but some patient's won't comply with these referrals. Any input from voices of experience?

 

[ExperiencedDPM]

Don’t worry about fraud, worry about the patient. If a wound isn’t improving you don’t need to worry about whether you are over utilizing, you may want to ask yourself why the wound isn’t responding.

Is the reason vascular? Is the reason nutritional? Is the reason because the patient’s A1C is 15? Does the wound need off loading? Does the wound need a biopsy?

I assure you it’s not what you’re putting on the wound. There are very few studies that confirm that one product is better than the other. As you’ve heard it’s not what you put on the wound, it’s what you take off the wound (debridement, off loading).

If you debride the wound, bill the appropriate code, not an office visit.

And if a patient isn’t improving, concern yourself with why, and not if Medicare is going to sniff you out.

 

[Creflo]

"Is the reason vascular?" yes, the reason is vascular and the patient won't comply with the vascular referral. should the patient be fired?

Actually I'm looking for answers for those patients who are noncompliant with their diet, a1c, tobacco use, follow up visits with referrals to endocrine, vascular, etc. In those situations what is the best approach when the ulcer becomes chronic and as the podiatrist you are the one managing the wound and don't want to overutilize medicare resources?

 

[bunNfxr]

Firing a patient is more complicated than it sounds especially with ulcers as it can be considered patient abandonment by crafty attorneys. It's also not in your best interest to fire every patient that YOU consider non compliant. Many patients do not have the resources to eat a Mediteranean fish diet to bring down that A1C. Quitting smoking causes an awful cough in many patients and they are torn between feeling like crap following instructions and the devil they already know. "Success" as a doctor revolves around plans that are less open to patient noncompliance. If a patient is getting blood in a sock after being told to keep weight off of the ulcer, put them in a cast above the knee with a bend in it and order a wheelchair. If there A1C is 15 ask them what they are eating and ask them to cut the carbs (Breads and pasta and potatoes), juices and yogurts, processed meats filled with sugar fillers. Most people actually don't realize this is all bad for them. Since elementary school they were told to have a diet primarily based on grains, yogurt is healthy, juice is good for you. Tell them to eat fish meats (chicken and tuna are cheap) and green vegetables/ lettuce until the A1C declines.
Try harder to come up with plans that are more difficult to foil than "stay off your feet, your being non compliant". I am not saying you are that simplistic, but I think we all overuse the non compliance excuse. This means actually blaming yourself and trying to find methods that work better.

 

[bunNfxr]

Wound clinics are a scam. You have no business sending them patients unless you just have more than you can handle. They run up a bill, using poorly research designed product studies. The patients you send to them pay the coffers that will pay the marketing team to steal your patients. If they can truly offer something you cannot, that is different. But 9/10 they are just carrying the "wound care center label" which makes patients think they have something special. This is nonsense and generally ignores the tenet stated above that it has more to do with what you take off than what you put on. Wound centers are all about getting paid putting on the next metal- mataloprotease inhibitor with dermal placental collagen fibroblastic vacuum fandanglement. You can put those on too!

 

[ldsrmdude]

"Is the reason vascular?" yes, the reason is vascular and the patient won't comply with the vascular referral. should the patient be fired?

Actually I'm looking for answers for those patients who are noncompliant with their diet, a1c, tobacco use, follow up visits with referrals to endocrine, vascular, etc. In those situations what is the best approach when the ulcer becomes chronic and as the podiatrist you are the one managing the wound and don't want to overutilize medicare resources?

Which resources are you concerned about over-utilizing? Advanced wound care products like biologic grafts? Imaging?

For me, if a wound isn't improving, I will look at using whatever I can to get it healed within reason. Constant visits with no end in sight is expensive for the patient and Medicare. Having a patient get admitted when the wound gets infected and requires multiple debridements is expensive. If something will cost more short-term but may potentially lead to quicker healing and possibly less cost over time, I don't consider that over-utilization. There are quite a few options that are cost-effective and are beneficial, so I don't think that jumping right to the newest product or graft is always the right choice, but as has been mentioned, look at why the wound isn't healing. If you're appropriately addressing all of the factors that may be slowing the wound down as best as you can, I think it's reasonable to look at advanced modalities.

 

[ldsrmdude]

Wound clinics are a scam. You have no business sending them patients unless you just have more than you can handle. They run up a bill, using poorly research designed product studies. The patients you send to them pay the coffers that will pay the marketing team to steal your patients. If they can truly offer something you cannot, that is different. But 9/10 they are just carrying the "wound care center label" which makes patients think they have something special. This is nonsense and generally ignores the tenet stated above that it has more to do with what you take off than what you put on. Wound centers are all about getting paid putting on the next metal- mataloprotease inhibitor with dermal placental collagen fibroblastic vacuum fandanglement. You can put those on too!

I don't mean to sound like a wound center apologist, but that's a pretty broad statement. There probably are wound clinics that are scams, but I wouldn't label them all as such. I've seen more abuses with advanced wound care products from VA medical centers and private offices than I have with wound care centers, but that's just my experience. For the record, I spend time every week at a wound clinic. I've never felt pressured to use the newest graft from anyone other than the reps that are selling them and trying to get me to use them. Maybe I've just been lucky and none of the 4 wound centers I've been personally involved with have been like the wound clinics you're describing. To be fair, I used to get pressure to recommend HBO to patients (and occasionally still get it recommended to me) but I am probably the lowest utilizer of HBO in our wound center and they've accepted that I think.

 

[bunNfxr]

Scam was an overstatement. The main point is that there is no reason for a podiatrist to send a foot wound to a wound care center. They offer little to nothing that you can't do in your office. By scam I mean to say that they will pander for your referrals while attracting your patients to their clinic offering nothing new, but the name wound care center. As far as the crap we all put on wounds, I still use them. I Put on an Apligraf a few days ago and a graft jacket I think the same day. But close look at the literature is almost amusing: if each product was as much better as the last product that insisted it was better than the one before that, we should be able to close an entire degloving wound in 4 days. But somehow wounds still stay open for 1,2 ,3... 6 months regardless of how much the technology "progresses". We exhibit complete self affirming confirmation bias when we apply these things. To the extent they do help , they don't likely help enough to justify the outrageous costs associated, when you factor in the failures with the successes together.
Medicare has released but not fully enforced limitations and positions on what I have stated above. This isn't just my wacky opinion. A few years ago they were going to limit all wound treatments to 4 grand per patient. It was never made official. May have been a lobbying issue or may still be in some lawmakers back pocket. This was thought (at that time)to shut down wound care centers (and some DPM practices relying heavily on wound care) when released, until it quietly went away.
https://www.mcknights.com/news/new-...d-care-practices-analyst-says/article/317233/

 

[Creflo]

Thanks for the informative replies. A portion of my practice is house calls, and these are often the ones that end up being long term ulcers as they have difficulty leaving the house and to get vascular and other specialties to the house is almost impossible. Thus I sometimes struggle with how long to keep seeing them in the home with continual debridements before referring them out, which presents a logistical problem for the patient to travel to the clinic. Again, most of my practice experience after residency was sports medicine so I'm a little behind the 8 ball with this type of pathology. In residency I didn't learn much about medicare compliance, but do recall one patient who came to the clinic for over 1 year with the same ulcer. Also, my MAC issued a new wound care LCD in December that pretty much says no more than 8 (maybe it was 7 or 9) 11042's can be billed for the same wound in one year.

 

[bunNfxr]

Always good to document why they did not comply (bedbound) and that your intentions are palliative and that you understand that they cannot improve without revascularization, but you are trying to maintain their limb, as a BKA and general anesthesia could be detrimental, given the fragile constitution of the patient. Home visits and Nursing homes are generally more frequently audited. But I think what you are doing is good for the patient and legitimate billing. ARRA increased the number of OIG/CMS auditors when it increased IRS auditors. So actually, everyone needs to spend some time and clarify why they are doing what they are doing. Hell, if non- curative, maintenance therapy gets disallowed, Rheumatologist will be out of work completely.