APWCA News

The Quality Payment Program (QPP) Final Rule was released last night. We are still reviewing every detail and considering comments to submit, but below you will find some of the big points we have pulled out so far.

• Threshold to avoid a penalty moves from 3 to 15 MIPS points
• 2014 and/or 2015 CEHRT allowed but bonus ACI points available if use only 2015 CEHRT
• Eligible clinicians or groups with <= $90K Part B allowable or <= 200 Part B beneficiaries excluded
• Cost category counts for 10% of MIPS score
• Cost category score will be calculated by Medicare Spending per Beneficiary (MSPB) and total per capita cost measures
• CMS will calculate Cost measure “performance” - nothing for us to report for that category
• Clinicians affected by Harvey, Irma, or Maria that do not submit 2017 MIPS data will not have a negative adjustment in 2019
• Clinicians affected by Harvey, Irma, or Maria can file a hardship exception application for Quality, ACI, and CPIA categories for 2018 performance period
• Still only allowed one submission method per category
• Quality category moves from 60% of MIPS score in 2017 to 50% in 2018
• Clinical Practice Improvement Activity category still counts 15% - can still avoid penalty with just a perfect CPIA score
• Clinicians in practices of 15 or less are exempt from ACI category and that 25% moves to Quality category
• Exceptional performance threshold remains 70 MIPS points
• Option to participate as a Virtual Group
• 2018 QPP Final Rule Reporting Periods: Cost - 12 mos, Quality - 12 mos, ACI - 90 days, CPIA - 90 days

Nothing discussed in this communication guarantees coverage or payment. This is our interpretation of the Final Rule. Coverage and payment policies of governmental and private payers may vary from time to time and in different parts of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APWCA does not claim responsibility for any consequences or liability attributable to the use of any of the information discussed in this communication.

With quality measure-based payment models now driving Medicare reimbursement under MACRA (the Medicare Access and CHIP Reauthorization Act), wound care practitioners have faced a unique challenge: few reportable quality measures relevant to wound care.

A study recently published in the International Society For Pharmacoeconomics and Outcomes Research's Value in Health journal shows the full burden and cost of wound care in the US Medicare population, highlighting the need for CMS health policy makers to develop more appropriate quality measures, episode of care measures and reimbursement models for wound care. The findings - particularly the insights regarding the costs of diabetic foot ulcers and diabetic infections - are of particular interest to the podiatry community.

The study "An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds" analyzed 2014 Medicare data and determined the cost of chronic wound care for Medicare beneficiaries in aggregate, by wound type, and by setting. The findings are compelling:

• Chronic nonhealing wounds impact nearly 15% of Medicare beneficiaries (8.2 million).
• A conservative estimate of the annual cost is $28 billion when the wound is the primary diagnosis on the claim. When the analysis included wounds as a secondary diagnosis, the cost for wounds is conservatively estimated at $31.7 billion.
• • Surgical wounds and diabetic foot ulcers drove the highest total wound care costs (including cost of infections).
  • On an individual wound basis, the most expensive mean Medicare spending per beneficiary was for arterial ulcers followed by pressure ulcers.
  • Hospital outpatient services drove the greatest proportion of costs - demonstrating a major shift in site-of-service costs from hospital inpatient to outpatient settings.
  • Surgical infections were the largest prevalence category, followed by diabetic wound infections.

This documentation of the economic impact of nonhealing wounds can be meaningful from a policy perspective moving forward. "The true burden of wound care to Medicare has remained relatively hidden and have not been a focus from a public policy standpoint in the U.S. We are hopeful that documenting the significant economic cost and impact of chronic wounds can influence priorities for Federal research funding in this space and for innovative payment approaches by the CMS, including quality and performance measures within MACRA," noted lead study author Dr. Samuel Nussbaum, Schaeffer Center for Health Policy and Economics, University of Southern California.

National quality measures have not been developed for use under MACRA's Merit-based Incentive Payment System (MIPS) that are relevant to the broad spectrum of wound care. With quality measure-based payment models driving Medicare reimbursement under MACRA, this is a problem for practitioners. "CMS needs to recognize the cost and prevalence of chronic wounds in the development of chronic care models and episodes of care. Chronic wounds can't be forgotten about if we want to drive better health outcomes and smarter wound care spending," said co-author Caroline Fife, MD, Medical Director, CHI St. Luke's Hospital (The Woodlands, Texas) and Executive Director, U.S. Wound Registry.

The study was funded by the Alliance of Wound Care Stakeholders, an association of clinician associations and medical specialty societies focused on promoting quality care and access to products and services for people with wounds and the providers who treat them. The Alliance has been leading advocacy initiatives to educate policy makers and regulators about the importance of more meaningful quality measures for the wound care space. The American Professional Wound Care Association is a member of the Alliance.

The full study is available online; the Alliance's comments to CMS seeking performance measures more relevant to wound care are posted on www.woundcarestakeholders.org.

Downloads: Full Article (PDF) / Fact Sheet / News Release

Novitas Solutions, Inc. is the Medicare contractor (MAC) for the following states and district:

Arkansas
Colorado
Delaware
District of Columbia
Louisiana
Maryland
Mississippi
New Jersey
New Mexico
Oklahoma
Pennsylvania
Texas

In January 2017, Novitas published a proposed rule for payment of wound care treatments to their beneficiaries which we thought was filled with many inconsistencies and confusion with aspects that did not seem to be based on the current state of wound care delivery by the wound care industry (many of whom are members of the APWCA). This proposed rule was subject to a 60 day comment period. APWCA, in conjunction with the Alliance of Wound Care Stakeholders, spoke on behalf of its Novitas members and submitted comments. Our voice was heard!

Novitas has just published their recently finalized LCD (Local Coverage Determination) L35125 entitled "Wound Care" which is due to go into effect on November 11, 2017. A copy of the entire LCD L35125 is available here. This update to membership is meant to review key points of the finalized LCD.

1. Surgical/excisional debridement of dermis, subcutaneous tissues, and fascia: There is no limit to the number of surgical debridements a patient may receive in a 360 day time frame. However, Novitas feels that greater than 8 debridements at any depth is "excessive". Therefore, the LCD states that should the patient require greater than 8 total debridements, "meticulous" documentation is necessary to explain why this "excessive" amount of debridement is indicated. Please keep in mind that providers should already be documenting medical necessity with each and every debridement. Please take this opportunity to review your documentation habits.
2. Surgical/excisional Muscle/fascia and bone debridement: Novitas feels that more than 5 total debridements that include muscle/fascia or bone in a 360 day period is "excessive" but will not place an "a priori" limit. Instead the LCD requires that more than 5 total debridements that include muscle/fascia or bone in a 360 day period be accompanied by "meticulous" documentation illustrating that the service is both medically reasonable and necessary.
3. Non-contact non-thermal Ultrasound for wound treatment (MIST): The LCD states it should be offered a minimum of 2-3 times per week. But, if no observable wound improvement is noted after 2 weeks (4-6 treatments), then this wound treatment is not reasonable or necessary. Furthermore, no more than 18 treatments in a 6 week period will be considered reasonable or necessary.
4. Negative Pressure Wound Therapy (NPWT): Two types are considered: a) that done with DME, and b) that done with disposable systems as an outpatient or homecare patient. Both are covered given proper indications and usage. The LCD states, "…the beneficiaries who undergo treatment utilizing negative pressure wound therapy, only a minority appears to require more than 6 NPWT services in a 120 day period to accomplish the desired objective of the treatment plan of the wound. Only when medical necessity continues to be met and there is documented evidence of clear benefit from the NPWT treatment already provided, should NPWT services be continued beyond this frequency or time frame."

There were numerous changes from the proposed LCD to the final LCD which was just published. The changes relevant to our comments include:

1. No frequency limit on total number of debridements in a year
2. No frequency limit on the total number of debridements including muscle / fascia and bone in a year
3. Disposable NPWT coverage was not removed as was proposed
4. Wound photography not required as proposed (but it is suggested especially when more than 8 total debridements or 5 debridements including muscle / fascia and bone are performed in a year)
5. Palliative wound care is covered
6. The statement in the proposed LCD that a wound needs to show a documented improvement of 10% per month or granulation tissue progression of 1 mm per month was removed

ICD-10 codes that start with L97- are used for non-pressure chronic ulcers of the lower limb. These codes are used for diabetic foot ulcers, stasis ulcers, and others. Since the onset of ICD-10, there were only five 6^th character options for these L97- codes. These were:

1 – limited to breakdown of skin
2 – with fat layer exposed
3 – with necrosis of muscle
4 – with necrosis of bone
9 – with unspecified severity

These did not leave the option to indicate with our codes that an ulcer had muscle exposed without necrosis of muscle or bone exposed without necrosis of bone. The APWCA worked with the Alliance of Wound Care Stakeholders to write to the World Health Organization (WHO) and explain this gap in code options and request that more options be created that would allow us to code these scenarios accurately.

Our efforts have been recognized! The WHO has announced new 6^th character options that can be used with all L97- codes. These go into effect October 1, 2017.

The following 6^th character options are being added:

5 – with muscle involvement without evidence of necrosis
6 – with bone involvement without evidence of necrosis
8 – with specified severity NEC

These new 6^th characters of “5” and “6” allow the option to indicate the ulcer is to the depth of muscle or bone without necrosis at that depth. The new 6^th character of “8” should be used if the severity of the ulcer is specified in the documentation, but none of the 6^th character options of 1-6 are appropriate.

These new 6^th characters can be used with any code that begins with L97-.

Note: Any ICD-10 code listed above that ends with a “-“ is not complete and requires more characters to complete the code.

Nothing discussed in this communication guarantees coverage or payment. The existence of an ICD-10 code does not ensure payment if it used. Coverage and payment policies of governmental and private payers may vary from time to time and in different parts of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APWCA does not claim responsibility for any consequences or liability attributable to the use of any of the codes discussed in this communication.

Thank you to all participants of the APWCA 2017 National Clinical Conference for helping make this year’s educational program a huge success! With almost 400 in attendance, 75+ presentations, standing room only review course, and a sold-out exhibit hall, this year’s meeting exceeded all expectations.

Presentations are available online for public viewing until September 30 http://www.apwca.org/2017-Presentations. Beginning October 1, educational content will be available to members only.

SAVE THE DATE and join us September 6-8, 2018 in Baltimore, MD for next year’s conference.

Masters Award (MAPWCA) Recipients: E. Cuauhtémoc Sánchez, MD; Cheryl M. Bongiovanni, PhD; Charles Andersen, MD; Tyler Sexton, MD; Randall Cook, MD; Steven Sprigle, PhD, PT along with President (L) Steven Kavros, DPM; Vice President (R) Jeff Niezgoda, MD and Conference Chairs Kathya Zinszer, DPM and Barbara Delmore, PhD, RN

APWCA was well-represented at the recent New Cardiovascular Horizons (NCVH) Annual Conference held in New Orleans on May 31-June 2. Steven Kavros, DPM, MAPWCA, FACCWS, CWS, APWCA President, presented excellent content during the Podiatry and Wound Care sessions including "Treatment of Ischemic Wounds with Non-Contact, Low-Frequency Ultrasound: The Mayo Clinic Experience" (View PDF) and "Improving Wound Healing Outcomes Using Hypocholorous Solution as a Therapy" (View PDF). He also participated in the NCVH Interview Arena to promote the upcoming APWCA National Clinical Conference, September 7-9, in Philadelphia, PA. 

This document provides the quality benchmarks and standard deviations for each quality measure that may be included in the Performance Year 2016 Quality and Resource Use Reports and used in the calculation of the 2018 Value Modifier. There are four types of quality benchmarks that may be used to calculate a TIN’s Quality Composite Score for the 2018 Value Modifier: 

1. CMS-Calculated Outcome measures (Table 1) 
2. Physician Quality Reporting System (PQRS) measures (Table 2) 
3. Electronic Clinical Quality measures (eCQM) reported to the PQRS (Table 3) 
4. Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures (Table 4) 

Starting with the 2018 Value Modifier, separate benchmarks will be used for eCQM and non-eCQM PQRS measures. The benchmarks for each quality measure are based on the performance of all solo practitioners and groups nationwide in 2015, the year prior to the performance period. The benchmarking and measure calculation methodology is described at the end of this document. 

Download full document from CMS here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/PY2016-Prior-Year-Benchmarks.pdf

The APWCA Board of Directors has reviewed the new NPUAP staging system. Additionally, we have reviewed responses from allied professional organizations, which have included commentary in support of as well as opposition to the new nomenclature presented by the NPUAP.  The Board applauds the dedication and the continued effort that the NPUAP has consistently delivered to enhance and promote the quality of care provided to patients with pressure ulcers.  The APWCA is confident that all issued statements and positions are well intended and primarily founded on patient centric motivations.  

The APWCA is devoted to the best practice clinical algorithms, which include regulatory and policy guidance.  As an organization committed to evidence-based best practice, we recognize that clinical standards, policy and nomenclature will change over time. Evolution in medicine and wound healing is based on new evidenced-based science, novel technology and an improved understanding of wound healing physiology.  

The APWCA is a membership-based organization with thousands of talented and skilled wound healing experts.  To issue a position statement without allowing our membership the opportunity for discussion and debate on this important topic would be inconsistent with the core principles of the APWCA.  As an organization, we plan to fully explore and deliberate the changes in the very near future.  Once we have accomplished our due diligence and allowed our membership to voice their opinions, we will join our colleagues and sister professional societies and issue a position statement. The APWCA will attempt to provide positive feedback and suggestions to improve and enhance the NPUAP staging system. In order to accomplish this goal, the APWCA Board of Directors will be sending a survey to all of the members to query your feedback on this important topic.

Click here to view/download our full position statement.

Sincerely,

Steven J. Kavros, DPM, MAPWCA, FAACWS, CWSP
President
American Professional Wound Care Association

American Professional Wound Care Association (APWCA) invites the submission of research abstracts for the 16th Annual APWCA National Clinical Conference, which will take place September 7-9, 2017 at the Loews Philadelphia Hotel, Philadelphia, PA.

Submission Categories:

• Wound Healing
  
• Limb Salvage
  
• Hyperbaric Oxygen Therapy
  

To submit an application or for additional information about abstract format and guidelines, visit http://www.apwca.org/2017-Abstracts

The deadline for submission is Tuesday, August 1, 2017

If you have questions about abstract submission, please contact APWCA at 337.541.2240 or abstracts@apwca.org