By Monica J. Smith
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General surgeons looking for ways to offset pandemic-related revenue loss might consider exploring wound care management. They may already have some of the skills, the need is high, and the reimbursement is there.

“If you’re doing wound care, you’re going to be very busy and you’re going to be compensated,” said Harold Brem, MD, the chief of the Division of Wound Healing & Regenerative Medicine at Newark Beth Israel Medical Center, in New Jersey. “You’ll probably see more hospital patients and be capitated at a higher rate than if you were doing gallbladder operations, and you’ll be providing an equally if not greater service by meeting an unmet patient need.”

This demand is especially high now because many patients delayed care last year out of fear of exposure to COVID-19 in medical settings. “They got precipitously worse,” Dr. Brem said. “These patients usually don’t have the advantages of being treated by a skilled surgeon, but when you apply the best surgical skills, the healing rates are terrific. And it’s extremely rewarding. For many surgeons, this work may turn out to be the most satisfying surgery they do.”

Who Owns Wound Care Management?

Currently, more than 7 million people in the United States live with chronic wounds. Despite this number, no doctors are formally trained in wound care. Once predominantly the domain of nurses, wound care management doesn’t belong to any specific specialty, although some may be a more natural fit than others. The four specialties that include wound care as part of their primary board certification are plastic surgery, general surgery, vascular surgery and dermatology.

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“In the last 20 years, we’ve seen a rise in wound care centers driven by reimbursement for hyperbaric oxygen care,” said John Lantis, MD, a professor of surgery at Mount Sinai Hospital, in New York City. “In most cases, these centers are run by a for-profit company that forms a partnership with a local hospital system. The for-profit company and the hospital determine who pays which employees and who pays for the development of the space. In addition, the hospital system benefits from the ancillary spinoffs.”

According to Dr. Lantis, “in that model, podiatrists have thrived; there are also providers in infectious disease, emergency medicine, physical medicine and rehabilitation, and general medicine.” However, even though there are certifications for wound care from organizations such as the American College of Wound Specialists, they don’t meet the level of rigor demanded by institutions like the American Board of Medical Specialties, he said.

“The organizations that give certificates may differentiate in which certification they give to different levels of training, but they will certify a medical assistant, a nurse, a physical therapist, a doctor—therefore, ownership is diverse,” Dr. Lantis noted.

So, apparently, is the quality of care. Wound care technology has advanced significantly, but overall outcomes are often subpar, sometimes as low as a 50% to 60% healing rate at six months. “That may be due to people not following algorithms and really not knowing what they’re doing,” Dr. Lantis said.

Since a large part of wound care is pain control and wound debridement, general surgeons may be better equipped than nonsurgical specialists to treat these wounds, he said. Especially in the outpatient setting, this can be well reimbursed.

“But there is a core knowledge you need to know: what you’re doing and why you’re doing it. The concept of just starting to do wound care is a bit like deciding to do laparoscopy without any training in it,” Dr. Lantis said.

The application and use of cellular tissue-based products (i.e., skin substitutes), which many surgeons know from the operating room, also can be remunerative. “But again, you need to be familiar with their use, handling, indications and expected outcomes,” Dr. Lantis added.

Basics of Starting Out

Any general surgeon getting into wound care will face some up-front costs: acquiring the appropriate products for debridement and postprocedural advanced dressings, and possibly reinforcing the front office staff, Dr. Lantis said.

“You may want to partner with someone more familiar with those dressings, such as a wound and ostomy care nurse. Also, home care provides a large amount of wound care, so you’ll need be able to handle the demands of communication coordination with home care and home care nurses,” he added.

An easy way to get your feet wet is to look up nearby wound care centers. Many are staffed five or six days per week, in half-day shifts, allowing for 10 to 12 blocks per week. Tell them you’re a board-certified general surgeon interested in doing two or three days weekly and ask if they have any openings. These wound care programs usually offer structured training and provide algorithms for care.

“That’s like buying a mutual fund. It minimizes your risk while maximizing your productivity, and enhances the general surgeon’s ability to provide good care,” Dr. Lantis said.

Another relatively easy entrance is to develop an on-call schedule for wound care at your local hospital. “Most hospitals would love to have a general surgeon rounding, where they could, say, call the general surgery service for any skin issues,” Dr. Brem said. “This could be separate from their regular general surgeon or wound care nurse on call or in collaboration with those services.”

Understanding Reimbursement for Wound Care

By Monica J. Smith

Several times per week, Kathleen D. Schaum, MS, a wound care reimbursement strategy consultant, fields phone calls from health care providers asking, “How can I get paid by Medicare for that?”

At the 2020 fall Symposium on Advanced Wound Care, Ms. Schaum, the founder and president of Kathleen D. Schaum & Associates, Inc., said the answer to this question requires understanding the three components of reimbursement: coding, coverage and payment that pertains to each specific scenario.

To determine clients’ potential for reimbursement, she asks them to focus on a few details. As an example, a client seeks Medicare reimbursement for negative wound pressure therapy. In this case, the questions are: “Are they using durable medical equipment or disposable negative pressure? Who is applying the negative pressure? What is the site of care? If another procedure will take place concurrently, what is that other procedure?”

In addition, there are other considerations, Ms. Schaum said. Medicare may reimburse:

  • if the procedure is covered for that patient. Since not every technology can be applied to every patient, Ms. Schaum advised checking National Coverage Determinations, Local Coverage Determinations and Local Coding Articles on the Centers for Medicare & Medicaid Services’ website (see links below).

“Physicians and qualified health care professionals often say, ‘Isn’t this the coder’s job? I don’t have time to read these.’ But I’ll tell you, these things are not that long and they are the playbook for physicians and qualified health care professionals,” Ms. Schaum said.

  • if the physician performed the procedure. For example, if the physician provides wound/ulcer management in a hospital–owned, outpatient provider-based department, that physician “can bill for it if he/she performed the procedure. But if they write an order for a department staff member to perform it, only the facility can bill for it.”
  • if the service/procedure is not part of a National Correct Coding Initiative procedure-to-procedure (NCCI PTP) edit. When two services/procedures are performed during the same encounter, verify whether an NCCI PTP edit exists that would cause payment denial for one of the services/procedures.
  • if the procedure is not included in the consolidated bill payment system of a skilled nursing facility.

Many wound and ulcer patients are in skilled nursing facilities, which submit consolidated bills to Medicare and get paid a lump sum for their patients’ care. “So, you’ll need to know which procedures are in the consolidated billing system and which are not,” Ms. Schaum said. For the latter, you can bill Medicare; for the former, you’ll have to contract with the facility to bill them for that work.

Resources From the CMS Website

This article is from the March 2021 print issue.