Wound Care Education Can Maximize PDPM Reimbursements

In April, the Centers for Medicare and Medicaid Services proposed a $320 million decrease in Medicare payments to skilled nursing facilities for fiscal year 2023.

Building wound care expertise and maximizing your organization’s reimbursements through the Patient Driven Payment Model (PDPM) is now more essential than ever. Understanding the reimbursement opportunities that wound care specialists can bring and investing in training are both wise business decisions that will allow your organization to thrive.

A study published in Value in Health on the cost of chronic wound care for Medicare beneficiaries revealed that nearly 15% of the patients (8.2 million) had at least one type of wound or infection. The total Medicare spending estimates for all wound types ranged from $28.1 billion to $96.8 billion.

Consider the financial implications

In a recent Relias webinar, Sue Grafton, RN, BSN, CWON, Clinical Support Manager at McKesson Medical-Surgical, said that nurses might sometimes feel uncomfortable discussing the financial side of patient care decisions.

She pointed to Atul Gawande’s observations in an article in The New Yorker that physicians are not taught to think about money in medical school or residency. Yet they must think about financial aspects of care from the moment they begin practicing. It is important to consider what is covered for a patient and what is not.

Making sure your nurses also understand the financial repercussions of care decisions is important.

Take advantage of reimbursement opportunities

Your skilled nursing facility can benefit from the incentives that PDPM offers by enhancing your staff’s wound care competency. Wound care fits under the nursing and the non-therapy ancillary (NTA) components of PDPM. The NTA scores are based on a point system, and additional points are given to patients based on the clinical complications of their conditions.

For a 65-year-old patient with diabetes, infected foot ulcer, positive MRSA infection, and osteomyelitis, diabetes would be two points, for example. If the patient was isolated, that would be another point. If she also took intravenous antibiotics to treat the osteomyelitis, that would qualify her for five points. The wound infection would be two points. Calculating all the points makes an NTA morbidity score of 10.

Michele Carr, RDN, DPM, NWCC, FAPWCA, COS-C, Clinical Support Manager at McKesson Medical-Surgical, said it is “extremely important” to use the accurate ICD-10 codes for the Minimum Data Set for each condition to calculate your reimbursement correctly. Since the base CMS payment for the medical condition is multiplied by the NTA case mix index, the higher the case mix index is, the higher your reimbursement.

Manage wounds better

You can provide consistent care if you have accurate documentation of your patient’s care at the hospital. This information will help you identify wounds and comorbidities correctly and apply the correct coding for reimbursement.

“Just a few missed points could result in hundreds of dollars a day of reduced payment for a skilled nursing facility,” said Grafton. “It is really important to arm yourself with as much information as possible about that patient’s history before they come to you. It is equally important to understand that ICD-10 coding begins the reimbursement process.”

Trained coders can understand and identify the outliers that could add to reimbursement, especially when you care for more complex patients. Make sure they speak with the physicians to understand what code they need to use. A comprehensive assessment and diagnosis of the patient can increase NTA points and your reimbursement.

Build clinical excellence

Care planning starts with an assessment and documentation of the wound. Diagnosing wounds correctly is critical for the best patient outcomes and accurate documentation for reimbursement purposes.

If your staff member documents a wound incorrectly as another type, you may not be able to be reimbursed for it. Besides losing the reimbursement, the successful healing of the wound could be negatively affected.

Wound care requires a lot of resources — more nurses and more time to care for each patient. If you plan to take on patients with higher acuity, make sure you have well-trained staff members to care for them.


Aliza Inbari

Content Marketing Manager, Relias

Aliza Inbari has more than 20 years of marketing and communications experience in higher education, nonprofit, and business organizations. At Relias, she partners with physicians, nurses, curriculum designers, writers, and other staff members to shape healthcare content designed to improve clinical practice, staff expertise, and patient outcomes. She has an MA in political science from the Hebrew University of Jerusalem and an MBA from the University of North Carolina at Pembroke.

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