Many factors contribute to wound care healing, including nutrition, age, moisture, pressure, and even stress. Consequently, treating a wound can be as much art as science. Experience and clinical studies provide guidelines of what works in which cases and how much time healing should take. But individual patients often defy conventional wound care wisdom.

It is a process not easily broken down into set, standard procedures. But many industry advocates complain the Centers for Medicare and Medicaid Services (CMS) attempts to do just that by including wound care supplies under the Prospective Payment System (PPS).

To establish payment rates under PPS, Medicare uses 80 home health resource group (HHRG) categories to classify patients based on their clinical, functional, and therapy needs. Each category has a set payment rate for 60 days of care. In the calculations for supplies, however, the system does not figure the expense based on severity but rather gives a flat average amount to each of the 80 HHRG codes.

Since many complicated wounds take months to heal and require many supplies, providers must choose between three options.

1. Take the patient and risk losing money on providing the wound care supplies.
2. Turn the patient away—which may mean forcing him or her into costly institutional care.
3. Take the patient but provide wound care supplies based on price rather than on what is best for the patient. For example, moist wound dressings improve the rate of healing for many patients, but these cost more than gauze dressings.

The second problem with providing wound care under PPS is that HME providers are ineligible for reimbursement for these products under Medicare part B as long as the beneficiary is still under a home health agency (HHA) plan of care. Since it can take weeks for a HHA to finish all the paperwork needed before they can officially discharge a patient, any HME provider that furnishes the wound care supplies while the HHA finishes up the discharge forms will see their claim denied by CMS.

Providers who bill Regional Home Health Intermediaries or other fiscal intermediaries can check if a patient has been discharged from a HHA through the Health Insurance Query systems, which access CMS’s data files. However, suppliers that bill through the Durable Medical Equipment Regional Carriers can not access these files because CMS’s current computer platforms will not allow it.

There are two answers to these problems, says Ann Howard, vice president of national policy and member relations for the American Federation of HomeCare Providers in Silver Spring, Md. First, wound care and other nonroutine supplies must be pulled out of consolidated billing and reimbursed on a fee schedule basis. Second, reimbursement for wound care should be increased.

The General Accounting Office plans to release a report on PPS on August 15. “Work with home health agencies and go together with their members to visit Congressional representatives,” Howard says.

Before going, call local nursing homes and gather figures on long-term care costs. Use the information to show how home care is saving the government money in your area. Also contact the American Association for Homecare at (703) 836-6263 and ask for their position paper on PPS.

If possible, bring a patient family with you to show how PPS is impacting these constituents, Howard says. Finally, stress the solution, not the problem.

Lena Lindahl is senior editor of Dealer/ Provider.