Clinical Geriatrics

This is Part II of a two-part series on pressure ulcers and Medicare reimbursement. Part I appeared in the June issue of Clinical Geriatrics and discussed specific factors that Medicare and other insurers may consider when determining whether a pressure ulcer is preventable.

Introduction
Medicare recently released new reimbursement guidelines that will deny payment for “preventable” complications that arise during hospitalization.1 These include such entities as catheter-related infections, fall-related injuries, transfusion with incompatible blood products, wrong-site surgery, and pressure ulcers. Expenses related to pressure ulcers are huge, as they add between $5 billion and $8.5 billion in treatment costs for hospitals and 2.2 million Medicare hospital days.2,3 Going into effect October 2008, these new guidelines will force radical changes in practice for hospitals with regard to skin assessment. Because reimbursement for hospital admissions is physician-driven, doctors will be encouraged to assess skin and provide detailed and accurate documentation in the medical record. It is hoped that this financial incentive will result in improved quality with early implementation of pressure-relief modalities and appropriate skin treatments. This article provides physicians with a guideline to pressure ulcer documentation and how to properly record skin condition in their medical notes.

This decision by Medicare is a result of the “pay-for-performance” movement, which encourages insurance companies to reimburse only for quality care.4 As pressure ulcers have been widely identified as a quality indicator, this policy intends to alter the way medicine is practiced in an effort to improve healthcare delivery. One of the issues challenging Medicare is that all pressure ulcers are not avoidable, and it is unclear at this time which criteria will be used to deem them as such.5 For hospitals, one strategy to circumvent this problem is to improve skin documentation within hours of admission to the facility. All too often, pressure ulcers occur in home environments, nursing homes, or other facilities prior to admission to the hospital. If the clinician does not document altered skin integrity until the third or fourth day of the hospital stay, there exists a good chance that the hospital will “own” the ulcer, and payment for care of this condition and its complications will be denied. Hospitals, therefore, stand to lose millions of dollars in reimbursement simply because of lack of timely skin documentation in the critical hours after entry into the facility.

This is not only a question of cost, but it is also a question of quality. Patients with impaired skin integrity require early assessment from a medical standpoint for implementation of prevention measures to prevent further breakdown, as well as adequate and appropriate treatment. 6 Increased vigilance for early skin breakdown is the first step in preventing pressure ulcers from worsening into more advanced stages that are more difficult and costly to treat.