The Novitas Wound Care LCD, Debridement Services, and Real World Data – Part 3

I’m tying some threads together about the Novitas Wound Care LCD and the cost of outpatient wound care. Check out the cost of chronic wound care article in Value in Health performed by the Alliance of Wound Care Stakeholders and available to you here:

http://www.valueinhealthjournal.com/article/S1098-3015(17)30329-7/pdf

You can find a pdf version of the Novitas LCD here. The LCD says that only “a minority” of beneficiaries require more than 8 surgical excisional debridement services involving subcutaneous tissue, and 5 involving muscle, fascia or bone, over 360 days. Is that true?

I decided to look at this with US Wound Registry (USWR) data. We did a quick analysis using raw data on all patients with wounds, regardless of how long they were in service or what their outcome was. That can skew the results, because patients who transfer their care or are lost to follow-up will have an artificial reduction in the number of debridements they receive over 360 days because their length of time in service is so short. The opposite is true for patients who heal very slowly, or keep returning with new ulcers.

Analyzing the USWR data from 2011 through 2016, what we found, as depicted in the table below, is that the average number of subcutaneous debridements per wound, per patient over a 360 day time frame, is less than 5. For muscle debridements, the average number of debridements per patient is only 2.29, and for bone debridements, less than 1.76. Even the sum of muscle and bone debridements together are less than 5 per patient (on average). Thus, USWR data suggest that the utilization guidelines in the Novitas LCD are reasonable.

US Wound Registry (USWR) Data: Average number of Debridements per patient at that tissue level over 360 days

  Code Patients Procedures Procedures per Patient
SubQ 11042 83,214 382,558 4.60
Muscle 11043 10,337 23,686 2.29
Bone 11044 4,261 7,480 1.76
Total 14,598 413,724

There are many ways in which a far more elegant analysis of the data would be preferred (e.g. looking at  number of debridements among patients who stay in service a precise length of time, looking at number of debridements within a specified time frame, analyzing by specific wound type, etc.). In fact, with USWR data we can control for just about any variable. Dr. Marissa Carter was a guest blogger on this site, discussing her paper on wound center visit frequency. It is the most carefully controlled study ever performed using real world data in wound care. That’s because the USWR is comprised almost entirely of structured data fields that allow cohorts to be compared on the basis of diagnoses, medications, quality of care, etc. If any of you have funding to PAY for a more rigorous analysis, do let me know!

https://carolinefifemd.com/2017/02/27/guest-blogger-dr-marissa-carter-on-clinic-visit-frequency-chronic-wound-healing-and-beyond/

It is ironic that while we spend perhaps as much as $96 Billion dollars per year on wound care, we spend almost nothing on wound care research. If only 0.001% of the money spent on chronic wounds was invested in comparative effectiveness research using the repository of data already available in the USWR, it would be possible to know what treatments work best among real world patients. We have been getting the USWR ready to support real world analysis for a decade. That’s why we published a paper on standards for reporting data directly from EHRs. http://onlinelibrary.wiley.com/doi/10.1111/wrr.12523/abstract

Although we do not have funding for comparative effectiveness research, what we CAN do right now is create benchmarking reports that allow providers and hospitals to compare various wound care metrics against the national aggregate. Benchmarking reports allow you to determine whether your frequency of debridement services is higher or lower than the rest of the country. Benchmarking allows you to visualize whether your activities might raise a red flag with a RAC auditor, since we know they have been auditing debridement services. If you read my previous blogs on this topic, you will understand the history of the debridement issue with CMS and the OIG, which has been on-going for a decade.

Here’s the bottom line about the Novitas LCD when it comes to debridement frequency: based on a very superficial USWR data analysis of over 14,000 patients who underwent more than 400,000 debridements, the Novitas utilization guidelines for debridement are reasonable.

Benchmarking with the USWR:

If you submit your patients’ Continuity of Care Documents (CCDs) to the USWR, you can participate in a national benchmarking program. Why would you do that? I occasionally hear physicians saying that they don’t want anyone looking over their shoulder, or hospitals saying that they don’t want to share data. However, every major medical specialty offers benchmarking programs, and most physicians WANT to participate in them. Why?

The Novitas LCD on Wound Care clearly says, “When services are performed in excess of anticipated peer norms, based on data analysis, the services may be subject to prepay or post pay medical review.”

How can you tell if your services are in excess of peer norms? The only way is by comparing your data with your peers. And, we do NOT want to do data entry by hand, besides which, there is always the risk of patient selection bias or data entry fatigue. However, all certified EHRs must be able to transmit CCDs, and these documents contain CPT codes. This makes it possible for the USWR to provide reports back to you which tell you whether your debridement activity is outside the national norm by either total volume or debridement level. If you do get audited for any reason, you can use national benchmarking data to show the auditors that your debridement activity is in line with national data and perhaps spare yourself a more in depth evaluation of these charges.

The ability to use CCDs for benchmarking can’t be over-emphasized. It could help providers with pre-payment review of debridement charges or hyperbaric oxygen therapy, and it can be used as part of the benchmarking program for anyone required to enter into a Corporate Integrity Program.