Last week CMS rejected a quality measure developed by the US Wound Registry (USWR) which was the Appropriate Use of Surgical Dressings from a DME for patients with wounds. That quality measure was designed to drive the electronic ordering of wound dressings for home use. The electronic ordering system incorporated analytics to determine if the DME order met CMS requirements. Surgical dressings are covered for full thickness wounds that have undergone debridement. The type of dressing covered is determined by a variety of elements which include the amount of drainage. Orders require a frequency and a duration as well as a physician’s signature. The beauty of electronic ordering is that within an electronic system, it is possible to nearly instantaneously run an analysis to make sure that the order has all the required elements. This quality measure was designed to promote interoperability (the use of the electronic health record), reduce improper DME orders, and ensure that the dressing ordered is appropriate to the needs of the wound.
Why did CMS reject this measure? Because it is a “process” measure. Process is a dirty word. You know, processes, like the “time out” we do in the operating room before a procedure – processes are just not where we are when it comes to quality measurement.
Why did I think we need that measure? Chronic wounds affect 15% of Medicare beneficiaries. Durable Medical Equipment (DME) costs for wound care represent $3.1 billion per year, based upon 2014 Medicare data. A lot of the DME cost in wound care is for surgical dressings and negative pressure wound therapy (NPWT). A major area of concern for improper payment in the Medicare system is that of Durable Medical Equipment (DME). The Office of the Inspector General (OIG) estimates that the national DME improper payment rate is 35.54%.  Annually, the Department of Health and Human Services (HHS)  and the Office of Inspector General (OIG) publish a report detailing the Top Management and Performance Challenges faced by HHS. In the 2018 report, HHS has identified reducing improper DME payment as a major focus. The definition of improper payment includes those cases in which documentation does not meet specific CMS requirements, even though the DME might have been medically necessary. Insufficient documentation (e.g. such as a missing or incomplete order) is the primary problem responsible for “improper” for DME payments.
Noridian, the Jurisdiction D, DME MAC, Medical Review Department is conducting Targeted Probe and Educate (TPE) reviews of HCPCS code(s) which describe the use of a specific surgical dressings in the alginate category (A6021, A6212, A6196 and A6197). Based on dollars, the overall claim potential improper payment rate is 86% (see Addendum). TPEs of NPWT are beginning in several jurisdictions. In many cases, as the dressings are retroactively denied, the patients are getting billed for the cost of dressings many months later. Keep in mind that no one disputes that they actually NEEDED the dressings. The issue here is that there was something missing from the order like the number of dressings or the duration, or the amount of drainage. Because of this payment was denied to the DME, so the DME then sent a bill to the patient. News flash – these are processes. Medicare decides whether they will pay for things based on whether providers follow processes. Medicare does this because apparently on the PAYMENT SIDE, CMS thinks that processes matter. What would happen if we decided whether we were paying for dressings based on whether the wound HEALED? That’s a very interesting idea.
At any rate, HHS has stated that it is seeking ways to foster the development, adoption, and effective use of HIT, specifically by:

  • Ensuring that Health IT companies and providers do not inappropriately block the flow of information
  • Ensuring program requirements are met for payment
  • Encouraging high-value uses of exchanged data

The OIG report calls on HHS to address barriers to the flow of secure data among providers. So, here’s the Reader’s Digest version:

  • 15% of Medicare patients have a chronic wound.
  • Chronic wound care represents a major portion of Medicare spending, with DME cost contributing a substantial portion.
  • HHS and the OIG estimate that one third of DME payments are “improper.”
  • Improper payments for DME services largely involve insufficient documentation.
  • More than 16 specific elements of documentation are required to substantiate claims for surgical dressings and requirements are similar for NPWT and orthotics.
  • As only one example, in the Noidian jurisdiction, the overall claim potential for improper payments of alginate dressings is 86%.
  • HHS has specifically stated that it wishes to encourage high value uses of exchanged healthcare data and to ensure that program requirements are met for payment.
  • End-to-end ordering of surgical dressings through the electronic health record (EHR) dramatically reduces the possibility of fraud and abuse and helps ensure program requirements are met for payment.

The US Wound Registry (USWR) created a QCDR quality measure focused on the Appropriate use of Surgical Dressings via the electronic ordering to encourage the high value exchange of healthcare data, a priority identified in the 2018 Top Management and Challenges Report. It would have allowed practitioners to satisfy several requirements of MIPS, including Advancing Care information.
CMS has rejected that proposed measure because it is a process measure. However, all of the programs used by HHS to address improper payments focus on improving processes. Most of these deficiencies can be remedied via “direct from EHR” transmission of EHR data to the DME.  Given the cost of wound care, the serious issues of improper payment reported with DME benefits, the priorities of HHS to advance HIT, and the fact that compliance with Medicare policies are largely “process” activities, we are mystified why CMS would not wish to use quality measures promoting data exchange as a way to accomplish the stated goals of HHS and the OIG to address a major problem with improper payment.

Check out page 4 of the Quality Payment Program Final Rule Executive Summary – CMS is prioritizing quality measures that support interoperability – UNLESS they have to do with wound care, improve appropriate use, and target areas of possible fraud and abuse.

We have prioritized interoperability, which we define as health information technology, that enables the secure exchange of electronic health information  . . .as defined by the 21st Century Cures Act (Pub. L. 114-255, enacted December 13, 2016).
In addition, we are prioritizing quality measures and improvement activities that support interoperability.