“For they sow the wind, and they shall reap the whirlwind.” (Hosea 8:7)
“Sowing the wind and reaping the whirlwind,” is a Bible verse from the Book of Hosea, a prophet of Israel. He was warning the people of a coming judgment for foolish behavior. The phrase is a farming illustration. A farmer sows a seed of corn and reaps an ear of corn, an example of the way one’s actions are amplified in time. Unfortunately, past foolishness can yield a storm of consequences, a lesson we have learned repeatedly in healthcare policy.
WPS, a Medicare Administrative Contractor, has issued a Local Coverage Determination (LCD) which limits the wound types for which a debridement can be billed and the list does not include Diabetic foot ulcers (DFUs). In making this change, WPS cited published studies which failed to show that debridement was clinically useful. Although WPS said they would reconsider if provided scientific evidence, the fact is, this WPS policy is the first stirring of the whirlwind.
In 2007, twelve years ago, the Office of the Inspector General (OIG) published a review of surgical debridement services from 2004. The OIG had seen a dramatic increase in the number of Medicare claims submitted for the surgical debridement of wounds under CPT codes 11040 – 11044. The OIG determined that in 2004, Medicare paid out $188 million for surgical debridement services of which (per their review) 64% did not meet Medicare program requirements. According to the review, 47% of were not actually surgical debridements and 29% did not have enough documentation to support the billed level of service. The OIG warned that they also saw evidence of inappropriate patterns in debridement. For example, one patient had 43 debridements involving muscle within a 9-month period (that’s a muscle debridement every 6.3 days).
The OIG recommended that CMS “strengthen program safeguards” around debridement services. They recommended that CMS instruct MACs to conduct additional medical reviews of surgical debridement services and that CMS either develop a National Coverage Determination for debridement or instruct carriers to develop debridement LCDs. Although the OIG report on debridement is more than a decade old, you can be pretty sure that we reaped the WPS LCD from seeds that were sown a long time ago, identified in the report.
We tried to warn people. In 2008, only a few months after the OIG document was published, the late Dr. Robert Warriner and I put together a presentation on debridement billing compliance. The U.S. Wound Registry (USWR), then only 3 years old, analyzed data on 20,302 patients with wounds. Skin and subcutaneous tissue was the most common level of debridement and accounted for 42% of all debridement services. Regardless of the depth of tissue debrided, the procedures were usually billed about 7 days apart. Dr. Warriner looked at his data on DFUs by Wagner grade (n= 5,427) and found that full thickness debridement was documented on 6 “grade 0” DFUs (no wound) and 20 partial thickness ulcers. He also found that among wounds with 76-100% granulation (n =4,994), 2.4 % of the debridements were billed at the level of skin and subcutaneous tissue and there were 5 done at the level of bone. This doesn’t mean that charges were fraudulent or that the debridement services were unnecessary, but it does mean the chart would probably not survive an audit.
At any rate, a decade ago, everyone was warned about the risks of using weekly subcutaneous debridement as the way to financial success in wound care. No one disputes that wounds need to be cleaned of necrotic debris and biofilm, but that’s not a subcutaneous debridement. It can be true that debridement is a vital part of wound care and also true that wound debridement as it is usually billed, is not.
We are reaping what was sown a decade ago. Get ready – there’s a big storm coming.