Medicare and Medicaid Eliminate Reimbursement for Treating Preventable Pressure Ulcers
By MaryAnn Ciccone

Medicare and Medicaid eliminated reimbursing facilities for treating eight conditions, one of them being pressure ulcers. This type of skin condition, according to CMS (Centers for Medicare and Medicaid Services), has a very high cost and high volume and is preventable. Traditionally, hospitals focused on treatment rather than prevention. This new policy now requires them to become proactive instead of reactive for the treatment of pressure ulcers. Additionally, private insurers are considering following this reimbursement policy.

Hospitals must begin tracking and documenting pressure ulcers upon admission within 24-48 hours. The hospital must be able to prove the patient was admitted with pressure ulcers before Medicare and Medicaid will issue a reimbursement. If the condition was developed during the patient’s stay, it may not be reimbursable.

In these days of reduced payments and denied claims, what can hospitals and other health care organizations do to make sure they receive the maximum allowable reimbursement from CMS and other health care insurers? Some examples include:

1. Develop procedures that document the patient’s skin condition upon admission
   Assessments are generally performed within 24 hours of admission. When hospitals use Cerner’s documentation system (Powerforms or IVIEW) and its push technology (rules), patients that have evidence of pressure ulcers can easily be identified. When a patient is admitted, the Cerner system can trigger a rule that will create an order and task for an admission assessment. The task opens a Powerform on which the provider documents the patient’s skin condition. An order for pressure ulcer prevention protocol with a frequency will be generated by the system using a rule if the charted results qualify. The order can also be linked to a task that will populate the provider’s work list as a reminder to perform the protocol.
2. Evaluate the patient during the stay to prevent and treat pressure ulcers that may develop
   Providers should perform ongoing assessments to track the progress of existing pressure ulcers or to document developing ulcers that were not previously identified. The provider documents ongoing assessments by charting on a Powerform or using IVIEW. This can be accomplished each shift or per hospital protocol. Patients who have an active protocol order will continue to be evaluated when due according to the order’s frequency. Patients without an active protocol order will be evaluated in the ongoing assessment. If they qualify for a pressure ulcer protocol order based on the charted results, a rule will trigger and generate the protocol order (similar to the admission assessment procedure outlined above). The protocol order is discontinued by the provider when it is no longer needed.

The key to the new pressure ulcer reimbursement is to require hospitals and other inpatient facilities to identify and properly document pre-existing ulcers through early evaluation. Screening will improve the quality of patient care and prevent potentially life-threatening infections that can result from pressure ulcers as well as bring in higher revenue.

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