Preparing for the New Medicare Reimbursement Guidelines: Part II—Documentation of Altered Skin Integrity in the Hospital
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.
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.
Skin Integrity Assessment
Pressure ulcers occur primarily in areas of bony prominences that are exposed to constant pressure.7 Physical examination, therefore, necessitates positioning the patient appropriately and using adequate light. This can present challenges, particularly in patients with severe pain from arthritis, fractures, or metastases. Persons with morbid obesity or severe pulmonary compromise may desaturate when turned on their side. Other conditions may hinder positioning for skin examination, such as cervical spine immobilization or life-support modalities such as endotracheal intubation. The important thing is to get a good look, measure any wounds that are present, and describe them in the medical record. This description forms the basis for further treatment, as well as serving as a baseline for further assessment as the wound condition evolves.
Direct trauma can result in several conditions that should be documented and treated, including excoriations, skin tears, and bruises. These traumatic injuries result from falls, fingernails, tight clothing or diapers, or physical abuse. Excoriations are superficial scratches or abrasions, while skin tears are traumatic wounds that result in separation of the epidermis from the dermis, or separate both the epidermis and the dermis from underlying structures.8 Bruises and hematomas are the seepage of blood from broken vessels into interstitial tissues, and may represent deep-tissue injury (described below). Increased fragility of aging skin makes geriatric patients more susceptible to damage, and any of these lesions in areas on or adjacent to bony prominences can evolve into pressure ulceration.
Several other conditions can be precursors to altered skin integrity that should be documented and treated. These include incontinence dermatitis (also known as diaper rash) and fungal rash. Incontinence dermatitis is usually thought of as a pediatric problem; however, there are more than 12 million adults suffering from incontinence who are at risk for dermatitis that is identical in etiology, prevention, complications, and treatment.9 If untreated when an elderly person is admitted to the hospital, this condition can evolve into yeast infection, bacterial infection, or pressure ulceration. The distribution of incontinence dermatitis is in the area of constant contact with urine or stool, thus the buttocks, inner thighs, lower abdomen, and genitalia are most affected. Mild cases can demonstrate patches of shiny red skin, while more severe cases can have inflamed, eroded, painful areas.
Fungal rash can occur in perineal areas of patients who are incontinent, overweight, diabetic, or those taking long-term antibiotics or immunosuppressant drugs. This rash is usually bright red in color, with smaller satellite lesions present near the outer perimeter of the rash area. The symptoms are itching or burning, and it is commonly seen on the buttocks, groin, and thighs. Fungal rash can begin with incontinence dermatitis, and if untreated can evolve into skin breakdown and pressure ulceration.10
The Staging System for Pressure Ulcers
Pressure ulcer staging was standardized by the Agency for Health Care Policy and Research (AHCPR) with assistance from the National Pressure Ulcer Advisory Panel (NPUAP) in 1992.7 Prior to that, there were several staging systems and definitions that were confusing or inaccurate. There were originally four stages but two more were added, including suspected deep-tissue injury and unstageable pressure ulcers. It should be noted that the four stages were meant as descriptive in nature, and not inferring developmental progression. For example, because an ulcer presents as stage III, it did not necessarily evolve from stages I and II.
Suspected deep-tissue injury is the newest stage of pressure ulceration added by the NPUAP.11 This is described as purple or maroon areas of discolored intact skin, and also includes blood-filled blisters. This latter entity usually occurs on the heels. Deep-tissue injury may also be preceded by tissue that has altered characteristics, such as being mushier, boggier, firmer, warmer, or cooler than adjacent tissue. Special attention should be taken in persons with dark skin, as these visual changes can be overlooked. Deep-tissue injury is an entity that may further evolve into eschar, or rapid breakdown through the skin into layers of deeper tissue.
Stage I pressure ulceration is nonblanchable redness of intact skin over a bony prominence. Again, persons with dark skin may be difficult to assess and warrant special attention to subtle changes in color. According to the NPUAP, this area may be painful or have physical changes such as softness, firmness, or warmth—similar to areas of suspected deep-tissue injury. Patients with stage I pressure ulceration or suspected deep-tissue injury should be assessed as being at immediate risk for progression to further skin breakdown, with appropriate and timely pressure-relief modalities put into place.
Stage II pressure ulcers present as a shallow open ulcer with loss of dermis and a pink wound bed without slough. Once the skin is broken over a bony prominence, there is little room for argument as to whether a pressure ulcer is present. The ulcer needs to be documented using the parameters outlined below, with pressure relief and treatment initiated.
Stage III is full-thickness skin loss with subcutaneous fat visible, but not deeper structures such as muscle, tendon, or bone. Stage III skin ulcers can differ widely in depth depending upon amount of subcutaneous tissue in the specific anatomic area of occurrence.
Stage IV ulcers represent full-thickness skin loss with exposed muscle, tendon, or bone. There may be slough or eschar, but this is not the predominant feature of the wound. As with stage III ulcers, the depth may vary greatly depending upon anatomic location. A stage IV ulcer of the toe showing exposed bone may be a few millimeters deep, where a stage IV ulcer of the trochanter of an obese individual may be several centimeters deep.
The unstageable ulcer is one with full-thickness tissue loss in which the true depth, and, therefore, stage, cannot be determined. In an unstageable ulcer, the wound bed is completely covered with slough or eschar. Once the area is debrided, or the eschar and slough are removed revealing the wound bed, the ulcer can be staged. Unstageable ulcers usually end up as stage III or IV once the wound is uncovered.
Documenting Altered Skin Integrity
Skin assessment should begin within hours of entering the emergency room or hospital. Physicians should place their skin documentation clearly in their assessment section, whether in the history and physical or the initial admitting note. Documentation of altered skin integrity begins with indicating the location. A drawn diagram can be helpful, particularly if there is more than one wound. Photographs can provide a helpful visual record to enhance documentation, provided they are used in conjunction with a strong policy that includes technique, timing, and a protocol for patient identification.7 Staging the ulcer is important using NPUAP criteria, as this gives a common language for indicating the degree of tissue-layer destruction. Other descriptors include color of the wound, amount and character of exudate (serous, serosanguinous, or purulent), and odor. If the wound is deep, the type of tissue should be described, as well as a description of the wound bed. Odor can indicate high bacterial count or infection, and should be noted as well.
Quantitative assessment can supplement and clarify narrative descriptions of the wound. Several techniques exist for measuring wounds, and these include tracings, volumetric methods, and linear measurements.12 Most will choose the latter, and this simply includes length and width as measured from wound edge to edge in centimeters. Many wound-care product suppliers offer disposable paper rulers, which can be very helpful to carry in one’s pocket for this purpose. The top of the wound is toward the patient’s head, while the bottom is toward the feet. Depth, if present, is measured from the surface to the deepest part of the wound base. Other wound characteristics such as tunneling or undermining should also be described and measured.
Pressure ulcers are often preventable complications of hospitalization for elderly patients, and as such, a low pressure ulcer rate is considered to be an indicator of quality care. Many pressure ulcers and pre-ulcerative conditions are present on admission, having been incurred at home, in nursing homes, or other hospitals. With the new Medicare guidelines denying payment for preventable conditions, hospitals stand to lose millions of dollars when these lesions develop. Physicians are on the front lines when it comes to Medicare documentation and, therefore, must know the basics of skin assessment. This begins with physical examination, but it also means knowing basic terminology related to wound assessment. Proper assessment leads to early pressure-relief interventions and implementation of appropriate treatment and consultations. Adequate and timely skin assessment is the first step in providing quality care for hospitalized geriatric patients.
The author owns a company that consults about wounds and wound care, and also speaks frequently on this topic.
Dr. Levine is Clinical Associate Professor of Medicine, New York Medical College, Valhalla, NY, and Attending Physician in the Geriatrics Section, St. Vincent Catholic Medical Center, New York, NY.
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