Q&A with Dr. Tom
Are there any risk associated diagnostic code that are associated with financial loss even if coded appropriately?
The risk scores for full thickness pressure ulcers significantly understate the true direct and indirect costs of caring for these horrific injuries, even if the patient’s co-morbidities such as malnutrition and obesity are taken into account.
Though it’s important to capture these codes accurately, there is no way to “get ahead of the cost curve” for these particular conditions. The only way to do so is to keep them from happening at all.
It used to be the entire spectrum of pressure-related skin injury was associated with increased risk scores and therefore increased revenue to offset costs. But over-coding and outright fraud led the actuaries and trustees to limit the risk model to paying for only the worst ones.
Pressure ulcers are not like chronic diseases that you can catch early and submit for revenue year after year, even as you are keeping their costs down by keeping them under control. Nor are they acute illness, where if you systematically catch and code each one, your overall revenue for that diagnosis will end up being greater than your average cost of care. No, pressures ulcers are just plain losers—for the patients personally, the nurses professionally and the insurers financially.
And so many are preventable.
Prevention of pressure ulcers is an enormous subject. However, there is a simple intervention, which has fallen by the wayside due to fragmentation of care.
Don’t allow any splints to be placed on your inpatients without a hospitalist’s order.
Don’t allow the hospitalist to place the oder without a hard stop confirming they examined the patient.
I know this goes against everything I say about making care simpler and removing obstacles to letting clinicians provide care. But n the current, fragmented system, this is one exception which is both necessary and creates an enormous payoff for everyone involved.
Patients come in to the hospital with a history of wearing supportive splints for neurologic injuries. The nurses or therapist read the histories and place the splints, often without asking the patient or family member if the patient is compliant at home. The result is hard splint placement of unchallenged integument—and rapid development of pressure injuries in an already infirm patient.
Alternatively, a patient with a new neurologic deficit has a new splint placed, with little or no eduction. The nursing staff often doesn’t even know that the splint is new and a new pressure injury results
In the old days, when the patient’s personal clinician was overseeing care, this was much less of a problem.
Today, with compartmentalized shift work and a cumbersome electronic health record, this is not an uncommon occurrence at all, and it can happen with startling rapidity and frequency. And even worse, since they generally show up in post-acute care environments, they are very difficult to measure.
Get your hospitalist to develop a plan for any splint, old or new, that’s going to be applied on your patient. Relive them of some of the other useless donkey work to make room, but by all means make this one mandatory.
If your pool is underperforming despite capturing a fair share of risk codes, do a deep dive on your pressure ulcers. I’ll bet their care costs are a significant source of your losses.
Prevent them and even if your RAF score goes down, your financial performance is certain to improve.
And your patients healthier.