HCFA's requirement chafes wound care providers
It's wrong, but you have to follow it
Nearly a decade ago, the Health Care Financing Administration (HCFA) took a well-meaning action that has transformed itself into one of the most irritating and protracted hassles in the wound care community: reverse staging.
In 1989, as part of the Omnibus Budget Reconciliation Act, HCFA instituted the first Minimum Data Set (MDS) to systematically collect documentation on the quickly growing number of Medicare patients. The information gathered was to be used to get a handle on costs and efficacy across a wide range of treatment areas, and even to track fraud and abuse in the system. The result was the MDS-1, soon to be superseded by the even more comprehensive MDS-2.
All long-term care facilities that provide care to Medicare patients must complete MDS-2 assessments quarterly. The source of ongoing angst for wound care professionals in long-term settings is Section M, which covers skin condition and requires a detailed description of chronic wounds. Section M incorporates the four-stage wound assessment system that has become ubiquitous throughout the wound care community, commonly known as the pressure ulcer staging system. After modifying prior wound classification systems, the National Pressure Ulcer Advisory Panel (NPUAP) introduced the pressure ulcer staging system in 1989. It has since been adopted by the Agency for Health Care Policy and Research.
'Reverse stage' during healing process
But Section M also requires evaluators to "reverse stage" wounds as they heal, a practice that is odious to wound care professionals. Several dedicated individuals and organizations have undertaken the task of changing the current system.
Reverse staging (also referred to as down-staging) is the practice of applying lower-stage classifications from the pressure ulcer staging system to describe a wound's appearance as it heals.
Reverse staging is physiologically incorrect and represents a patient's condition falsely, explains Kathleen Wright, RNC, MS, CETN, an enterostomal therapy nurse with Nanticoke Health Services in Seaford, DE. As any experienced bedside wound care provider knows, muscle, subcutaneous fat, and dermis that are lost in a Stage IV pressure ulcer do not return but are replaced with granulation tissue composed mostly of endothelial cells, fibroblasts, collagen, and extracellular matrix, she explains.
Therefore, a Stage IV wound cannot revert to an earlier stage, appearance notwithstanding.
"This is not just an academic exercise," says Diane Krasner, PhD, RN, CETN, CWS, a postdoctoral nurse fellow at the Center for Nursing Research of Johns Hopkins University School of Nursing in Baltimore. "It has a critical impact on the availability of products for patients."
Krasner explains, for example, that a patient who has a Stage IV pressure ulcer of the trochanter and is reverse-staged according to HCFA guidelines as the wound fills in, may no longer qualify for specialty beds or appropriate dressings. That's because the patient has, in HCFA's eyes, "healed to a Stage II." In fact, that wound is actually a granulated Stage IV wound.
"Take that specialty bed away too soon, and the wound may regress," says Krasner. "That's not good practice, nor is it cost-effective. There's a real practical side to this, which is what makes us so passionate about the issue. It has enormous ramifications for access to products for patients on Medicare."
Krasner adds that the NPUAP staging system originally was developed only for the initial assessment of pressure ulcer formation, and that using it to assess healing of all wounds and skin conditions is a misapplication and medically inappropriate. "The practice of reverse staging will eventually have to be eliminated," she says.
The NPUAP has made its aversion to the reverse-staging policy clear in a number of published documents. A position paper issued by the NPUAP echoes the concerns voiced by Wright, Krasner, and many others in the field: "Pressure ulcer staging is only appropriate for defining the maximum depth of tissue involvement. Unfortunately, pressure ulcer staging definitions appear to have erroneously been used in reverse order, for example to describe improvement in an ulcer."1
A subsequent NPUAP report highlights further shortcomings of the MDS-2: The definition of a pressure ulcer in the MDS-2 "fails to acknowledge etiologic factors in pressure ulcer development and lacks the specificity to differentiate pressure ulcer injury from other types of injury. The MDS-2 definition implies that injuries arising from shear and friction . . . would not be considered as pressure ulcers."
Defining stasis ulcer
The MDS-2 definition of a stasis ulcer as an ulcer caused by poor circulation in the lower extremity contrasts with the usual clinical definition of a stasis ulcer as a wound associated with chronic ambulatory venous hypertension. The MDS-2, originally intended as a clinical tool for assessing a patient's condition and planning care, has evolved into a tool used in long-term care facilities for quality assurance, reimbursement, long-term care recertification, and clinical research databases - purposes for which it was never intended.
The bottom line, according to the NPUAP: "Reverse staging should never be used to describe the healing of a pressure ulcer."
Health care professionals at long-term care facilities are constantly faced with the predicament of simultaneously complying with HCFA regulations while applying correct wound evaluation methodology. Opting for only the latter has proved financially hazardous.
Krasner reports that HCFA hit a number of long-term care facilities with $1,000-a-day fines for not following the national coverage policy. HCFA's enforcement of that requirement when there has been so much confusion has bewildered many professionals.
While Krasner and others who have confronted the issue do not endorse reverse staging or applying the MDS-2 criteria to wounds other than pressure ulcers, they have taken the realistic approach and understand that for now, providers must reverse-stage in order to stay in HCFA's good graces - and to avoid hefty penalties.
Krasner and Wright have proposed two temporary, pragmatic solutions to the conflict until a lasting answer is found. Both approaches are designed to accommodate the need for sound medical practice and HCFA compliance.
A simple form
Wright's approach was to alter an existing skin evaluation form to include a place for medically appropriate diagnoses of skin condition as recommended by the NPUAP, while allowing for reverse staging designations of wounds as visualized. The resulting form is to be used as an adjunct to Section M of the MDS-2. (See copy of form, inserted in this issue.)
Lifecare at Lofland Park, a long-term care affiliate of Nanticoke Health Services, has put the form to use, says Wright, and Delaware Medicaid is considering official use of it.
A statement at the bottom of the form acknowledges the NPUAP recommendations not to reverse-stage pressure ulcers and serves to remind those involved in the patient's care that the initial depth of tissue injury and loss must be considered, according to Wright. Wound photographs are taken monthly until the wound has re-epithelialized.
Wound care professionals also should note that the NPUAP definition of a Stage I ulcer has been changed to the following: An observable pressure-related alteration of intact skin whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
With input from other wound care specialists and nurses at the Health Standards and Quality Bureau at HCFA, Krasner and her colleague Dot Weir, RN, CETN, regional wound healing manager with Ortho-McNeil Pharmaceutical in Windermere, FL, introduced a set of recommendations to cope with reverse staging.
"We took the existing nomenclature and redefined it on the way back up," Krasner explains. "So if you see a patient with a Stage III pressure ulcer, you would use the NPUAP staging system. But thereafter, as you continued to fill out the MDS-2 you'd have new definitions, which are those of the wound as it's healing."
Formal psychometric testing
The next step in the development of the recommendations will be formal psychometric testing for reliability and validity. Krasner adds that she welcomes any comments on the recommendations, and she emphasizes that short-term answers are not sufficient. What's needed, she says, are substantial and farsighted changes to the current Section M evaluation system. HCFA and wound care professionals are currently working together on permanent changes, but no results are expected soon.
Krasner and Weir make this statement in an addendum to the recommendations: "We believe that in order to stay in compliance with current HCFA regulations and to avoid being cited or fined, providers must use the terminology currently required by HCFA for completing the MDS-2, including the terms `staging' and `stasis ulcers,' by which HCFA means venous ulcers. Hopefully, in two or three years, when the next version of the MDS is adopted, changes will be made to MDS-3 so that the problems discussed here are resolved."
References
1. National Pressure Ulcer Advisory Panel. NPUAP position on reverse saging of pressure ulcers. NPUAP Report. Buffalo, NY; September 1995.
2. National Pressure Ulcer Advisory Panel. The Minimum Data Set-2 (MDS-2) and skin ulcer assessment. NPUAP Report. Buffalo, NY; April 1996.
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