Photo documentation gives you the proof you need for care and reimbursement
January 1, 1998 6 minutes read
Photo documentation gives you the proof you need for care and reimbursement
New technology aids providers
In the context of health care, a picture is worth a lot more than a thousand words; it could well be worth thousands of dollars. Practitioners who use photographs to document wound care are finding out the value of images.
Wound care leaders have persistently emphasized the need for accurate and consistent documentation in wound care. The reasons are clear: Without appropriate documentation, wound care providers lack ammunition to support requests for reimbursement from Medicare and managed care companies. Many practitioners have told Wound Care that solid documentation of the course of treatment, including detailed records of a wound’s improvement or deterioration, helped avert a protracted fight with insurers. Photographs provide the kind of unequivocal record practitioners need.
Photo documentation has proven valuable for Robin Tellez, RN, CWS, director of wound recovery at Home Health Care, Inc. in Miami. When a managed care company declines a request for a specialty bed, verbal explanations are unlikely to sway case managers, she explains. "They may not know what we’re talking about, but once we send them a photo or series of photos, they can see how bad a wound really is. Usually the request is not an issue after that," Tellez says.
A year ago, Tellez initiated a program to help her supervise Home Health Care’s field nurses. First, the nurses began photographing wounds, which allowed Tellez to discuss the cases from a more knowledgeable footing. "We put the photos in a patient’s record, and once a week I visit our branches and conduct wound rounds using the photographs to discuss treatment options and progress. It’s a good way to coordinate care when you can’t actually visit the patient and see the wounds first hand."
Tellez helped to adapt the concept at a long-term care facility for which she consults. When patients are admitted, photos of wounds are taken and placed in a treatment book, she explains. The book is shared among the various specialties, such as infection control, nursing, physical therapy, occupational therapy, and physicians. "It puts everyone on the same wavelength," she says. The photos are also shared with home health care professionals when a patient moves back home.
Documentation practices in health care are generally fragmented, so communication between providers regarding a particular wound patient is often insufficient to maintain the continuum of care during the transition between, for instance, long-term care and home health. Photo documentation, she says, can fill in some of the gaps with minimal ambiguity. Unlike verbal descriptions, clear photos leave little room to debate the severity or size of a wound.
At ManorCare Health Services, photos are taken during the admission process to make sure residents who enter the system with pre-existing ulcers are not incorrectly included in ulcer development statistics. The result has been an ulcer development rate far below the national average.
Photo documentation allows health care professionals to clearly and precisely document the healing process over time, says Jeff Kane, senior manager of product development at Briggs Corp., which manufactures and markets photo documentation systems. "It accurately and legally documents patient conditions, and is becoming more and more important for supporting reimbursement claims," he says.
Researchers agree. In a 1995 study, researchers found that in 1992, Medicare initially denied payment of a home care agency’s claim for average monthly bills of $17,000 during a seven-month period for treating an elderly woman with progressive systematic sclerosis (scleroderma). Medicare questioned the providers’ use of certain products. After the agency submitted a series of photographs accompanying a denial appeal, however, Medicare reversed its decision.
The authors stated that "serial, controlled photo documentation [should] be part of a standard protocol for documentation of complex wound care [because the process] clearly influenced the decision of the payer."1
Kane says approximately 15,000 Briggs Corp. systems are currently in use in the United States. At the heart of the system is the HealthCam2, which produces photographs with a superimposed grid scale. The scale serves as a standard measurement reference from photo to photo, and aids in tracking wound changes.
According to Tellez and others, the Briggs system is easy to use. The camera focuses automatically, and can be set to assure that every photo in a series is taken from precisely the same distance away from the targeted area, even when the camera is hand-held. The camera itself was developed by Polaroid, so photos are processed instantly at the time they are taken, thus eliminating the risk of losing the film during the development process.
The basic system costs under $300, which includes the camera, a close-up lens, a carrying case, one box of high-definition Polaroid film, one box of high-definition Polaroid grid film, and a documentation accessory pack. The documentation kit includes mounting sheets, diagrams, and places to record wound descriptions, dates, and the name of the photographer.
The digital option
Emerging digital photographic techniques give health care providers another option for photo documentation, albeit a costly one. Instead of immediately producing a "hard copy" of the photograph, digital cameras store images as a digitized file. To view the photo, the file must be downloaded into a computer equipped with appropriate software. A color printer is required to print out a hard copy.
One advantage of digital photography is that the images can be sent instantly via e-mail to anyone who has a computer, a modem, Internet access, and the proper software. Film is not required. The drawbacks of usage are significant, however. Digital cameras cost from $600 to $1,000, and not everyone has the computer capabilities for viewing, printing, sending, and receiving these images. Also, there is no digital camera system designed specifically for wound photo documentation, so one must be assembled from off-the-shelf equipment.
"Digital photos are more detailed and clearer, but not everyone can afford them or has access to the necessary equipment," says Tellez. "You’re losing a lot if you make the switch now, because a lot of people won’t know how to use the equipment properly."
Another option for photo documentation is digital videotaping, which requires a specially adapted computer to digitize the images. The images are then measured automatically by dedicated software. This system costs even more than still digital photography and is unlikely to become standard practice in wound care any time soon, according to industry observers, though its time may come later if the technology becomes price-competitive.
At the 1997 Clinical Congress of the American College of Surgeons, researchers presented a three-dimensional computerized system to measure burns. Traditionally, burn specialists measure the second- and third-degree burns using a method known as Lund-Browder charting, in which areas of burned skin are sketched on two-dimensional projections of the human figure.
But this system has inherent limitations. Its accuracy and reliability are limited by the fact that ratings are still somewhat subjective, and because the method does not account for variations in human size and shape, or for burns that extend from the front to the back of a patient. While experienced burn specialists can overcome these limitations, less-experienced people may find it more of a challenge.
The new system relies on commercially available software used by architects to produce precise drawings of buildings and other structures in three dimensions. The result is a "morphable" three-dimensional video display for calculating burn wound surface area while projecting views of the human body from every angle at the request of the user.
"Precisely measuring burn surface area is important in order to determine whether or not new treatments for burns are achieving a beneficial impact on patient outcomes," says the system’s designer, Raphael Lee, MD, FACS, professor of surgery and anatomy and director of the University of Chicago Burn/Electrical Trauma Unit. "So one of the most important reasons for accurately measuring the burn surface area is to speed up the rate at which progress is made in advancing burn care, whether it is a new antibiotic or new type of coverage for burn wounds."
Now, patients admitted to the University of Chicago Burn Unit have their burns sketched into the system. The resulting diagram is converted into a three-dimensional shape that matches the patient’s body type. Each type of burn can be clearly differentiated (full-thickness, superficial, etc.) The computer then calculates factors such as the total burn surface area, fluid resuscitation, and nutritional requirements in seconds.
Reference
1. Campbell CA, Sacramento L. Photo documentation reverses Medicare reimbursement denial. Ostomy Wound Mgmt 1995; 41:18-23.
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