Many patients have wounds that simply can’t be healed, and the goal of wound management is to reduce serious complications like hospitalization or sepsis. Then there are patients whose wounds get better on such a slow a timeframe that it is best described as glacial. It may not appear that those wounds are making any “measurable progress.” In those situations, you may have found that the patient’s Skilled Home Health agency tells you that the patient must be discharged from service due to lack of improvement. In addition, some Medicare auditors have determined that a patient’s continued treatment in the outpatient wound center was not medically appropriate because the wound was not making wound progress. (I should clarify that there may be some Medicare policies restricting certain TYPES of treatment in patients who are not on a trajectory to heal such as NPWT or cellular and/or tissue based products, but that is a different topic.)
In 2013, the Jimmo v. Selebius settlement agreement dictated the standards for skilled nursing and skilled therapy in skilled nursing facilities, home health, and outpatient therapy settings and determined that coverage does not turn on the presence or absence of a beneficiary’s potential for improvement. Here’s a Medicare fact sheet on the ruling:JimmoFactsheet-04032013-final
Unfortunately, some Medicare auditors are not following the law as it pertains to the presence or absence of a beneficiary’s potential for improvement. Attorney Knicole Emanuel discusses this issue in her recent blog post. She reminds everyone that auditors usually have no clinical background, nor are they lawyers and they often are ignorant of the laws that apply. It’s up to us to know the rules so that we provide care appropriately and can defend ourselves when unfair determinations are made during an audit.