The problem with boring documents is that they might be vital to your survival – like drug package inserts or the fine print of legal contracts. The situation is made more frustrating because special knowledge is required to understand the fine print and avoid disaster. While you are certain a document is important, you are also certain that you can’t figure it out alone. When it comes to the Medicare Cost Measure for ulcers, we’ve got two choices: 1) give up and resign ourselves to being victims of CMS or 2) work together to figure it out and advocate for ourselves.
If your plan is to give up – stop reading now. If your plan is to engage and figure it out – keep reading.
The non-victims are going to sign on to the QPP website and use the Step-by-Step instructions I provided to download their Cost Measure Field Test. I will post Step-by-Step instructions on how to read it. Before you do that, you need the big picture on Medicare cost measures. The detailed methods is in the PDF. This is also as special shout out to professional coders. If you have coding experience, particularly in the field of wound care, we need your help.
Here’s more information from the APMA: Prepare for 2026 Field Testing for Non-Pressure Ulcer Episode-Based Cost Measure
How CMS Measures the Cost of Non-Pressure Ulcer Care
CMS used cost measures to understand the costs associated with various conditions. CMS is testing a new way to measure the Medicare costs of patients with what they are annoyingly calling “non-pressure ulcers”—such as diabetic foot ulcers and venous leg ulcers. What they really want to understand is how much practitioners “spend” in caring for these patients and to compare costs fairly across clinicians. The ultimate goal is to figure out whether any given practitioner’s spending (meaning, Medicare charges) is significantly higher than the “expected” charges. If a practitioner’s charges are excessive by the definition they create, then CMS can clawback some of that practitioner’s Medicare payments.
To do the above, CMS must first decide what services and treatments are required to care for non-pressure ulcer patients, and then they must decide which clinician is responsible for those charges. CMS has provided a document explaining the methods in some detail (see PDF). However, it is impossible to tell if the methodology will work until it is tested across the US by analyzing claims from thousands of practitioners who treat chronic ulcers, and by getting feedback from those practitioners as to what data in their personal report did not make sense. Below is an oversimplified explanation of this complex process.
What exactly is a “non-pressure” ulcer?
- It is not a “wound” – which means that traumatic wounds and surgical complications are NOT included in the cost measure.
- It is not a “pressure ulcer” – so the costs of those are not included.
- What is left is all other chronic ulcers, which include clinical entities such as diabetic foot ulcers, venous leg ulcers, arterial ulcers, and “generic” chronic ulcers that do not fall into any of the above categories. Remember that while we think these are real clinical concepts, none of them have their own specific ulcer diagnosis code. Yes, it is possible to code the underlying conditions like diabetes and atherosclerosis associated with an ulcer, but those are codes for the underlying condition and not the ulcer, and believe me that the lack of specific diagnosis codes will haunt us in the process of developing costs. And L97 and L98 are generic, not specific to the type of ulcer.
How the Cost Measure works
- CMS must first determine which practitioner is responsible for the care of a chronic ulcer – and thus the costs associated with treatment. CMS calls that “attribution” – deciding what patients/ulcers that you as a clinician are responsible for treating.
- Certain Medicare charges “start the clock”:
- Two ulcer-related visits within 45 days signal that a clinician is managing the ulcer.
- This opens a 90-day tracking window.
- Ongoing care extends your responsibility:
- Continued ulcer-related services keep extending that window, sometimes for many months.
- Care is broken into episodes:
- CMS groups care into 90-day (or longer) episodes, so (hopefully) costs are measured once and only once. (The previous measure used 365 days and that failed miserably because clinicians were held accountable for costs far outside their control.)
- Only ulcer-related costs count (at least, that’s the idea):
- Office visits, procedures, hospitalizations, post-acute care, dressings, medications, and supplies are included; unrelated care is (supposed to be) excluded.
- Patient complexity is adjusted for:
- CMS accounts for age, comorbidities, frailty, ulcer type, number of ulcers, and ulcer severity. (We won’t know if their method worked until we look at some Field Test Reports.)
- Costs are compared to expectations:
- Actual episode costs are compared to what similar patients were expected to cost. (Yes, there is a lot to unpack here.)
- The costs are supposed to be “risk adjusted”
- Risk adjustment factors include patient comorbid conditions and having multiple ulcers
- CMS attempted to include ulcer severity in the risk model, but this is hard to do when not all practitioners code these ulcers with a chronic ulcer code the way they are supposed to.
- If your costs are lower than expected, you score well. If they are higher than expected, you don’t. And yes, money is at stake. It is possible to experience a clawback of money from Medicare if your costs are much higher than your “peers.” Hopefully, this sentence got your attention.
What Clinicians Should Know
- Theoretically, higher quality care should result in lower costs – but some interventions that are part of high quality care are costly such as revascularization or the diagnosis and treatment of infection. That is another reason we need clinicians to review (and if possible, to share) their Field Test Report so that we can understand whether the model is able to identify high quality care.
- You may be held accountable for downstream costs such as hospitalizations, SNF stays, amputations, antibiotics, and supplies over which you had no control. That is why we need practitioners to download their Field Test Report and be willing to discuss it with us.
The post A Message for Practitioners Who Aren’t Ready to Give Up: the “Non-Pressure Ulcer” Cost Measure in Plain English appeared first on Caroline Fife M.D..