1C-Chronic Wound Care From The Inside Out
10/10/2012CHRONIC WOUNDCARE FROM THEINSIDE OUTLinda Martien, CPC, CPC-H, CPMA, CEDC1WELCOME TO WOUND CARE 201Index Terminology Anatomy Surgical Treatment Medical Treatment Hyperbaric Oxygen Therapy SkinSki SSubstitutesb tit t1
10/10/2012WOUND CARE TERMINOLOGYAcute vs. ChronicTypes of ulcers Acute Chronic Pressure Diabetic OtherLevels of skin and underlying tissues Partial thickness Full thickness Subcutaneous Muscle BoneGraftsGunkBig gunk Fibrin, slough, eschar Infection, abscess, gangrene Autograft Homograft Allograft XenograftACRONYMS 101RS – Reimbursement SpecialistRCM – Revenue Cycle ManagementFI – FiscalFi l IIntermediarytdiMAC – Medicare Administrative ContractorLCD – Local Coverage DeterminationNCD – National Coverage DeterminationEOB – Explanation of BenefitsR/A – Remittance AdviceADR – Advance Documentation Request2
10/10/2012WAIT – THERE’S MORE!RAC – Recovery Audit ContractorABN – Advance Beneficiary NoticeCMS – Centers for Medicare & Medicaid ServicesAPC – Ambulatory Payment ClassificationE/M – Evaluation & ManagementUB04 – Uniform Billing Form for hospitals1500 – Universal Billing Form for physiciansCDM – Charge Description MasterANATOMY OF THE SKIN3
10/10/2012PHYSIOLOGY OF HEALING1.Hemostasis– Vasoconstriction, platelet release, clot formation2.Inflammation– Vasodilation– Neutrophils appear to destroy dying cells– Macrophages clean the ulcer and produce growth factors3.Proliferation– Angiogenesis– Fibroblasts synthesize collagen fibers– Collagen fibers produce keratinocyte4.Maturation– Shrinking and strengthening of the scarCHRONIC VS. ACUTE WOUNDS4
10/10/2012BUT IS IT REALLY A WOUND?Wound – arises from traumaUlcer – has an underlying etiologyBurn – is a burn, is a burn, is a burnThese are each coded differently andsome require additional codes, such asE codes ((External Causes))WOUND REMOVAL/LOSS OF TISSUECoded to the: Status of wound, superficial or openp Superficial Abrasion Blisters Bites Scratch Open Lacerations Punctures Dehiscence Incisions Complexity of the wound Simple Intermediate Complex5
10/10/2012WOUND CODINGSuperficial Simple Intermediate ComplexOpen Simple Intermediate ComplexWOUND VS. ULCERWound – Open wound of the foot Wound Open Foot (any part except toe[s]alone – 892.0 With tendon involvement –892.2 Complicated 892.1 How and where? External Cause E920.8 – Other specifiedcutting or piercinginstruments (glass) Place of Occurrence E849.3 – yardUlcer – Diabetic ulcer of the plantarmidfoot, neuropathic complication,type IIII, controlled 250.60 707.14Ulcer – Pressure ulcer of the rightlateral ankle (lateral malleolus) 707.05 707.206
10/10/2012PRESSURE ULCERSPressure (Decubitus) 707.00 – 707.09 and 707.20 –707.25Specific to site Specific Must be staged 1 – persistent focal erythema 2 – partial thickness skin lossinvolving epidermis, dermis, or both 3 – full thickness skin loss extending throughsubcutaneous tissue 4 – necrosis of the soft tissue extending tomuscle and bonePRESSURE ULCER STAGE - IStage 1: Nonblanchable erythema (redness that doesn't quicklyfade) of intact (unbroken) skin; could also include warmth,swelling. Dark skin might appear discolored instead of red.7
10/10/2012PRESSURE ULCER STAGE - IIStage 2: Superficial (not very deep) ulcers with loss of epidermis(outer layers of skin), dermis (underlying, still developing skintissue) or both. Might look like a scrape, blister, "zit" or crater.PRESSURE ULCER STAGE - IIIStage 3: Skin loss to both outer and underlying layers of skin tissue,with damage all the way down to fascia (connective tissue ofbody).8
10/10/2012PRESSURE ULCER STAGE - IVStage 4: Skin loss to both outer and underlying layers of skin tissue,with a great deal of damage and dead tissue in the fascia,muscle, bone, tendon or joint capsule.DIABETIC AND VENOUS ULCERSNon-pressure (DFU and VLU) 707.10 – 707.19Specific to site707.10 – lower limb, unspecified707.11 – ulcer of thigh707.12 – ulcer of calf707.13 – ulcer of ankle707 14 – ulcer of heel and midfoot707.14707.15 – ulcer of other part of foot707.19 – ulcer of other part of lower limb9
10/10/2012DIABETIC AND VENOUS ULCERS Must code underlying etiology Atherosclerosis of extremities with ulceration(440 23)(440.23) Chronic venous hypertension with ulceration(459.31) Chronic venous hypertension with ulceration andinflammation (459.33) DiabetesDiabetes mellitus (249.80 – 249.81, 250.80 –250.83) Postphlebitic syndrome with ulcer (459.11) Postphlebitic syndrome with ulcer and inflammation(459.13)DIABETIC ULCER WAGNER GRADES0 No open lesions: may have deformity or cellulitis1 Superficial ulcer2 Deep ulcer to tendon or joint capsule3 Deep ulcer with abscess, osteomyelitis, or joint sepsis4 Local gangrene – forefoot or heel5 Gangrene of entire footGrade 1 ulcers are superficial ulcers that may span thefull thickness of the skin or only partial thickness.10
10/10/2012DOCUMENTATION The medical record is the main document validating careand treatment provided. Documentation provides the opportunity to state thedecision making process and the results of treatment. The medical record documentation will be the primarydocument used to defend a lawsuit. It is used to determine reimbursement ProvidesP id iinformationfti ffor qualitylit assurance/peer/review.i Demonstrates compliance with applicable regulatory andaccrediting agency requirements. (The Joint Commission,CMS, State Law – Title 22)DOCUMENTATION REQUIREMENTSDocumentation should be legible, maintained in thepatient’s medical record and available toMedicare on request and must confirm allrequirementsiiin theh “I“Indicationsdi iandd LiLimitationsi iof Coverage and/or Medical Necessity” sectionare satisfied re: the clinical characteristics of theulcer, the presence of qualifying or disqualifyingconditions, and nature of and duration ofpretreatment conservative management. Exact location of each ulcer treated must beincluded.11
10/10/2012DOCUMENTING THE H&P OR PROGRESSNOTEThe H&PProgress Note ChiefChi f ComplaintCl i t (CC) History of Present Illness(HPI) Review of Systems (ROS) Family Social Past History(FSPH) Exam Medical Decision Making(MDM) ChiefChi f ComplaintCl i t (CC) Interim History & Physical(H&P) Relevant Review of Systems(ROS) Exam Medical Decision Making(MDM)EVALUATION & MANAGEMENT New vs. Established Patient – how do you know? Initial visit or not seen for more than three years by the provider orsame specialtyi lt providerid off ththe group New Requires all three key elements History Exam Medical Decision Making EstablishedE t bli h d Requires two of the three key elements One of which should be Medical Decision Making12
10/10/2012NEW VS. ESTABLISHED FURTHERDEFINED Newly Revised DefinitionAn established patient is one who hasreceivedi d professionalfil servicesiffrom ththephysician or another physician of theexact same specialty and subspecialtywho belong to the same group practice,within the past three years2012 CPT, Professional EditionEXAMPLE Drs. Green and Blue are in the samecardiology practicepractice. DrDr. Green is ageneral cardiologist. Dr. Blue doeselectrophysiology exclusively. Dr.Blue has separate boards in EP andthe payer has him classified in thatspecialty.i lt Dr.D GreenGrefersfa patientti t totDr. Blue for consideration of an ICD. Isthis a new patient for Dr. Blue?13
10/10/2012ANSWERThe patient is “new” to Dr. Blue Specialty is not the exact same Payer recognizes specialty andphysician designation There are distinctly subspecialtyboardsE/M AUDIT TOOL – HPI AND ROSHISTORY OF PRESENT ILLNESS (HPI) Location Timing QualQ lit y ContextC t t Severity Modifying Factors Duration Associated signs and symptomsREVIEW OF SYSTEMS (ROS) Constitutional Eyes Ears, nose, mouth, throat Card/Vasc Resp GI GU Musculo Integumentary Neuro Psych Endo Hem/lymph All / imm All Others Neg14
10/10/2012E/M AUDIT TOOL – EXAM AND MDMBODY AREAS Head, including face NeckNk Chest, including breasts and axil ae AbdomenLOW Genitalia, groin, buttocks Back,B k inclluding spiine Each extremity- 2 or more selflimited or minorproblems.- 1 stable chronicillness.- Acute uncomplicatedillness or injuryORGAN SYSTEMS Constitutional EyesE Ears, nose, mouth, throat Cardiovascular- Physiologic tests notunder stress.- Non-cardiovascularg g studies withimagingcontrast.-Superficial needlebiopsies- Clinical lab testsrequiring arterialpuncture- Skin biopsies Resp GIGI GU Musculo Skin NeuroN Psych Hem / lymph / imm- Over the counter drugs- Minor surgery with noidentified risk factorsyTherapypy- Physical- Occupational therapy- IV fluids withoutadditivesCONSULTS Medicare deleted consult codes in 2010 Commercial payers may still recognize Remember the 3 “R’s” Request Response Report15
10/10/2012DEBRIDEMENT GOALS Wound Cleansing – Remove necrotic tissue Reduce bacterial burden – avoid infection P id optimalProvideti l environmentit ffor wounddhhealingli g Removal of MMPs Reintroduction of inflammatory phase Remove of senescent cells To assess extent of wound and determinedegree of penetration Serial wound bed preparation.DOCUMENTATION FOR EACH VISITPhysician Order – Required for all services Diagnosis, signature, time and dateEvaluation – Initial Initial History and Physical/Interim H&PRe-evaluation – minimum, every 30 daysDaily Treatment Notes (time with patient) Progress Note (Physician Documentation) Physician Orders (Physician Documentation) Include indications and impression Changes in condition, improvements, etc. Wound size and details, (photo at least once per month preferred) Procedure details Signed, dated and timed16
10/10/2012DEBRIDEMENT DOCUMENTATION EXAMPLE:Location Anatomic locationAppearance Surface dimension and depth Presence/absence/extent of granulation tissue, eschar, slough, fibrin Presence/absence/extent of obvious signs of infection Presence/absence/extent of necrotic, devitalized or non-viable tissue Stage or grade where indicatedAnesthesia If not used, document why (neuropathy, paraplegia)Instrument Scalpel, scissor, curette, rongeurType of tissue removed Partial thickness Full thickness Subcutaneous Muscle (includes tendon, ligament) BoneBleeding and its controlDressingPatient tolerance to the procedureSUBCUTANEOUSSkin Full Thickness, and SubcutaneousTissue – 11042, first 20 sq cm11045; ea add 20 sq cmPunch BiopsyPenetrating WoundStage III or Grade III17
10/10/2012PERI-ULCER HYPERKERATOSIS (CALLUS)WITH ULCERMUSCLESkin, Subcutaneous and Muscle – 11043, First 20 sq cm. 11046;; ea add 20 sqq cmIncludes fascia, tendon, joint capsuleStage IV18
10/10/2012BONESkin - Subcutaneous Tissue,Muscle and Bone – 11044,first 20 sq cm11047; ea add 20 sq cmNot common in clinic settingStage IV pressure ulcerDehisced surgical woundOPEN ULCER TO BONE19
10/10/2012E/M AND PROCEDURES Modifier -25: Appended to the E/M code to indicate a “Significant, separatelyidentifiable service by the same physician on the same day ofthe procedure or other service” What does this mean? “Significant, separately identifiable E/M service above andbeyond the other service provided or beyond the usualpreoperative and postoperative care associated with theprocedure performedperformed ” In other words: Unrelated to the condition or procedure performed”CPT, Professional Edition, 2012, Appendix A, page 567EXAMPLES:1. The established patient presents for wound care to include theusual encounter and a subcutaneous debridement. Thepatient had no complaints and the ulcer is healingsatisfactorily. However, upon evaluation, the patient’s bloodsugar (by finger stick) was found to be 370. The physicianinstructs the patient to see his PCP as soon as possible for hisdiabetes management.2. The established patient presents for wound care to include theapplication of Dermagraft .Dermagraft She has no related complaintsand is otherwise doing well. However, on her way into thecenter she slipped and fell and is now complaining of wristpain. The doctor examines her and sends her to radiology foran x-ray. The x-ray reveals a non-displaced fracture of theradius. She is sent to an orthopedist for casting and followup.20
10/10/2012SO WHEN CAN YOU BILL FOR AN E/M WITH APROCEDURE?1. New patient2 New2.Nproblembl3. E/M unrelated to the procedureprovidedSELECTIVE DEBRIDEMENTActive Wound Care Management 97597Debridement (eg, high pressure water jet,with/without/suction,, sharpp selective debridement withscissors, scalpel and forceps), open wound, (e.g., fibrin,devitalized epidermis and/or dermis, exudate, debris, biofilm),including topical application, wound assessment, use ofwhirlpool, when performed and instructions for ongoing care,per session, total wound surface first 20 sq cm 97598; ea additional 20 sq cm 97602Removal of devitalized tissue from wounds, nonselective debridement, without anesthesia (wet to moistdressings, enzymatic, abrasion), per session21
10/10/2012SELECTIVE DEBRIDEMENT/ACTIVEWOUND CARE MANAGEMENTSkin Partial Thickness – 97597/97598EpidermispOnlyy SuperficialpwoundStage I pressure ulcer or first degree BurnSELECTIVE DEBRIDEMENT/ACTIVEWOUND CARE MANAGEMENTSkin Full Thickness – 97597/97598pand DermisEpidermisExample includes healingwounds, a wound which does notpenetrate through the subcutaneouslayer or blister.Occasional debridement22
10/10/2012UNNA BOOT, COMPRESSION WRAPS &TOTAL CONTACT CASTINGMedicare considers these to be a component of theprocedure, regardless if debridement, I & D, application ofskin substitutes, etc.However, there are times when the separate charge isappropriate and should be coded and billedCommercial payers may consider separate paymentRemember modifier – 51Unna Boot29580Compression29581Total Contact Casting29445WHEN IT’S APPROPRIATE Debridement of ulcers on the right and left heel with Dermagraftplaced on the right heel only. A pressure ulcer of the sacrum wasalso debrided and a wound vac placed. Bill for the Dermagraftapplication to the right heel and the debridement of the left heel,andd theth sacrall debridement.d b idt 11043 11046 15275-5911042-59muscle debridement of the sacrum, first 20 sq cmmuscle debridement of the sacrum, ea add 20 sq cm x 2Application of Dermagraft, first 20 sq cmsubcutaneous debridement left heel, first 20 sq cm Debridement of left calf and compression placed bilaterally. Billfor the debridement of the left calf and application of thecompression wrap on the right leg: 11042 –subcutaneous debridement, first 20 sq cm 29581-59-RT – application of multi layer compression system23
10/10/2012NEGATIVE PRESSURE WOUND THERAPYWound vac 97605Negative pressure wound therapy (eg,(egvacuum assisted drainage collection), including topicalapplications, wound assessment, total wound surfacearea less than or greater to 50 sq cm 97606; greater than 50 sq cmSKIN SUBSTITUTES - DFU Diabetic neuropathic foot Full thickness ulcers that extend through the dermis but do notinvolve tendon, muscle, joint capsule or bone Present greater than 6 weeks Failed conservative wound care for at least 4 weeks Free from infection Adequate blood supply Without active Charcot’s arthropathy Must document waste Know your LCD!24
10/10/2012SKIN SUBSTITUTES - VLU Indicated for chronic non-healing ulcers Venous stasis ulcer Full thickness ulcers that extend through the dermisbut do not involve tendon, muscle, joint capsule orbone Present greater than 3 months/4 weeks Failed conservative wound care for at least 8 weeks/2weeks Free from infection and underlying osteomyelitis Appropriate steps to off-load pressure duringtreatment Must document waste Know your LCD!DEFINITIONSApligraf – Apligraf is supplied as a living, bi-layered skin substitute: the epidermallayer is formed by human keratinocytes and has a well-differentiated stratumcorneum; the dermal layer is composed of human fibroblasts in a bovine Type Icollagen lattice. While matrix proteins and cytokines found in human skin arepresent in Apligraf, Apligraf does not contain Langerhans cells, melanocytes,macrophages, lymphocytes, blood vessels or hair follicles.Dermagraft - Dermagraft is a cryopreserved human fibroblast-derived dermalsubstitute; it is composed of fibroblasts, extracellular matrix, and a bioabsorbablescaffold. Dermagraft is manufactured from human fibroblast cells derived fromnewborn foreskin tissue. During the manufacturing process, the humanfibroblasts are seeded onto a bioabsorbable polyglactin mesh scaffold. Thefibroblasts proliferate to fill the interstices of this scaffold and secrete humandermal collagen, matrix proteins, growth factors and cytokines, to create a threedimensional human dermal substitute containing metabolically active, living cells.Dermagraft does not contain macrophages, lymphocytes, blood vessels, or hairfollicles.Oasis - OASIS Wound Matrix is an intact matrix naturally derived from porcine smallintestinal submucosa (SIS), indicated for the management of wounds.25
10/10/2012DOCUMENTATION FOR SKIN SUBSTITUTESMust indicate medical necessity for each visitFailed conservative treatment documentation must includetype of unsuccessful wound care such as: Enzymatic and/or surgical debridement Wet-to-dry dressings Infection control Non-weight bearingFailed conservative treatment documentation must indicatetype of unsuccessful ulcer healing such as: NoN changeh Increase in size Increase in depth No healthy granulation No signs or progress towards healingSKIN 5275152761527715278DESCRIPTIONAPLIGRAF PRODUCT (44 SQ CM) PER SQ CMOASIS PRODUCT (MULTI SIZES) PER SQ CMDERMAGRAFT (38 SQ CM) PER SQ CMAPPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CM,TRUNK/ARMS/LEGS; EA ADD 25 SQ CM, TRUNK/ARMS/LEGSAPPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,TRUNK/ARMS/LEGS; EA ADD 100 SQ CM, TRUNK/ARMS/LEGSAPPLICATION OF SKIN SUBSTITUTE 1ST 25 SQQ CM,,HANDS/FEET/DIGITSEA ADD 25 SQ CM, HANDS/FEET/DIGITSAPPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,HANDS/FEET/DIGITS; EA ADD 100 SQ CM, HANDS/FEET/DIGITS26
10/10/2012DERMAGRAFT - SUPPLIED IN 37.5 SQ CMCPTDESCRIPTIONQ4106DERMAGRAFT PRODUCT15271APPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CM,CMTRUNK/ARMS/LEGS15272; EA ADD 25 SQ CM, TRUNK/ARMS/LEGS15273APPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,TRUNK/ARMS/LEGS15274; EA ADD 100 SQ CM, TRUNK/ARMS/LEGS15275APPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CM,CMHANDS/FEET/DIGITS15276EA ADD 25 SQ CM, HANDS/FEET/DIGITS15277APPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,HANDS/FEET/DIGITS15278; EA ADD 100 SQ CM, HANDS/FEET/DIGITSOASIS - SUPPLIED IN 10.5 SQ CM, 21 SQ CM, 70 SQ DESCRIPTIONOASIS PRODUCTAPPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CMTRUNK/ARMS/LEGS; EA ADD 25 SQ CM, TRUNK/ARMS/LEGSAPPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,TRUNK/ARMS/LEGS; EA ADD 100 SQ CM, TRUNK/ARMS/LEGSAPPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CM,HANDS/FEET/DIGITSQ CM,, HANDS/FEET/DIGITS//EA ADD 25 SQAPPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,HANDS/FEET/DIGITS; EA ADD 100 SQ CM, HANDS/FEET/DIGITS27
T PER SQ CM15271APPLICATION OF SKIN SUBSTITUTE 1ST 25 SQ CM,TRUNK/ARMS/LEGS15272; EA ADD 25 SQ CM, TRUNK/ARMS/LEGS15273APPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,TRUNK/ARMS/LEGS15274; EA ADD 100 SQ CM, TRUNK/ARMS/LEGS15275APPLICATION OF SKIN SUBSTITUTE 1ST 25 SQQ CM,,HANDS/FEET/DIGITS15276EA ADD 25 SQ CM, HANDS/FEET/DIGITS15277APPLICATION OF SKIN SUBSTITUTE 1ST 100 SQ CM,HANDS/FEET/DIGITS15278; EA ADD 100 SQ CM, HANDS/FEET/DIGITS2012 CPT CHANGESCPT15271first15272DescriptorApplication of skin substitute graft to trunk, arms, legs, total woundsurface area up to 100 sq cm; first 25 sq cm or less wound surface area up to 00 sq25 sqcm or less wound surface areaeach additional 25 sq cm wound surface area, or part thereof (List separately inaddition to code for primary
Wound – arises from trauma Ulcer – has an underlying etiology Burn – is a burn, is a burn, is a burn These are each coded differently and . Simple Intermediate Complex. 10/10/2012 6 WOUND CODING Superficial Simple Intermediate Complex Open Simple Intermediate Complex WOUND VS. ULCER Wound – Open wound of the foot
wound care treatment plans of patients who smoke. Chronic Wounds A chronic wound is defi ned as one that fails to progress through the timely, sequential steps of healing that end with wound closure; chronic wounds generally remain open for greater than 3 months. 12 Nearly all chronic wounds can be grouped into 3 major categories: leg ulcers,
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Sloughy Wound (Pale layer of dead or fibrinous tissue over all or part of the wound bed) Macerated Skin (Soft, pale/white, wet or soggy skin surrounding wound) Granulating Wound (Wound bed filled with highly vascular, fragile tissue) Determine if present dressing regime is Goal of Treatment Keep woundRemove non-vital tissue and management of
Wound edges open Not healing Wound with 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but nongranulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appro-priate comprehensive wound management Note. Data from WOCN (2009).
Podiatrists provided the majority of wound care services (for the selected wound types) in office-based settings (Table 8). In outpatient facilities, a mix of specialties (e.g., podiatrists, surgeons, internists) provided wound care. The mean episode length for a wound care episode was 15.5 days (for the selected wound types), with a
Triad was applied to the wound bed and periwound skin. Wound as presented on Day 2. Triad is applied to the wound bed. Wound as presented on Day 2. Triad is applied to wound bed and periwound skin. "After 1 application of Triad, wound was progressing and the patient was able to continue to use Triad at home for wound treatment."
wound care OR skin care OR wound dressings OR dermatology. 2. Wider search: n Epidermolysis bullosa OR EB OR wounds OR chronic wounds OR non-healing wounds OR skin damage or skin in-jury AND wound care OR skin care OR wound dressings OR dermatology AND research OR randomised controlled trial OR guidelines OR clinical trial. 3.
Aliens' Behaviour Connectives Game This game was originally developed in 2006 for Year 5/6 at Dunkirk Primary School in Nottingham. It has also been used at KS3. We have chosen this topic because we hope it will encourage children to produce their own alien names (a useful use of phonically regular nonsense words!), portraits and sentences .
