June 17, 2005
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I am taking on some new physicians that will be doing wound care and I would
like to know if you can point me in a good direction to find out information
on CPT, ICD-9 and modifiers used for wound care billing.
Any help would be greatly appreciated.
ABC Medical Solutions
Don’t know much about codes but I know of someone who does---He is an
excellent source for the business aspect of wound care--- John Peters. He
can be contacted at Diversified Therapy Corp. Go to their Web site---www.diversifiedtherapy.com
find the info link and contact them. Ask to get in touch with John Peters in
regards --- or they may have a number that you can contact them directly.
Hope you get assistance.
Jamie Pinnock RN, CWCN
I am a third year nursing student and i am carrying out a research proposal
on patients perceptions of larval therapy. I would be very grateful if you
could tell me of any relevant information to my study.
thank you for your time
Hi, this is not really a wound care question. I
believe you had information one time in your e-mail about a wound that was
noted by a nurse in Indiana that occurs on the coccyx of terminal pts. It
was noted shortly before death occurs. It had a certain shape to it, but I
cannot recall anymore of the details. Can you help me out here. MMM
This would be called a Kennedy Terminal Ulcer. It is shaped like a pear
with a yellow appearance usually within 2 wks. of death. There is a website
you can look at. www.kennedyterminalulcer.com
The wound is called a "Kennedy Terminal Ulcer" and is pearshaped - ir has
irregular borders and sudden onset - it is usually on the sacrum - they
start out larger than other pressure ulcers and rapidly progress -
Hilary Tobin, ARNP
This particular wound is called a Kennedy ulcer.
Elsy Stiebel ANP New York
The ulcer that you are referring to is called the Kennedy Terminal Ulcer.
It is described as pear-shaped. It was described by Karen Lou Kennedy. It is
on the sacrum, coccyx or ischium with sudden onset and it is stated that
death usually occurs within 2 weeks unless delayed by IV fluids or other
means. There is a pictorial guide by Gaymar titled "Gaymar Pictorial Guide
to Pressure Ulcer Assessment". You may be able to order through
There is a lot of discussion whether or not all pressure ulcers are
preventable. Regardless, everyone agrees that to even have a remote chance
of proving that a pressure ulcer is development you must document your risk
assessment and preventative measures. If the preventative measures (such as
frequent turning or assuring adequate nutrition) are not consistent with end
of life goals such as pain control, then the likely outcome of pressure
ulcer development must be discussed with the patient and family and
I hope that this helps.
Thanks. April Kuhlman RN CWOCN
What you are referring to is a kennedy terminal ulcer and it can be
shaped like a pear and is usually on the sacrum. It can include the colors
red, yellow, black. The borders of the ulcer are usually irregular. This
ulcer has a sudden onset and most patients die within 8-24 hours of onset.
For reference see "wound, ostomy, continence secrets" by Milne, Corbett, and
Sherrilyn Shannon RN, Clinical Nurse Manager in LTC
Many more people sent answers to this question with similar responses.
Thank you. You taught me something !
Dr. Allan Freedline
I work at a Developmental Center where the client's laundry is done on their
home unit, unless contaminated with blood or body fluids. They use regular
washing machines on the unit. We recently had a Environmental Survey which
suggested hot water temp should be >160F to kill MRSA. Our machines are not
set to that due to safety issues because some clients are trained to do
their own laundry. Any comments or ideas?
|I am not sure this is the required
However, I do have a concern about the temperature.
This is higher than scalding temperature and most
facilities require you have less than scalding temperature
OSHA-related. This is very unsafe for the general public.
Maria Carunungan, DPT, CWS
have you had clients with MRSA? If not, don't worry about it. If you
have, perhaps their laundry can be stored and cleaned separately then wash
their clothing with a 10% bleach solution (won't work for colors) or
increase water temp for their clothes only.
Chris Berke RN CWOCN
My husband had six surgeries on the upper back
of his head in an effort to remove malignant fibrous histiocytoma.
Unfortunately this was not accomplished and the cancer entered his blood
stream. At that point, four large “doses” of radiation were given in an
effort to slow the growth of the cancer which had already destroyed a
portion of his skull. The radiation treatment resulted in several “ulcers”
on the skin graft. In addition, several small scratch type injuries to the
graft, which is very thin, have resulted in exposure of several small areas
of his skull. I’ve been using saline solution and Vigilon (as recommended by
the surgeon) to dress these wounds but see no improvement, and we were told
by the radiologist that they may not heal. Just wondering if you have any
suggestions as his last radiation treatment was 3-4 months ago. Thanks for
any assistance you can offer. Arlene Jutting
I am a certified wound care nurse and also a certified hyperbaric
technician. Hyperbarics is a covered treatment therapy for the condition you
describe. It essencially is using 100% oxygen under pressure either in a
single person (monoplace) chamber or a multiplace (several people and a
technician) can be treated. It can stimulate regeneration (angiogenesis) of
microvascular circulation to the tissue and skull bone that was treated with
radiation. You are not alone in having complicated wounds that do not heal
post radiation treatment. That is why Medicare has approved Hyperbaric
Oxygen (HBO) for such tissue and bone damage. The treatments would be for
"radionecrosis" and would be scheduled Monday through Friday for 30
treatments or about six weeks. I would definitely recommend you go through
you primary physician as the radiologists don't like to admit that radiation
can have longterm effects to bone and soft tissue. I hope you live near a
facility that can offer this treatment. The total treatment time is for 90
minutes once you are at pressure, and your ears would feel like popping
during the period you would be taken to the treatment depth - about 8-10
minutes. You can research this information on the Undersea and Hyperbaric
Medical Society (UHMS) the official governing body of the hyperbaric field.
I have seen alot of success treating patients Arlene, and wish you well.
Please feel free to contact me at my email address - email@example.com.
Sincerely, Kathy Bucci RN/WCC/CHT
I would suggest a silver dressing. Sometimes with chronic wounds bacteria
can keep it from healing without it becoming infected. The silver dressing
will decrease the bacteria load by killing over 150 different bugs. so with
his skull exposed he for sure need infection control. There are several
types out there and over the counter. If I can suggest a dressing it would
be would be Arglaes - made by Medline, its a sticky thin film, if you can
trim his hair around the wound then apply the arglaes, It can be changes
every 7 day or if leaking.
I hope this helps
Sherri Merrill, RN WCC
aloe vera may help
Liz Willson-Chandler RN, Wound Healing Specialist, RSA
The wounds on your husband’s skull may take a very long time to heal since
radiation destroys the capillary bed and deeper tissue for the remainder of
his life. This tissue is very difficult to grow.
Some points to consider:
1. Ask a Reconstructive surgeon for his opinion on a free flap (best
option), skin grafts are not strong enough to survive radiation.
2. Ask a therapist to debride the senescent cells off the margins of the
3. Lazer treatment may aid in healing
4. Keep ALL pressure off the area, do not allow pressure on the area even
when your husband is sleeping. This can be achieved by tying tennis balls
into his T shirts whilst he sleeps. Simply place the tennis ball in the
location of the T shirt which would cover the area that you don’t want the
patient to lay on, secure the tennis ball in the T shirt with an elastic
band. Ie. If the wound is on the back of the head, the patient should not
lay on his back, therefore place the tennis ball in the centre of the back
of the T shirt and secure with an elastic band.
5. Prevent the wound from becoming too wet, if the margins become white, the
wound is too wet. Drier wounds heal better than wet wounds, however moist
wounds heal fastest. The margins should always be pink.
Hope you win this one!
These wounds are difficult to heal because the tissue has been damaged by
the cancer and the radiation. I would have to see this wound to make any
specific recommendations. I do know that Biafine gel is a very good dressing
for radiation wounds ---it is very soothing. If bone is exposed –it needs to
be kept moist. What you are currently using appears appropriate. Consider
nutrition for overall health support. After the body goes through such an
inury one needs to help the body to do the best to repair itself. Have you
spoken to the surgeon about short and long term goals? I would recommend
Jamie Pinnock RN CWCN
I am a nurse practitioner working in a birth
defects clinic. I have a 38 year old male patient who has spina bifida and
he has constant problem with a red scrotum. The area has not broken down
yet. His mother cares for him and she has tried everything. Any new ideas
Susan, Chattanooga, TN
|We have had a lot of luck with
Bourdeaux's Butt Paste. Not a glamorous name I know. Make sure it isn't a
fungal rash. Calmoseptine, Aquaphor, and even Laniseptic are others you
might want to try. Goodluck. Cheryl LPN WCC HBOT
Suggest you look into if he is bladder incontinent,
hygiene practices (can he effectively use a urinal);
also I've seen this also in some patients who were
obese and the scrotum is irritated by the fat pads with
the legs rubbing against the scrotum. Do they look
anything else but red, or do they look yeasty?
Management depends on what other areas you need
to look at to consider as contributors.
Maria Carunungan, DPT, CWS
You might try Xenaderm, an ointment from Healthpoint pharmaceuticals. It
works nicely on inflamed or scored skin, with no dressing needed.
Vicki, MSPT, CWS
I prefer to use a barrier ointment such as zinc oxide or a product
containing peruvian balsam on this type of problem.
You really don't provide enough information. I assume the pt is
incontinent of urine and stool. what is the mom using for absorbency and is
it a product that wicks the moisture away from the skin? Is she changing the
product when it is wet (I often see staff/families try to change briefs only
every two hours but change should be determined by need - have you had mom
complete a voiding diary to determine if there is any pattern to the pt's
elimination). Finally, is mom using an appropriate skin cleanser with each
change and then following up with a good skin protectant with dimethicone or
chris Berke RN CWOCN
You might try Xenaderm. It is perfect for these type of problems.
Cheryl Treatment Nurse
Hi. I practice Long Term Care and would like
My patient is a 94 yo female with a chronic open wound located between the
gluteal folds. I first thought it might be a pilonidal cyst based on its
location, but given that my patient is an elderly female (rather then a
young male) and that there is no D/C, I now believe it is simply a pressure
ulcer that formed a sinus tract and has stopped healing. The edges are
epobilized. It is about 1cm deep and just wide enough for me to place in a
cotton swab. I was thinking of treating the margins with silver nitrate,
filling the sinus with liquid hydrogel and covering the whole thing with an
op-site. My concerns: I don’t want the superficial skin to close over and
create a cavity. What (if anything) should I do to the tract itself? It
seems too small to be packed with anything. I read in the past about
abrading the tract skin with a pap smear brush – is this necessary? I’m also
concerned that if I periodically check the sinus depth with my cotton swab-
I’ll disrupt the healing granulation tissue (that will hopefully be inside).
Note that I did have my friendly, neighborhood surgeon look at the wound. He
felt that opening it up surgically (to allow it to heal by secondary
intention) would pose too many complications. Any advice would be greatly
|If it's only 1 cm deep, silver
nitrate to the opening would allow it
close inside. Every dressing change using forceps or a cotton
applicator stick to keep the opening open while the tract fills in
could help too.
Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
You are correct, you need to keep the wound open and allow it to heal
from the inside out. There are a lot of impregnated gauzes on the market
that can be cut to fit in the wound, I personally would look at DermaGran
impregnated gauze, it comes in a 2x2 and the type of material used doesn't
fray went cut.
Tina (L.V.N./wound care nurse)
Do you have the Turning Clocks that can be
posted on a patient's bed to help remind staff of when the patient needs to
Julie McClure, RN, BA
I found sometimes the staff got used to the clocks
and they forgot to turn patients anyway. This becomes
even more a problem when there is a clock schedule,
visitors (including surveyors) walk in and see that the schedule
was not followed. We used a system before where there is
a chime every 2 hours (all even number hours) sounding
via intercome and you could see staff scrambling to work on
turning their patients when the chime is heard. It helped
staff plan their activities around the turning schedule.
At the latest, because of unforseen delays, longest
delay was 15 minutes.
Maria Carunungan, DPT, CWS
I'm 55, female with RA for 30 years. I've had a leg ulcer for 4 years,
healed for 6 months and it reopened now I'm on 2 years of not healing of
same ulcer. I just developed 2 new ones on other leg and anticipating more
grief. I have done everything, HBO chamber, vac, all the creams, dressings
etc. I go to a great wound center that's as frustrated as I am. We are
cyclosporine which I'm not thrilled about. If its to attack my immune system
wouldn't it seem that trying the newer RA drugs be less drastic? I use
Relafan and methotrexate as of now. Any suggestions out there?
Donna, a patient
I can only imagine how frustrating this is for you. I have dealt with
patients with RA complicated wounds. These wounds are difficult to heal.
Have you used biological engineered tissues like Dermagraft or Oasis? Do you
have venous disease as well?. You may want to consider your diet-- are you
consuming enough nutrients to help your wound heal---you may want to talk to
your physician about nutritional support and supplements.
Jamie Pinnock R.N. CWCN
Hi Dona. I am not a health care professional but I had similar story to
yours. I am a 42 year diabetic and I had two ulcers on my feet. They were
treated with "everything" IV antibiotics, creams, Oasis, surgical
debridements, etc., etc. Nothing worked after 2 years. I turned to Maggot
Therapy and healed them both up and my osteomyelitis, in a few months.
Sounds gross, yes, but it works and whatever it takes. These a sterile
maggots, raised just for this purpose. They also have been FDA approved.
Please check out our website for more information. Good luck.
Board of Directors BTER Foundation
I suggest you contact a wound care specialist
who can coordinate your care with your rheumatologist.
You are probably immunosuppressed with the RA
meds which can happen. This would delay healing,
but, delay may also be due to other causes.
Where is the legs are the wounds? Do you have
edema and are your legs discolored? You need a
CWS to identify what kind of wounds you have
(whether venous, arterial, diabetic, neuropathic?, etc).
Management is different for each type and immunosuppression
is only one factor to consider. Other factors are
nutritional status, other meds (some steroids can
actually delay healing and are given help from
some nutritional supplements to counter effects),
stress (which is common in RA), your activity level, etc.
Best combination to look into your wounds-
rheumatologist and wound care specialist in your case.
Maria Carunungan, DPT, CWS
Has the wound been biopsied? Have you ruled out CA and pyoderma
Have you tried hydrofera blue?
My name is John Davis and I too have a stasis ulcer on the interior of my
left calf. It has been the same size for the last 3+ years.
I have been to 3 vascular surgeons; 12 months of wound care at Hoag hospital
in Newpor Beach; and have tried all the debrieding compounds on the market
with NO success.
I am hoping to find a physician who will prescribe microcyn as a new method
of debrieding. I have read remarkable results using this solution. It was
approved by the FDA this month.
It is truly a shame that modern medicine cannot offer a cure for an open
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