Wound Care Information Network



June 17, 2005


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 Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

Hello –

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.


Tanya Gastelo

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

Baljinder Bains
sorry, no replies
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 Kennedy Ulcer



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 -

Best Regards,

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 www.gaymar.com

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 documented.

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 Dubuc.

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 temperature. 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 Hi Arlene!
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 - kathybucci@hotmail.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 wound.

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!

Liz, RSA

Hi Arlene:

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 this.

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 out there?
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.
Debby RN/WCC


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 petrolatum?
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 some advice.
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 appreciated! Thanks

(Gluteal Folds)

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 be turned?
Thank you,
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.
Good luck,
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 discussing maybe
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
Hi Donna:

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.

Pam Mitchell
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.
Good luck,
Maria Carunungan, DPT, CWS


Has the wound been biopsied? Have you ruled out CA and pyoderma gangrenosum?
Debby RN/WCC


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 wound.

Good luck

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