The AMA's official coding guidelines published in the "cpt Assistant" has some useful information in the June,2005 issue. A procedure note should contain a detailed description of the wound and technique used including instrument(s), medications and dressings.

Francine Acevedo
Financial/Clinical Analyst

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There is a sharp debridement course that goes over all that and I found it very helpful. Check out www.sharpdebridement.com

Shelley

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I state what instrument used (eye sharps, currette, scalpel), what tissue was removed (fibrinous slough, loose necrotic slough, eschar, etc) and in what quantity (10%, 50%, etc).
Hope this helps
Michelle , PT, CWS

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Hello, I would contact a wound care center that employs physical therapists and ask for a copy of their documentation forms. Also if you do some research, some of the text books give examples of good documentation. Also, exploring the Medicare guidelines for woundcare. Good luck.

Heidi Aga, MSPT

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You can look on the package for the manufacturer and google it to see who you can purchase it from. With what you are saving by the company billing Medicare for your facility, you should be able to buy the particular dressing you like for the patients you are using it on, because one particular dressing in and of itself, can not be the standard for every wound because every wound is different. A good rule to follow is, keep your dressing orders category specific and not brand name specific (i.e.; hydrogel, calcium alginate, hydrocolloid, collagen, bordered dressings etc), unless it is one of a kind dressing (i.e.; Polymem, Contreet, Iodosorb etc). Hope this helps.
R. DeLaney LPN, CWS, FACCWS

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Kim, if you would like to ask specific questions, please email me at sbishop@woundcareresources.net

Best regards,

Sheri Bishop
Wound Care Resources
VP Sales and Marketing

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Kim –

Please contact Jason @ MAR-J Medical Supply regarding the product you are interested in. We can bill Medicare for your patients. I can be reached @ (888)347-7997 or at info@mar-jmedical.com. We are located in South Florida, but we ship anywhere in the country. I look forward to hearing from you.

Jason Housenbold
President
MAR-J Medical Supply, Inc.

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Kim,

What is the product line you are looking for, I am a WCC with a Medical Supply Distributor. I might be able to help.

Pam
www.promedsupply.com

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It would help if you would say what the product is you that you are looking for. It may be that medicare will no longer cover the charges for that particular product but that may not be the case.
Without knowing what you were using, it is hard to say.

Dave

Karen,
Currently, my partners and I chart in the Dr. progress notes, narrative style. First of all we document that the patient is at risk for skin breakdown, but don't specify details, like the Braden score. That is available in the nurses notes if anyone wants to know. Then, we describe the wound, and document that the pt. is on a pressure redistribution mattress (we have KCI Atmosair housewide). I only discuss nutrition, vascular status, etc if it's pertinent, or make a brief comment such as 'nutritional status satisfactory', or 'vascular studies done'. I've gotten away from charting my recommendations, unless there is something I want to bring attention to. I might say, 'recommend mechanical and enzymatic debridement', (i.e. pulsavac and accuzyme) and instead of charting specific recommendations in the progress notes, I write, 'wound care orders written'.
Hope this helps,
Dawn, RN, CWOCN
acute care

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Our Medicare fiscal intermediary's coverage criteria (LCD) indicates that documentation must include wound description (size, location, stage, drainage/exudate, odor, periwound condition, etc.), treatment provided (type of dressings, ointments, enzymatics, techniques, etc.) plan of care (assessment for pain, circulation, nutritional needs/status, goals, and patient teaching.
Would recommend a review of you FI's requirements and any professional references noted in your wound care center's policies as far as stadards of care.

Francine Acevedo
Financial/Clinical Analyst
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My notes tend to be quite long also. I want to be very complete, therefore they are long. I include reason for consult, brief history of the patient and the wound, nutritional history (includes appropriate lab work), braden score, orientation of the patient, any continence issues that would involve the wound. I then describe the wound and give any recommendations, such as what type of dressing, specialty bed, dietary needs/involvement. Better safe than sorry when it comes to documentation.

Cheryl R. RN, BSN, CWCN, BC
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HI,

I AM A PTA WITH AN INTEREST IN WOUND CARE. WE HAVE RECENTLY BEGAN USING WOUND VAC, IT IS MY UNDERSTANDING THAT INTERMITTENT SETTING PROMOTES GRANULATION BETTER THAN A CONSTANT SETTING. I BELIEVE THE MANUAL STATES THAT ALSO. GOOD LUCK. IF THIS WERE MY MOM I WOULD BE CONSIDERING THAT IF THE WOUND VAC WORKS IT IS TEMPORARY, A COLOSTOMY WOULD BE PERMANENT AT HER AGE AND MIGHT BE HARD TO HEAL ALSO.

Lori O’Brien PTA
 

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Randy, I haven't heard of the use of vaseline being ordered by a Physician but MY mom use to use it on us kids for everything. Some how it worked.We healed without infections or antibiotics. I didn't see a Docror untill I was 15y/o and had appendicitis.I am now D.O.N. and wonder how we survived!

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Hi,
Vaseline is one of the best things that you can use in wound care. I use it almost 90% of the time to heal wounds and it works almost 10% of the time. don't worry - the wound will heal fine.
linda

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What is vaseline? It is petroleum, what we make gasoline from. Not a good choice. There are many new high tech ointments and dressings that would be much better. silver dressings work very well, Multidex, Xenoderm, silversorb, etc.

Bryan - DOR, PTA, CWS

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 I recently have seen several physicians and specialists ordering the same- petroleum jelly ( Vaseline) for clean open wounds. As long as there is no infection or bacteria burden, it seems to be effective for the wounds I have treated with it. The theory to keep a moist wound base seems to be met with the application and by not using an antibiotic ointment, the ability for the bacteria to become resistant to a certain antibiotic is prevented. It is still something I'm not comfortable with but Understand the theory behind it. Antibiotic ointments are vaseline without the antibiotic anyway. Hope this relieves your doubts somewhat. Cheryl WCC

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Moist wound healing is the "gold standard". Using petroleum based product assists in maintaining the the moisture level and providing a barrier against the germ filled word. This is very much like applying bacitracin or neosporin however without the antibiotic component. There are different opinions about this. Neosporin kills more bacteria then other topicals however generally more people have a reaction the the antibiotic and develop a lovely rash. bacitacin only kills some bacteria and not others, this can create an imbalance in the general wound environment. If no medication is needed, it is generally considered good practice to just keep it clean, moist and protected.

Michelle PT, CWS

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I would suggest xeroform dressing qd.

unsigned

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Hi Randy, I think your dad went to the same surgeon my dad went to I am a certified wound care nurse and depending on the what the wound bed looks like there a couple of ways you can go. If the wound bed is beefy red then using a wound gel and gauze dressing done either daily or two times a day would be appropriate. If the wound bed is yellow, tan, or black more than 50% you may need to use a chemical debreider like accuzyme covered with dry gauze daily. The next problem you will face is how to attach the dressing!!! You may have to play around with different ways to attach it depending on how much tissue was removed, I have had to shave a portion of the head to use tape to secure the gauze or have been able to secure a small piece of gauze and use a band aid. DO NOT USE VASELINE! Vaseline is petroleum based and it is not good for wound healing. You need a moist wound bed for this wound to heal. If the family Dr. did the surgery you may need to take him to a dermatologist or plastic surgeon. My dad went to a dermatologist (who I never have had faith in) and he actually stapled a telfa pad to his head, ear and below the chin and above the chin, which as you can imagine it interfered with eating. Protein is very important with wound healing and a good rule of thumb is two sources of protein at each meal and a small protein snack between each meal and at bed. I hope this helps. Bonnie RN CWCN, bsn48623@netzero.com

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Randy,
I use vaseline or vaseline gauze on wounds all the time. The vaseline keeps the wound bed moist, which is optimal for wound healing. The vasline also is occlusive, so bacteria can't invade the wound and cause an infection. The wound does need to be kept clean, so make sure that it gets cleansed daily, washing it with the daily bath is a great way to clean a wound, and makes it easier than needing a separate product such as wound cleanser or saline. Vaseline is also very cost effective and easy to access.
Dawn, RN, CWOCN

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I have utilized Jelonet for areas as mentioned.
BEE L.P.N.

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Vaseline will hold moisture in. It is an inexpensive alternative to hydrogels. There was an article some years back that compared vaseline with silvadene and neosporin, and vaseline prevented bacterial growth better. In this case it is probably to keep wound from drying out. Aquaphor is similar but better for wounds.

Catherine M. Walsh RN,BSN,CWOCN
 

Belinda

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Albumin or Prealbumin is really only value you need to be interested in.
They give you idea of protein stores patient has alerting you to nutritional deficiency.
Protein is the building blocks of cells. You don't have adequate protein there is no foundation for wound healing to take place.

lynn RN

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We only culture if wound actually presents with true infection qualities, if it is critically colonized silver dressings will usually decontaminate the wound surface, once it infliltrates the tissue a culture, punch prefered, and a good antibiotic would be warranted. We rarely use antibiotics or cultures and have a 91% healing rate with good wound care.
Bryan DOR, PTA, CWS

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In long term care stasis has to be staged for MDS purposes.
Robin
Wound Care Nurse

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You are correct. Pressure Ulcers are to be staged. Stasis ulcers are not. The exception is of course on the MDS. I believe this is where people get confused. Hope this helps

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The NPUAP staging system is for pressure ulcer staging. There are six staging categories as of Feb. 2007 (Suspected Deep Tissue Injury, Stage I, Stage II, Stage III, Stage IV and Unstageable). The confusing part is that MDS "stages" for MDS purposes, and should be able to do this by reading the nurses narrative. There are other staging systems for other type wounds (Wagner Scale for diabetic ulcers etc.), but the staging is much different than pressure ulcer staging and is not commonly used in nursing, due to a lack of knowledge in the different staging systems. All wounds outside of pressure ulcers, are either partial thickness ulcers (into but not through the dermis- visible hair folicles) or full thickness ulcers (into subcutaneous, or slough present, or muscle, or eschar etc), determined by the tissue destruction involved and should be documented as such. You can also refer to www.npuap.org for more info. on pressure ulcer staging. Hope this helps.
R. DeLaney LPN, CWS, FACCWS

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Usually correct, stasis ulcers are usually easily resolved with good wound care with compression, check ABI to be sure it does not have an arterial component. Any ulcer can be staged though depending on the involved tissue, usually stasis ulcers are very superficial though. Bryan, DOR, PTA, CWS

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You are correct. Along with your assessment you would describe it as full thickness or partial thickness

Carol RN

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You are correct-staging is only valid for pressure ulcers. All other wounds should have documented dimensions (length, width, depth), undermining, and wound bed description (slough, eschar, granulation, etc.)

Sue Connor, PT, CWS, FCCWS

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My name is Joyce Henson and I am a RN. I work in a long term care facility. In long term care, for MDS purposes, you do stage stasis ulcers. For those of you not familiar with long term care, the MDS is the Minimum Data Set that is submitted to CMS for payment purposes.

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You are correct. pressure ulcers are recorded by stage, burns by degree, all other wounds buy thickness, (superficial, partial thickness, full thickness. A good assessment would also include LxWxD, wound bed color, percent necrotic tissue, drainage color and quaint, and periwound skin assessment

Michelle PT, CWS

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Pressure ulcers are staged. Stasis ulcers would be "partial thickness" or "full thickness" based on the depth of the wound.

Best regards,

Sheri Bishop
Wound Care Resources
VP Sales and Marketing

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You are correct, according to the National Pressure Ulcer Advisory Panel, only pressure ulcers are staged. Other wounds can be classified as full or partial thickness. A partial thickness wound would be equivalent to a stage II pressure ulcer, where the epidermis is disrupted and the dermis is exposed. A full thickness wound would be equivalent to a stage III or IV pressure ulcer, past the dermis, into the subcutaneous tissue (Stage III) or muscle or bone (Stage IV).
Dawn, RN, CWOCN
acute care

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The facility I work at does not stage stasis ulcers, but for MDS purposes the nurses need to stage the ulcers and 1, 2, 3 and so on. I recommed going to facility protocal and asking DON what is required.

L.G. LVN

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You are correct you only stage pressure ulcers. A stasis ulcer would be classified as either a partial thickness wound (PTW) or full-thickness wound (FTW).

Bill Richlen PT, WCC, CWS

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You are correct-only pressure ulcers are stagable. For stasis ulcers use descriptions such as "full thickness" or "partial thickness" tissue loss.
Amy Pastor RN, CWS
Director of Nursing

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You are correct. Pressure ulcers are staged, but stasis ulcers are not. Stasis ulcers are described as either partial or full thickness, with length, width, and depth measurements, along with a description of the character of the wound bed (presence of slough/devitalized tissue or eschar, granulation or epithelial tissue), amount and color of drainage, and character of the wound margin/periwound area. In addition, since edema or trophic changes are often also present, their presence and degree needs to be documented as well.

Sara, PT, WCC
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You are right. You only stage Pressure ulcers.
Venous wounds will either be full-thickness or partial thickness.

lynn RN
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That’s correct you only stage pressure ulcers. You can describe stasis ulcers by partial thickness or full thickness depending on how deep they are. Full thickness would be with exposed tendon etc. Kathy McFerron LPN WCC

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Hi Ken

I'm a Tissue Viability Specialist in South Africa. I also work in a vascular clinic. The Nurses are absolutely right about avoiding debridement and any enzymatic debriding agent. Internationally the accepted protocol is not to cause ANY tissue destruction or debridement in a limb that is poorly vascularized. Any arterial wound which cannot be healed due to lack of functioning small vessels (microvascular disease), or if the age of the patient prohibits surgery to correct large vessel disease (macro vascular) should be kept dry. Dry gangrene is quite easy to contain, wet gangrene spreads like a wild fire. The only surgery your Grand Dad should have is arterial bypass/ stent if his condition allows for it. Keep us updated on what transpires.
Liz

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Without knowing the particulars of your father's situation, generally debridement is used to remove devitalized tissue which decreases the risk of infection. It should be used sparingly in peripheral vascular disease because if healthy tissue is removed, there may not be enough blood flow to heal an even larger wound. Accuzyme, an enzymatic debrider, uses chemicals to selectively debride nonviable (dead) tissue, so there would be little concern about this product making the wound worse. A vascular consultation is essential, preferably a surgeon who uses the Silverhawk procedure, a less invasive "Roto-Rooter" which can remove plaque in appropriate patients.
S Raybuck, DO

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Sound like the kind of PVD your father has is his arterial flow. It is true that if you have a hard black scab( called eschar) that is firmly attached, no drainage around the edges and no
soft spots in it that you leave it alone; it is protecting the foot from further damage an infection. However, if this is not true, then the dead material on the surface must come off as it is food for infection. It can be sharply debrided (cut off) or removed with an enzymatic medication (like Accuzyme). When the wound bed is clean then a silver should be used to keep the wound surface clean and prevent infection.

If your father is not a candidate for stinting or bypass there are other options. I have successfully used electrical stimulation to increase circulation and obtain wound healing in patients when there vascular grafting failed. Also, blood thinners like aspirin, coumadin may be helpful if he is not already on them. You may also want to see if there is a Hyperbaric chamber around your area. This treatment creates a high oxygen concentration in the blood and has the potential to heal some very complex wounds.

My best to you an your father, there is lot of material out there to sort through!

Michelle

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Ken, There are several factors that need discussion before a decision can be made. You stated that the wounds are on his foot but you didn't state where on the foot. Is there any necrotic tissue or yellow slough present? Is there a bacterial bioburden present? What is his nutritional status? Is there any blood flow to the area? Is he diabetic? How much pain is he experiencing? Is the wound moist with drainage? The products you stated that have been used and have been suggested are all good products and are effective depending upon the type of ulcer present, his nutritional status and comorbidities. To help clear up some misconception about accuzyme: it is a great means of debriding or chemically eating away the dead tissue that may be present. It does NOT, I repeat does NOT destroy or injure healthy tissue. There was a product used in the past that did this , but it is no longer being used. Accuzyme will debride yellow slough more quickly than black eschar which actually heals quicker with a sharp debridement. When using accuzyme, a protective layer of a barrier cream like Pro Shield should be applied to the area surrounding the wound to prevent any maceration of the healthy tissue. maceration is what happens when you stay in a wet bathing suit too long- the skin becomes overly moist.You stated that the NP suggested a silver product which is the current hot ticket in wound care at present, but there are several products and you need to adjust the product to fit the needs of the type of wound you are treating. And again, if there is black eschar present, healing can not occur unless there is healthy pink tissue present. Maybe the facility where your father resides could have a specialist in wound care consult with their staff and indicate an appropriate treament plan. Good Luck and I hope that you find some help. Cheryl W BSN,RNBC, WCC

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Dear Ken,
If the blood supply to the foot is severely impaired, then it does not matter what fancy wound dressing you use or don't use - nothing will make any difference because of the underlying inability to heal. What is important is to prevent infection, use simple, comfortable and inexpensive wound products that do not cause more harm, and keep your father as comfortable as possible and his pain under control.
Julie Miller
Podiatrist (and Wound care student)
Melbourne, Australia

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The most important question is are the wounds open and draining. If so they do need to be debreided because if the drainage can get out bacteria can get in. If the wounds are black or tan and their is no drainage the goal is to just keep them dry. So if they are draining then accuzyme is appropriate to open the wound so you can see the wound bed. The nurse wanted to use silver, was that silvadede which is an antibiotic ointment or was it a silver impregnated dressing which is also an antibiotic absorptive dressing. The best course of treatment with poor circulation is if it is dry keep it dry and protected with a dry dressing if draining it needs debreading. Hope this helps. Bonnie RN, CWCN, bsn48623@netzero.com

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Ken,
The practitioners are correct-if there is poor arterial blood flow to the extremity, the wound will not heal. If re-vascularization is not an option, the best option is to prevent the wound from becoming infected.
Silver is anti-microbial--meaning it will kill bacteria and help to prevent infection. However, many of the silver products also work to help debride, or remove dead tissue, which is what accuzyme will do.
In situations like this, I usually recommend betadine solution, paint on the wounds daily. This will kill bacteria and keep the wound dry.
Dawn, RN, CWOCN
acute care

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i am caroly wound care nurse i have had sucess with silverdene cream on this type of wound clean wound with sterile water and apply silvedene sparingly cover with dry gauze and wrap with kling wrap change everyday or
more if needed depending on drainage.

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Accuzyme is an enzymatic debrider that only affects non-viable tissue. It will not harm healthy tissue, which is why it is appropriate for someone with vascular insufficiency, where you don't want to risk creating another wound with either sharp or non-selective debridement. Silver dressings are used for infected wounds & not for debridement. It is important for the non-viable / necrotic tissue to be removed before healing can begin. Of course proper blood supply is imperative as well. They do make hydrocolloid dressings, such as duoderm, that are impregnated w/ silver. This would enhance autolytic debridement & also have the infection fighting principles of silver.

Justin, PT