Email - April 13, 2004

Wound Care Information Network

April 13, 2004

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Does anyone have any information on how to get Medicare guidelines for coding and billing related to wound care in Pennsylvania. Do you know if there is a difference for billing wound care if its an outpatient hospital owned clinic or if its a department of the hospital. Its so frustrating because I cant find anything in black and white that you can decipher and understand and its a problem for our hospital coders so now its been placed in the RNs realm of duty.Know of any good seminars related to this. Thanks DB	The Symposium on Advanced Wound Care, www.woundcaresymposium, has a long session on this in May, by Kathy Schaum. Renee C., MSPT, MPH, CWS Renee ---- Coding/Billing depend very much on your license. Are you an RN, advanced practice RN, PT, etc? Do you have physician's or a medical director? Hospital based either on site or off will be the same. If you are advanced practice and your state allows independent practice you will use the appropriate procedure codes and evaluation and management code out of the CPT book, per their description. Provider charges and facility charges apply. If you are not advanced practice, you will only be able to charge facility fees. Michelle Cassell RN, CNS, CWOCN Program Manager--wound clinic --- You would need to go to the web site for Centers for Medicare and Medicaid. When the home page pops up type in Wound Care in the search engine and it will take you where you need to go. This is how our billing ladies do ours, Good Luck Janalene, LPN Wound Care Coordinator. --- Some product manufacturers may have additional information
What is a treatment protocol for using high volt pulsed galvanic stimulation? Background - my patient has 2 medial and 2 lateral chronic leg ulcers. She has significant arterial and venous insufficiency. Currently we are using an Unna boot to treat her, with no compression bandage, and we are changing it every 4 days. The wounds have a granulation bed, but are mostly covered with yellow fibrin. She is slowly healing, but I want to see if I can help her along with estim and we have a HVPG unit at our hospital. Can anyone offer recommendations? Thank you very much for your time! Sincerely, Shari Holder, PT	There is not "best" protocol, as each study has a different one, and no has compared protocol A to protocol B. I suggest you look at the work of Kloth and McCulloch. Their text Wound Healing: Alternatives in Management is excellent. A protocol would be too lengthy to post here, with the different variables. Renee C, MSPT, MPH, CWS
I am a PT working in a nursing home. I have a patient that as a 0.8x0.8x2.5 cm sacral tunnel. I am waiting on culture results. I pack the wound daily with Panafil soaked Nu-Gauze, cver with 4x4 and tegaderm. My problem is that this patient removes her dressings daily (patient is demented). We have tried mittens on her left hand and this has not worked. My director of nursing is trying to not resort to soft wrist restraints tied to her bed, but I am unsure what to try! Any ideas? Also, are there alternatives to the wound dressing I am doing? Can you do a wound vac on a tunnel that small? Thank You, Laurie LeJeune, PT	Laurie, If the patient is tearing off the tegaderm she would probably remove the wound vac as well. You could try Mefix tape as a cover dressing it's more secure and less easily removed that transparent dressings. I've used it in the past for this type of situation and it has worked well. Dee Potts PTA, DOR --- Have you tried putting a one piece garment that snaps under the crotch? can even wear to bed. --- Laurie- Try hiding the bandage... I have used panty hose with the legs cut off to help hide and secure the dressing... your resident can rub it all she wants but the panty hoses being slick will keep her from picking it off. As far as other treatments, if your culturing I am going to assume you have a fair amount of drainage- look into Multidex powder. It is activated by moisture. But you might want to start covering the wound with something like medifix tape instead off tegaderm to help avoid maceration. Tina (LVN, treatment nurse) --- Laurie - One way to keep your patient from removing her sacral dressing is to put a regular (fairly narrow) long nightgown on her. It will require a little extra work to change a diaper, but it should keep her hands off her sacrum. My experience is that a 0.8 x 0.8 opening is too small for the sponge as there is significant depth involved - maybe others have had different experiences. I think Nu-Gauze is a good choice, but if I was worried about infection (hence the culture) I would stir the Nu-Gauze into Iodosorb Gel and then pack. Hopes this helps - Becky Adkins, FNP, CWS --- A VAC would be hard to pack. If you tried, you would need to use the white foam, for increased strength and integrity. But, if she takes off films, she'd remove the VAC too. Also, make sure you're not packing too tightly. I usually put one strip in, shorter than the length of the tunnel. Packing too tightly delays healing. Maybe you could put some gauze and tape (something cheap) in easier reach for her (abdomen or leg), and let her pick at that harmlessly instead? Don't know if she'd stop there, but it might be worth a try. Renee C, MSPT, MPH, CWS --- I just attended an inservice provided by KCI re: wound vacs. From my understanding your patient would be an excellent candidate for the wound vac. They have a product called versafoam that you might be able to use to pack. There number is 1-888-275-4524. KCI also has a website but don't know the address offhand. Call them. They will come to you with the information and for a consult. Good wound healing, Pam O'Boyle LPN Dynacare Home Health --- Hi Laurie, Yes you can do a wound vac, but use the white foam instead of the black foam. Debbie Bridgewater, PTA ---
Does any one have the latest treatment modalities,for post radiation therarpy burns? Johnny	Have heard devotees of both Biafine and Elastogel (not used together) extol the benefits of both of these products for radiation burns. Laurie M. Rappl, PT, CWS --- Typically, I debride if necessary, and apply topical agents. Hydrogels are soothing. Also, Biafine is great for radiation injuries. Renee C, MSPT, MPH, CWS --- Carrington has a line of products for radiation injury. Michelle R. Cassell RN, CNS, CWOCN --- Biafine cream is wonderful for radiation burns as are hydrogel sheet dressings Chris Berke RN CWOCN --- Biafine RE a topical Radiodermatitis Emulsion works well unsigned --- Hi Johnny. I am a CWOCN and work at an Outpatient Wound Center. We have found excellent results using Biafine deep dermal hydration ointment. The product was put out by KCI but recently bought by another company I believe. It should be applied topically BID, cover dressing only if necessary. Excellent results, patient expressed almost instant relief from discomfort and saw major results within 2-3 days. Good Luck. JS --- Why don't you try some Aquacel Ag? Diane --- HBO unsigned
Do you know what revenue code that a hospital would bill for a specialty bed. The only thing I can find is Revenue 947, which mentions SNF billing, but not hospital in the UB92 editor. Thank you, Michelina	As far as I know, there is no code for billing specialty beds as separate charges to Medicare for hospitals, or for nursing homes. The cost of the rental is taken from the daily rate reimbursed to the facility; it’s the burden of the facility, considered part of the cost of treatment for that patient. Laurie M. Rappl, PT, CWS --- specialty beds are bundled, sometimes you can arrange for extra payment if the pt has a insurance policy. Chris Berke CWOCN --- Under Medicare, beds are included in the DRG. There is no separate billing for them. Renee C., MSPT, MPH, CWS --- I do not believe there is any billing code for a specialty bed while a patient is hospitalized, it is part of the DRG. Michelle R. Cassell RN, CNS, CWOCN --- At our facility we use the Aircell XL specialty mattress and hyperbaric beds. Since this is handled through central supply we have it coded and billed as a supply item with a daily rental charge. Hope this helps....It works for us. Janalene, LPN Wound Care Coordinator
I know that reverse staging is not appropriate. However, is it appropriate to stage the pressure as more severe during the same hospital admission? Example: 78 WF admitted with 1.5.1cm stage I pressure ulcer to the coccyx. 4 days later it is obviously a stage 2 ulcer. Do I document stage 1 worsening or document that it now is a stage 2? DDavidson	You can advance stage a pressure ulcer just not reverse stage one. If a stage IV is less than a stage IV then you state it is a healing stage IV. If a stage I develops to a stage II then you would classify it as a stage II then research and document reason for decline. Hope this helps...Janalene Eaton, LPN Wound Care Coordinator --- It's now a stage II. It is no longer a I. Renee C, MSPT, MPH, CWS --- Dear DDavidson, Your wound would now be a Stage II, if there's depth. You would also need to document pressure reduction devices you are using in order to prevent further worsening of the OA. In addition, to your plan of treatment to healing. Dee Potts, PTA, DOR --- There is no such thing as reverse staging anymore, you stage it at the time frame (MDS) you are looking at the wound. If it is a Stage II, then stage it a II. And, yes, obviously the Stage I did worsen, except it appeared that there was depth in the initial staging, secondary to the 3 measurements you provided (1.5.1), was that 1x0.5x0.1cm? If so you already had depth of the wound and it was initially a Stage II. Hope that helps you. I am currently a Quality Assurance RN, I have also been a Nurse Consultant with long term care, DON, ADON, and taught MDS nursing. CTocco RN QA --- Pressure ulcers are often much worse than they first appear and moving up to the correct stage is correct, if it is now a II, stage it as a II, unless there is eschar or other necrotic tissue and then it is not stageable. You are correct though, if it starts healing, it does not go from a 4 to a 3, because the level of tissue damage and scar is that of a 4, it will become a healing 4 and describe the wound, ie bone now covered. Michelle Cassell RN, CNS, CWOCN --- Yes, if the ulcer gets worse you document. full thickness ulcers can not regenerate muscle and subQ tissue but fills in with scar tissue, that is why you cannot reverse stage. Chris Berke RN CWOCN --- Pressure sores should always be classified at the deepest stage. Once it has met the assessment that classifies it based on the anatomic depth of soft tissue damage it should be re-staged at that level and will remain that level. Kate P. RN WCC --- Document that it is a stage 2 DMS, RN CWS

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