CONTROLLO GLICEMICO ED ESITI DELL’ULCERA DEL PIEDE DIABETICO: UNA REVISIONE SISTEMATICA E UNA META-ANALISI DI STUDI OSSERVAZIONALI

PUNTI SALIENTI

Il ruolo del controllo glicemico nelle ulcere del piede diabetico (DFU) non è chiaro.

Le meta-analisi precedenti hanno incluso un numero limitato di studi.

Alti A1C e glucosio a digiuno sono associati ad un aumentato rischio di amputazione nei pazienti con DFU.

A1C e glucosio non erano associati alla guarigione delle ferite.

ASTRATTO

Obbiettivo

Per valutare l’associazione tra controllo glicemico (emoglobina A1C, glucosio a digiuno e glucosio casuale) e gli esiti della guarigione delle ferite e dell’amputazione degli arti inferiori (LEA) tra i pazienti con ulcere del piede diabetico (DFU).

Progettazione e metodi di ricerca

Medline, EMBASE, Cochrane Library e Scopus sono stati cercati studi osservazionali pubblicati fino a marzo 2019. Cinque revisori indipendenti hanno valutato in duplice idoneità ogni studio sulla base di criteri di ammissibilità predefiniti e due revisori indipendenti hanno valutato il rischio di parzialità. È stata eseguita una meta-analisi per calcolare un odds ratio (OR) o un hazard ratio (HR) raggruppati utilizzando effetti casuali per misure glicemiche in relazione agli esiti della guarigione della ferita e del LEA. Sono state condotte analisi di sottogruppi per esplorare la potenziale fonte di eterogeneità tra gli studi. Il protocollo di studio è registrato con PROSPERO (CRD42018096842).

risultati

Dei 4572 record di studio sottoposti a screening, 60 studi osservazionali hanno soddisfatto i criteri di ammissibilità degli studi, di cui 47 studi avevano dati appropriati per l’inclusione in una o più meta-analisi ( n  = 12.604 DFU). Per gli studi di coorte che hanno confrontato A1C> 7,0 al 7,5% rispetto a livelli di A1C inferiori, l’OR aggregato per LEA era 2,04 (IC 95%, 0,91, 4,57) e per gli studi che hanno confrontato A1C ≥ 8% vs. <8%, l’OR raggruppato per Il LEA era di 4,80 (IC al 95% 2,83, 8,13). Per gli studi di coorte che hanno confrontato la glicemia a digiuno ≥126 rispetto a <126 mg / dl, l’OR aggregato per LEA era 1,46 (IC al 95%, 1,02, 2,09). Non c’era associazione con la categoria A1C e la guarigione delle ferite (OR o HR). C’era un alto rischio di distorsione rispetto alla comparabilità delle coorti poiché molti studi non si sono adattati ai potenziali fattori di confondimento nell’associazione tra controllo glicemico e risultati della DFU.

conclusioni

I nostri risultati suggeriscono che livelli di A1C ≥8% e livelli di glucosio a digiuno ≥126 mg / dl sono associati ad un aumento della probabilità di LEA nei pazienti con DFU. È necessario uno studio prospettico progettato appositamente per comprendere meglio i meccanismi alla base dell’associazione tra iperglicemia e LEA.

[Tratto da: https://diabeticfootonline.com ]

Quando vi è una porpora bilaterale non blanda di porpora secondaria alla tossicità da metotrexate

Presentando un caso intrigante di vesciche dolorose recalcitranti e porpora in un paziente con comorbilità multiple, questi autori discutono del lavoro del paziente, dei test diagnostici e dell’importante ruolo della valutazione multidisciplinare.

Il metotrexato è un farmaco anti-metabolita che agisce come analogo dell’acido folico per inibire la sintesi del DNA. Inizialmente, i medici utilizzavano il metotrexato esclusivamente per il trattamento della leucemia pediatrica, ma il farmaco è stato successivamente approvato per la psoriasi, l’artrite reumatoide, la dermatite atopica e la malattia vascolare del collagene. 1,2 

Sebbene il metotrexato sia efficace, ci sono effetti collaterali comuni che includono anomalie epatiche, nausea, soppressione del midollo osseo e problemi gastrointestinali. 3 Secondo quanto riferito, gli effetti collaterali meno comuni includono eruzioni cutanee vescicole, necrosi cutanea ed erosione di placche psoriasiche preesistenti. 4,5 Quando si tratta di estremità inferiore, la vescica e la porpora non sbiancabile sono segni clinici di tossicità da metotrexato. 4-7

Questo caso clinico evidenzia un caso di un paziente, che inizialmente si è presentato a un centro traumatologico di Livello I per dolore bilaterale, gonfiore e formazione di vesciche ai suoi piedi. Questo caso sottolinea l’importanza di un’anamnesi approfondita e di un esame fisico per una diagnosi e un trattamento adeguati di una condizione rara. 

Uno sguardo più attento all’allenamento per un paziente con dolore acuto, aggravante, gonfiore e vesciche di entrambi i piedi

Un maschio di 61 anni con diverse comorbidità, tra cui artrite reumatoide, ipertensione, malattia coronarica e cancro alla prostata, si è presentato in ospedale con una storia di due giorni di peggioramento del dolore, gonfiore e formazione di vesciche ai piedi bilaterali. Il paziente non aveva una storia precedente di questa vescica e non ha riportato una storia di traumi. Tentò di alleviare il dolore immergendo i piedi nell’acqua calda senza miglioramenti significativi. 

Il paziente ha avuto un completo workup al momento del ricovero in un altro ospedale qualche mese prima per neutropenia e trombocitopenia. L’allenamento includeva una biopsia del midollo osseo, che era negativa per la malignità. A causa della soppressione del midollo osseo del paziente, i fornitori dell’altro ospedale hanno interrotto la sua malattia modificando i farmaci anti-reumatici (DMARD), ma il paziente ha riavviato i farmaci da solo dopo questo ricovero senza che il medico lo sapesse. 

Quando il paziente si presentò al pronto soccorso alcuni mesi dopo, la sua diagnosi iniziale fu una vescica acuta bilaterale al piede secondaria a ustioni basata sulla storia dell’immersione in acqua calda. Il team di chirurgia plastica ha valutato il paziente nel pronto soccorso e il paziente è stato successivamente dimesso con sette giorni di doxiciclina orale. Tuttavia, il paziente è tornato due giorni dopo con un peggioramento dei sintomi e dati anormali di laboratorio rispetto alla visita iniziale al pronto soccorso. 

Al momento del ricovero, la conta dei globuli bianchi del paziente era di 2,6 x10 3 cellule per mm 3 , la sua conta piastrinica era di 81 x 10 3 per mm 3 , l’emoglobina era di 9,4 g / dl e il volume corpuscolare medio (MCV) era di 98,4 fL. La nostra preoccupazione immediata e urgente per questo paziente era la fascite necrotizzante. Il team di chirurgia generale ha escluso questo processo di malattia sulla base dei risultati clinici e ha raccomandato che la chirurgia plastica rivalutasse il paziente. 

Con una seconda occhiata, il team di chirurgia plastica non ha avuto ulteriori raccomandazioni oltre a raccomandare la cura della ferita locale e la valutazione podologica. Dopo aver valutato il paziente, il team podiatrico ha notato porpora non blanchable e formazione di vesciche con drenaggio sieroso, ma non ha apprezzato i segni di infezione acuta o malattia vascolare (vedere le prime due foto sopra). I team di podologia e dermatologia hanno entrambi concordato sulla necessità di una biopsia del punch e i risultati hanno dimostrato emorragia subdermica e infiammazione cronica. I risultati del test hanno anche escluso condizioni gravi come la sindrome di Stevens-Johnson, il pemfigo volgare e il pemfigoide bolloso. 

Per quanto riguarda ulteriori test diagnostici, un angiogramma di tomografia computerizzata ha rivelato il deflusso di tre vasi al piede, che escludeva la malattia vascolare periferica. Gli ultrasuoni duplex venosi degli arti inferiori hanno escluso la trombosi venosa profonda. Dato che la diagnosi non era ancora chiara a questo punto, il paziente è stato sottoposto a malattia infettiva, ematologia e reumatologia per ulteriori valutazioni e input.

Dopo aver ottenuto e rivisto uno striscio di sangue periferico, l’ematologia ha notato l’anisocitosi con ovalociti, poikilocitosi, cellule lacrimali sparse e alcuni granulociti ipersegmentati (vedere le ultime due immagini sopra). Sulla base del processo megaloblastico, il team ha stabilito che ciò potrebbe essere secondario alla tossicità del metotrexato. La reumatologia ha suggerito l’uso dell’acido folinico (noto anche come leucovorina) come trattamento empirico per la vasculite poiché il farmaco può fornire un trattamento indiretto della tossicità del metotrexato se ciò si dimostra la causa.

Con il trattamento, la citopenia è migliorata insieme al sollievo immediato dal dolore dei piedi bilaterali del paziente. Sulla base del trattamento con leucovorin, i team hanno concluso che questa porpora non sbiancabile dei piedi era effettivamente secondaria alla tossicità del metotrexato. Il paziente ha quindi iniziato il prednisone orale 70 mg al giorno e ha interrotto il metotrexato. Fu dimesso dall’ospedale in condizioni stabili e con un appuntamento di follow-up programmato con reumatologia. 

In sintesi

Un paziente può presentare tossicità da metotrexato sotto forma di nausea, soppressione del midollo osseo e anomalie epatiche. Tuttavia, secondo quanto riferito, l’eruzione cutanea della vescica è meno comune in letteratura. 7In questo caso di un maschio di 61 anni con porpora inspiegabile a pedale bilaterale inspiegabile, i sintomi non erano diretti a una diagnosi ovvia. Durante il corso in ospedale del paziente, diversi team di consulenti lo hanno valutato per i bassi livelli di cellule del sangue e per le vesciche inspiegabili. I risultati della biopsia del punzone hanno guidato la diagnosi verso la tossicità del metotrexato. Il trattamento successivo con leucovorin per via endovenosa ha portato a un significativo miglioramento della sua neutropenia e trombocitopenia. I medici curanti hanno consigliato al paziente di interrompere l’assunzione indefinita di metotrexato e hanno programmato un attento follow-up con il paziente in regime ambulatoriale. 

Questo caso dimostra l’importanza di una storia approfondita e di un esame fisico per una valutazione completa della patologia poco chiara. Mentre i podologi vedono comunemente ischemia periferica, congelamento e ustioni, questa presentazione clinica unica e il case work up forniscono l’intuizione e l’importanza di ampi differenziali per il trattamento ottimale e gli esiti dei pazienti.

[Tratto da: www.podiatrytoday.com ]

Oneri della disabilità globale delle complicanze degli arti inferiori legate al diabete nel 1990 e nel 2016

 Nessuno studio ha riportato stime del carico globale sulla disabilità per le complicanze individuali degli arti inferiori associate al diabete (DRLEC). Lo studio Global Burden of Disease (GBD) offre una solida opportunità per colmare questa lacuna.

PROGETTAZIONE E METODI DI RICERCA Sono stati utilizzati dati GBD 2016, tra cui prevalenza ed anni vissuti con disabilità (YLD), per i DRLEC di neuropatia diabetica, ulcera del piede e amputazione con e senza protesi. Il GBD ha stimato la prevalenza utilizzando i dati delle revisioni sistematiche e DisMod-MR 2.1, uno strumento di meta-regressione bayesiana. Gli YLD sono stati stimati come il prodotto delle stime di prevalenza e dei pesi di disabilità per ciascun DRLEC. Abbiamo riportato stime globali e per sesso, età, regione e nazione per ciascun DRLEC per il 1990 e il 2016.

RISULTATI Nel 2016, circa 131 milioni (1,8% della popolazione mondiale) avevano DRLEC. Si stima che 16,8 milioni di YLD (2,1% di YLD globali) siano stati causati da DRLEC, di cui 12,9 milioni (intervallo di incertezza del 95% 8,30-18,8) solo per neuropatia, 2,5 milioni (1,7-3,6) da ulcere del piede, 1,1 milioni (0,7-1,4) dall’amputazione senza protesi e 0,4 milioni (0,3-0,5) dall’amputazione con protesi. I tassi YLD standardizzati per età di tutti i DRLEC sono aumentati tra il 14,6% e il 31,0% dalle stime del 1990. I rapporti YLD maschio-femmina variavano da 0,96 per la neuropatia solo a 1,93 per le ulcere del piede. La fascia d’età di 50-69 anni rappresentava il 47,8% di tutti gli YLD dei DRLEC.

CONCLUSIONI Queste prime stime globali suggeriscono che i DRLEC contribuiscono in modo ampio e crescente all’onere della disabilità in tutto il mondo e colpiscono in modo sproporzionato i maschi e le popolazioni di mezza età. Questi risultati dovrebbero consentire ai responsabili politici di tutto il mondo di indirizzare le strategie alle popolazioni colpite in modo sproporzionato dai DRLEC.

[Tratto da: www.care.diabetesjournals.org ]

Sesamol incorporated cellulose acetate-zein composite nanofiber membrane: An efficient strategy to accelerate diabetic wound healing.

Recently, the function of nanofiber membranes prepared from electrospinning in accelerating wound healing has attracted wide attention. In this study, novel nanofiber membranes consisted of cellulose acetate (CA) and zein were fabricated to provide efficient delivery vehicles for sesamol, then the effect of sesamol-loaded composite nanofiber membrane on the wound healing process for diabetic mice was studied. It was found the critical concentration of CA was between 15% and 25% (w/v), and the most suitable concentration of stabilizing fibers was 22.5%. When the CA/zein ratio was 12:8, the fiber obtained the small diameter and uniform distribution, the stable intermolecular structure, the low infiltration speed and high stability in water. The composite nanofiber membrane with high-dose sesamol (5% of total polymer concentration, w/w) promoted formation of myofibroblasts by enhancing TGF-β signaling pathway transduction, and promoted keratinocyte growth by inhibiting chronic inflammation in wounds, thus enhancing wound healing in diabetic mice. This study could further broaden the application range of sesamol, CA and zein, and provide reference for the design and development of new wound dressings in the future.

[Tratto da: www.bioportfolio.com ]

Progettazione di una medicazione colloidale antinfiammatoria e adesiva per il trattamento delle ferite.

Materiali medicazione sono ampiamente utilizzati per proteggere le ferite dall’esterno dell’ambiente e per promuovere la ferita guarigione. Tuttavia, le medicazioni per ferite convenzionali mancano di proprietà adesive dei tessuti e di funzioni antinfiammatorie, che portano a fibrosi e stenosi, in casi come ferite gastrointestinali dopo chirurgia endoscopica. Nel presente studio, riportiamo le proprietà adesive e antinfiammatorie dei tessuti di una medicazione composta da particelle di gelatina modificate con corticosteroidi. L’idrocortisone (HC), che è una classe di corticosteroidi antinfiammatori, è stato usato per modificare la gelatina di pollock dell’Alaska (ApGltn) per sintetizzare l’ApGltn modificato con HC (HC-ApGltn). Le microparticelle (MP) di HC-ApGltn sono state fabbricate aggiungendo etanolo in soluzione acquosa HC-ApGltn ed eseguendo la reticolazione termica (TC) senza l’uso di tensioattivi tossici e reagenti di reticolazione. La modifica di ApGltn con HC idrofobo contenente la struttura della spina dorsale del colesterolo ha migliorato la sua forza di adesione ai tessuti sottomucosi gastrici in condizioni umide a causa di interazioni idrofobiche. Questa ritenzione della proprietà adesiva in condizioni di bagnato consente una protezione stabile delle ferite dall’ambiente esterno. Abbiamo scoperto che gli MP di HC-ApGltn sono stati ripresi dai macrofagi e hanno efficacemente soppresso i cambiamenti morfologici dei macrofagi attivati ​​da LPS e il livello di espressione della citochina infiammatoria. Adesivi per tessuti robusti e MP anti-infiammatori possono servire da medicazione avanzata in grado di proteggere le ferite e sopprimere le risposte infiammatorie per promuovere la guarigione delle ferite. Questa ritenzione della proprietà adesiva in condizioni di bagnato consente una protezione stabile delle ferite dall’ambiente esterno. Abbiamo scoperto che gli MP di HC-ApGltn sono stati ripresi dai macrofagi e hanno efficacemente soppresso i cambiamenti morfologici dei macrofagi attivati ​​da LPS e il livello di espressione della citochina infiammatoria. Adesivi per tessuti robusti e MP anti-infiammatori possono servire da medicazione avanzata in grado di proteggere le ferite e sopprimere le risposte infiammatorie per promuovere la guarigione delle ferite. Questa ritenzione della proprietà adesiva in condizioni di bagnato consente una protezione stabile delle ferite dall’ambiente esterno. Abbiamo scoperto che gli MP di HC-ApGltn sono stati ripresi dai macrofagi e hanno efficacemente soppresso i cambiamenti morfologici dei macrofagi attivati ​​da LPS e il livello di espressione della citochina infiammatoria. Adesivi per tessuti robusti e MP anti-infiammatori possono servire da medicazione avanzata in grado di proteggere le ferite e sopprimere le risposte infiammatorie per promuovere la guarigione delle ferite.

[Tratto da: www.bioportfolio.com ]

Case study: Maggots help heal a difficult wound

Using maggots to treat wounds dates back to 1931 in this country. Until the advent of antibiotics in the 1940s, maggots were used routinely. In the 1980s, interest in them revived due to the increasing emergence of antibiotic-resistant bacteria.

At Select Specialty Hospital Houston in Texas, we recently decided to try maggot therapy for a patient with a particularly difficult wound. In this case study, we share our experience.

About the patient

Mr. Green, age 52, had a history of diabetes, which led to bilateral below-the knee amputations. His medical history also included coronary artery disease, peripheral arterial disease, and anemia.

Alert and oriented, he was able to give a detailed account of his recent wound. On August 12, 2015, Mr. Green cut the distal tip of his right third finger while preparing food. Having already lost his legs, he was concerned about the possible need for another amputation, so he made an appointment to see his primary care physician. The physician instructed him to keep his finger clean and dry and to observe it. Nonetheless, it became infected and his finger had to be amputated at the base on September 11. A week later, he was admitted to an acute-care hospital for pain, swelling, and erythema. He received I.V. antibiotics along with pulsed lavage, treatment with Arobella Medical’s Qoustic Wound Therapy System™, ultrasound, and finally, negative-pressure wound therapy (NPWT).

When Mr. Green was admitted to our long-term acute care hospital, the wound bed was pale pink with the hazy, gelatinous look associated with high bioburden tissue, although no bacteriologic testing was done. (See About biofilm.) The wound measured 5 cm x 3.2 cm x 0.9 cm, and lacked the cobblestone appearance usually seen with recently discontinued NPWT.

Maggot therapy

Based on the difficulty of healing this wound, we decided Mr. Green was a good candidate for maggot therapy, which we’d been wanting to introduce into our facility. Mr. Green and his family were concerned about his lack of healing and eager to try maggot therapy. We selected maggots contained within mesh bags because nurses were reluctant to handle free-range ones. (See Maggot application options.)

Applying the maggots

With Mr. Green’s consent, 10 clinical staff members attended the first day of maggot therapy, when the maggot-therapy containment dressing was applied to the wound. Most were surprised to learn that larvae don’t have teeth in their mouths and don’t bite. Instead, they score the wound surface with their mandibles and secrete an enzyme that liquefies the microbes, which they then ingest. The excess fluid is absorbed by the upper dressing.

Applying the containment dressing took 5 minutes. Then zinc oxide cream was rubbed into the periwound skin to protect it from moisture damage and the bag containing the maggots was placed where it contacted the wound bed. Wound location made this a bit difficult, but we managed it by placing multiple pieces of fluffed saline moist gauze on top of the bag and wrapping it firmly with a sterile gauze bandage.

Changes in the wound bed

After 24 hours, the wound bed was predominately a beefy red color and the dressing was saturated. What we’d assumed was slough in the bed actually was a tendon; striae were clearly visible and the surface had a shiny cream color. After 3 days of maggot therapy, the wound bed consisted entirely of moist red granulation tissue. Mr. Green experienced some pain, as would be expected with a wound proximal to nerves in the hand. We also suspected the biofilm had been coating and protecting the nerves until this time, so we chose to remove the maggots with the understanding that the biofilm should have been eradicated.

Additional therapy Mr. Green then underwent NPWT for 1 week, after which antibiotic ointment, petrolatum gauze, and sterile gauze were applied daily until discharge. He was discharged November 25, 2015 with an appointment to see a plastic surgeon to evaluate him for a planned skin graft; at discharge, the wound measured 1.6 cm x 2.5 cm x < 0.1 cm. The plastic surgeon told Mr. Green he’d need no further treatment.

Broadening the treatment options

Engaging other staff members and encouraging them to attend dressing changes contributed to the success of this first use of maggot therapy in our facility. After the first dressing change, Mr. Green’s wound improvement was so dramatic that it made a vivid impact on staff. This motivated them to discuss the results with their coworkers. Soon, staff from other disciplines began to approach me with questions and ask if they could attend the next scheduled dressing change.

Thanks to the success of our experience, we introduced maggot therapy throughout the Select Specialty Hospitals’ network of facilities in January 2016. Since then, we’ve treated at least a dozen patients.

Sally Anne Jewell is manager of wound care at Select Specialty Hospital Houston in Texas. (Mr. Green’s name in the case study was fictitious.)

[Tratto da: www.woundcareadvisor.com ]

Global Silver Antimicrobial Wound Dressing Market Research 20152019 and Future Forecast 20202025 [Published by 99Strategy] Prices from USD $2805

Silver Antimicrobial Wound Dressings are a relatively new family of advanced wound care dressings for the treatment of infected wounds. A silver dressing is a wound dressing impregnated with ionic silver. The ionic silver is responsible for the antimicrobial activity against infection caused by bacteria.

The report forecast global Silver Antimicrobial Wound Dressing market to grow to reach xxx Million USD in 2019 with a CAGR of xx% during the period 20202025.

The report offers detailed coverage of Silver Antimicrobial Wound Dressing industry and main market trends. The market research includes historical and forecast market data, demand, application details, price trends, and company shares of the leading Silver Antimicrobial Wound Dressing by geography. The report splits the market size, by volume and value, on the basis of application type and geography.

First, this report covers the present status and the future prospects of the global Silver Antimicrobial Wound Dressing market for 20152025.

And in this report, we analyze global market from 5 geographies: AsiaPacific[China, Southeast Asia, India, Japan, Korea, Oceania], Europe[Germany, UK, France, Italy, Russia, Spain, Netherlands, Turkey, Switzerland], North America[United States, Canada, Mexico], Middle East Africa[GCC, North Africa, South Africa], South America[Brazil, Argentina, Columbia, Chile, Peru].

At the same time, we classify Silver Antimicrobial Wound Dressing according to the type, application by geography. More importantly, the report includes major countries market based on the type and application.

Finally, the report provides detailed profile and data information analysis of leading Silver Antimicrobial Wound Dressing company.

Key Content of Chapters as follows Including and can be customized :

Part 1:

Market Overview, Development, and Segment by Type, Application Region

Part 2:

Global Market by company, Type, Application Geography

Part 34:

AsiaPacific Market by Type, Application Geography

Part 56:

Europe Market by Type, Application Geography

Part 78:

North America Market by Type, Application Geography

Part 910:

South America Market by Type, Application Geography

Part 1112:

Middle East Africa Market by Type, Application Geography

Part 13:

Company information, Sales, Cost, Margin etc.

Part 14:

Conclusion

Market Segment as follows:

By Region

AsiaPacific[China, Southeast Asia, India, Japan, Korea, Oceania]

Europe[Germany, UK, France, Italy, Russia, Spain, Netherlands, Turkey, Switzerland]

North America[United States, Canada, Mexico]

Middle East Africa[GCC, North Africa, South Africa]

South America[Brazil, Argentina, Columbia, Chile, Peru]

Key Companies

Molnlycke Health Care

ConvaTec

Smith Nephew

Coloplast Corp

Acelity

3M

Integra Lifesciences Corporation

Laboratories Urgo

Medline

Cardinal Health

Hartmann Group

McKesson

Hollister Incorporated

Deroyal

Milliken Healthcare Products

PolyMem

DermaRite Industries

Market by Type

Silver Foam Dressing

Silver Alginate Wound Dressing

Silver Barrier Dressing

Market by Application

Surgical Wounds

Burns Wounds

Chronic Wounds

Others

[Tratto da: www.bioportfolio.com ]

Pertinent Pearls In Coding For Wound Care Services

With the ongoing increase in available wound care products and services, this author discusses how to approach coding for these complex cases. 

Wound care is a large part of many podiatry practices today. There has been an explosion of wound care products and techniques that we may utilize in trying to treat the stubborn wounds we deal with on a day-to-day basis. Unfortunately, with the increased volume and cost of these items comes increased scrutiny of how and when we use these products and services. It is important to understand the most common aspects of billing and coding for wound care in order to succeed for both your practice and your patients.

Wounds can be very complicated with frequent and ongoing reevaluation of treatment outcomes. Some wounds go on to heal with simple measures and we are primarily monitoring progress until healing is eventually complete. These two scenarios differ from one another when considering proper coding. When billing an evaluation and management service (E&M) at the same encounter for which you are billing a procedure (such as debridement), there must be a significant and separately identifiable E&M service from the procedure in order to be paid for both services. This would require taking a history, performing an examination and then eventual decision-making. These three key components are the basis for an E&M service.

Remember that for a follow-up E&M service to be eligible for payment, you must document two of the three E&M components as being significant and separately identifiable. Also, for every procedure, there is an “E&M” portion built into the allowed fee. In this instance, one must document and show that there is more history, examination and decision making than would be included in the fee allowance for the procedure.

For example, a patient presents to your office with a new wound. You obtain a history of the wound, examine the wound and then decide what treatment to pursue. You also perform an in-office debridement. As a result, at this initial presentation of the wound an E&M service would be appropriate in addition to the procedure. The level of E&M service billed would NOT necessarily be based solely upon the complexity of the wound (e.g. exposed bone) but rather the level of each key component performed and the resulting level of documentation in your chart. As always, charting is key.

The patient then returns the next week for a follow-up visit. If there are no significant history or examination changes from the previous visit and the wound is progressing as expected, then there may not be an eligible E&M service separate from any procedure that one may also perform on that day. However, if at a subsequent visit, the physician needs to alter the wound care protocol (if the wound is deteriorating and additional imaging is necessary, or one needs to initiate or change antibiotic therapy), then an E&M service would be appropriate to bill based upon your level of documentation. The chart notes would need to document the changes that occurred since the last encounter and the associated decision-making.

Benefits And Pitfalls Of EHRs In E&M Documentation

With many office EHRs, there is the ability to bring information forward from previous patient encounters. This can be deemed templating or cloning of charts, but this is a double-edged sword. EHR-associated templating can make our lives easier when it comes to documentation and completeness of a chart note. However, you cannot use patient data or information brought forward from a previous chart note to augment your current chart note just to bill an E&M service, or a higher level of service.

Simply cutting and pasting the history from week to week does not meet proper documentation requirements. You would only get “credit” for any history that has changed since the last encounter. Similarly, if the examination is unchanged except for the fact the wound is getting smaller and progressing as expected, then there is no real “credit” there either. Lastly if your decision making is essentially to “continue with current treatment course,” there is no added consideration there as well. Without documentation of changes in history, additional examination or decision making (at least two of three components), there is no additional E&M service to bill. Lastly, be very careful with templates as one may inadvertently bring charting errors forward as well that can make your chart look poor and clearly templated.

Key Concepts In Coding For Wound Debridement

Debridement is a common part of the treatment algorithm for wounds. There are two debridement code series, Current Procedural Terminology (CPT) 9759X and 1104X, that clinicians can utilize. CPT series 9759X involves selective debridement of epidermal and dermal tissue, and superficial biofilm. CPT series 1104X involves the excisional debridement of deeper tissue including subcutaneous tissue, muscle, tendon or bone. One also needs to clearly identify the type of tissue he or she has debrided in the chart notes.

In addition, proper documentation should include the location of the wound, the size of the wound, the instruments one uses for debridement, if anesthesia is required and the type and anatomic depth of debridement. Additionally, examination documentation should include the condition and characteristics of the wound bed as well as notation on any drainage, odor or cellulitis.

We often see multiple wounds on the feet and selection of the appropriate code is based upon the aggregate size of similar wounds, not on a right foot or left foot basis. Remember that wound codes are not foot specific. They apply to the entire body. Accordingly, one determines the codes based on the tissue type debrided and these codes are applicable to any body part. Therefore, add up all similar wounds of similar debridement depths and combine them into one code per the appropriate aggregate sizing.

If there are three wounds on a foot, two of which require debridement to subcutaneous tissue and a third wound requires only dermal debridement, the proper coding would be CPT 11042 (debridement of subcutaneous tissue) for the composite two wounds requiring subcutaneous tissue debridement and CPT 97597 (debridement of non-viable tissue) for the third wound, which requires only more superficial selective debridement. Do not use right or left foot modifiers as those are incorrect and will result in your claim being denied. A -59 modifier is necessary to be paid for both debridement codes when you bill them on the same day.

These wound care codes are listed per 20 sq cm. If the aggregate size of similar wounds exceeds that amount, there are add-on codes that clinicians can bill. Accordingly, for the debridement of an aggregate 60 sq cm wound through subcutaneous tissue, CPT 11042 applies for the first 20 sq cm and CPT 11045 (two units in this case) applies for each additional 20 sq cm.

Correct measurement of wounds is important not only to document the presence or absence of improvement, but also to properly select the appropriate CPT debridement code. A wound may be 4 cm in overall diameter but the base of the wound, which has the subcutaneous tissue you are debriding, is only 2 cm in diameter. Billing is based upon the deepest tissue debrided and the amount of that specific tissue in square centimeters. In this scenario, one is debriding two sq cm. Keep in mind that if the wound extends deep to bone but you only debride subcutaneous tissue, the proper billing level would be CPT 11042 (debridement subcutaneous tissue), not CPT 11044 (debridement of bone).

When applying skin substitutes, one needs to perform some basic wound preparation/care prior to the application of the product. This wound preparation may include some tissue debridement. CPT 15271 is used for application of the product on the leg and CPT 15275 for the foot. You cannot bill both CPT series 1527X in combination with either CPT 9759X/1104X series codes as this would be essentially duplicate billing. You can only bill for the wound preparation codes when applying a wound care product. CPT 15271 for application of the product on the leg and CPT 15275 for the foot are designated in 25 sq cm increments. The add-on codes are CPT 15272 (for the leg) and CPT 15276 (for the foot) are used for aggregate wounds greater than 25 sq cm and billed per each 25 sq cm increment. If the wounds were to exceed aggregate 100 sq cm in size, CPT 15273/15274 and CPT 15277/15278 codes are to be used as a single code (i.e you cannot bill CPT 15277 in addition to 15275 and 15276, but these should be rare in the foot and ankle).

Choosing Proper Coding For Skin Substitute Products

The next issue is selection of a skin substitute product. Many products have specific FDA indications. Some are only indicated for diabetic foot wounds or venous leg ulcers. Reimbursement for the use of these products is limited to those indications. If the patient has an ulcer but is not diabetic, some wound care products may not be approved if the indication is only for a diabetic foot wound. Not all products are indicated for exposed bone or tendon, either. Some insurance companies have additional requirements. One example may be in regard to the coverage or lack thereof for small wounds. There may be a minimum one cm diameter wound size requirement, which clinicians need to be aware of. Additionally, some insurances have limitations on the number of times a clinician can use a product without additional authorization.

Each skin substitute product has a specific Q code, which identifies the product. Make sure the product you use is properly identified. Exercise caution if a manufacturer representative tells you to bill his or her company’s product using a certain Q code just because it is “similar” to some other product.

Therefore, when dealing with private insurance carriers, it is important to pre-authorize every wound care product. This applies to both primary as well as any secondary insurance carriers. These products are very expensive and if the product is not allowed for any reason then the facility, provider or patient will be billed in full for the product.

Many patients today have insurance plans with very high deductibles so even though the use of skin substitute and other advance wound care products maybe a covered benefit they may or may not be affordable. Even a 20 percent co-insurance may be out of reach for some patients. Keep this in mind when selecting products for your patient. One may need to make compromises when selecting products based, unfortunately, on financial concerns. In addition to any medical indications, the place of service may also be an issue. Some products are only reimbursable when the application is in an operating room setting versus a private office or wound care center.

The next question is when to start using skin substitutes. That obviously depends on the quality of the base of wound. This documentation is also necessary from a medicolegal aspect as well. If the wound bed is poor, one first needs to perform proper debridement and wound preparation. If there is significant venous insufficiency and edema, physicians need to address that promptly. Other things to consider are addressing out of control hemoglobin A1c levels and overall vascular status. Superficial or systemic infections warrant primary treatment as well. There also needs to be proper offloading. If one does not address these factors, these products, although very effective, can be significantly hindered in their ability to heal wounds.  If the insurance carrier only allows five product applications, then using the product on an improperly prepared wound bed would be wasteful and detrimental to the patient.

Many insurance carriers require some level of more conservative care before initiating the start of skin substitutes or other advanced wound care products. This is obviously controversial. The current standard in wound healing is 50 percent closure of the wound in four weeks. One could make the argument of starting wound care products, such as skin substitutes, as quickly as possible for patients who have high morbidity issues. However, many carriers may want at least four to six weeks of conservative treatment that could include documentation of offloading, local debridement, compression and addressing infectious or metabolic issues. Documentation of wound size and quality is very important in these cases.

If one institutes conservative wound care measures and the wound is showing steady progress with these measures alone, then the question becomes “Should a skin substitute be used at all?” This is an area of discussion right now with various Medicare carriers. If the wound is going to heal on its own based upon addressing factors such as glucose levels, infection, offloading, and compression, then it may very well heal without applying skin substitutes. There needs to be documentation of why, if a wound is healing on its own in a reasonably steady fashion, skin substitutes are required. This is a current area of audit and Medicare scrutiny. If the wound healing has stalled or is progressing very slowly, then proper documentation of this may result in authorization from the insurance carrier and also protect you in the case of an audit.

I personally recommend making patients aware of insurance company regulations and restrictions so they can also help advocate for themselves. This can be helpful when dealing with the insurance company to get authorization for wound care services and products.

Navigating Off-Label Uses For Wound Care Products

There have been many recent audits surrounding wound care products. Many of these audits are related to not using the proper product for the proper type of wound. Newer audits are for non-wound-related uses of skin substitutes. Many products, imaging systems that are commonplace now were at one point off-label. If you are using a skin substitute for an off-label use, make sure you and/or your staff are very clear about the product you are using, and how you will use it when obtaining a pre-authorization.

Physicians are using wound care products in non-wound-related foot surgery to augment tendon repairs and act as an interface between tissue layers to limit adhesions and/or scarring. Unfortunately, I have seen requests for the use of these products in simple hammertoe repairs and even matrixectomies! Be able to prove some level of medical basis for the off-label use of these products in an appeal situation. A surgeon’s personal preference/past experience is not enough.

Also be careful when interacting with manufacturer representatives who may imply proper use of these products in situations that may indeed be inappropriate. This may get you flagged for an audit. Make sure you document the off-label use of the product and that you informed the patient you were using the product off-label. You should have the patient sign a form similar to an ABN stating that he or she acknowledges the off-label use of the product, agrees to pay for the product and that the insurance company will not be billed for it

In Conclusion

Wound care has been an integral part of the podiatric profession for quite some time. This field and its available treatment options has exploded over the past few years. It can be a very professionally rewarding part of your practice. In order to best succeed in the treatment of wounds, make sure you and your staff are well versed in treatment options, product availability, indications and proper billing protocols.

Dr. Poggio is a California Podiatric Medicine Association Liaison to Noridian JE MAC and a medical consultant to several national health insurance and review organizations. He is a member of the American College of Podiatric Medical Reviewers and is board-certified by the American Board of Podiatric Medicine and the American Board of Podiatric Orthopedics and Primary Podiatric Medicine. 

[Tratto da: www.podiatrytoday.com ]