Ask the Experts: What is the Current Perspective Regarding Supervision of Hyperbaric Dives by Nurse Practitioners?

  • The Wound Care Education Partners blog, Rx Pad
  • Volume 06 - Issue 2

Question: “I would be interested in the current perspective regarding supervision of hyperbaric dives by nurse practitioners.

  1. Is it safe?
  2. What preparation for supervision is appropriate?
  3. How many centers across the nation are using NPs?
  4. What are the pros and cons to having an NP supervise dives?

Other policy or procedure recommendations for NP supervision of dives.”

Question from Carol, BSN, RN and student of Wound Care Education Partners.

Our Experts Offer the Following Answers:

Question 1. Is it safe?

Answer. It is safe with appropriate preparation. As with other disciplines within medicine that utilize nurse practitioners and physician assistants, the provision of safe care is a function of proper training and sufficient supervision. The UHMS (Undersea and Hyperbaric Medical Society) and the National Board of Diving and Hyperbaric Medical Technology (NBDHMT) consider mid-level practitioners qualified to safely supervise Hyperbaric Oxygen Therapy (HBOT) so long as those criteria are met (see position statements below).

Question 2.  What preparation for supervision is appropriate?

Answer. The UHMS position statement provides the following information:

The Non-Physician provider specific recommendations:

     a) The UHMS supports the on-site supervision of hyperbaric oxygen therapy by a nurse practitioner or physician assistant if each of the following conditions is met:

      i. The supervising physician meets the UHMS recommendations for physician attendance as per UHMS guidelines.

     ii. The supervising physician is immediately available to the Hyperbaric Medicine Department as specified by applicable government regulations.

    iii. The nurse practitioner or physician assistant has obtained appropriate specialty certification through the NBDHMT as a Certified Hyperbaric Registered Nurse (CHRN) or Certified Hyperbaric Technologist (CHT), or international equivalent.

 The NBDHMT position statement provides the following information:

     a) HBO must be directly supervised by a physician (or nurse practitioner/physician assistant where permitted by prevailing credentialing and regulatory standards) who is formally (UHMS or other authoritative body) trained in hyperbaric medicine, involving face-to-face classroom versus online setting. Such supervision should extend to:

       a. Assessment of suitability for HBO therapy

       b. Determination of risk benefit profile

       c. Interpretation of any related diagnostic testing

       d. Generation of a therapeutic dosing profile

       e. Evaluation of subsequent clinical course, and

       f. Management of any related side effects and complications

Further, the hyperbaric physician must be on the premises and immediately available to the chamber facility at all times that the chamber(s) is occupied. Immediately available would meet the intent of this Position Statement if the physician could arrive at the chamber facility within five minutes of being summoned and in doing so, would not place in jeopardy any other patient presently under his/her care.

It is the duty of hyperbaric nursing and technical personnel to safely implement ordered therapy and closely monitor patients during their treatments. Should a patient voice complaints or manifest signs suggesting an unanticipated change in status, considered to be hyperbaric related or otherwise, the hyperbaric physician should be immediately notified. Importantly, hyperbaric nursing and technical personnel do not assume any of the physician responsibilities noted as complaints or manifest signs suggesting an unanticipated change in status, considered to be hyperbaric related or otherwise, the hyperbaric physician should be immediately notified. Importantly, hyperbaric nursing and technical personnel do not assume any of the physician responsibilities noted above and cannot initiate hyperbaric treatment without patient-specific hyperbaric physician signed medical orders.

Question 3. How many centers across the nation are using NPs?

Answer. At this time, there are only a few.

Question 4. What are the pros and cons to having an NP supervise dives?

Answer. As with many pro/con discussions, the determination of which elements fit into a given category hinges largely on one’s perspective. Any substantive answer must acknowledge the parties represented in this discussion, which include: patients, mid-level providers, physicians, and administration. Each group will see this topic through a unique lens and there are opinions that won’t be represented here. The points made below are not listed as pro or con for those reasons.

Patient: Some may prefer physician-level supervision, but there shouldn’t be any difference in the actual treatment provided.

There are no cost savings to the patient subsequent to having mid-levels supervise HBOT.

Mid-level: Enjoyment of engaging in hyperbaric medicine, expanded scope of practice, potential for additional income.

Physician: Potential for reduced work hours and revenue loss due to less time working in HBO, increased requirement for direct supervision of mid-levels and immediate availability. Responsibility for mid-levels requires additional work and liability which are frequently not associated with added compensation.

Administration: Potential for greater scheduling flexibility as more people can supervise treatments. Mid-levels are paid less but physician supervision and immediate access may offset these overhead reductions.

Question 5. Other policy or procedure recommendations for NP supervision of dives.

Answer. One recommendation is to include a nurse practitioner job description per NP scope of practice guidelines. In addition to broadening the scope of practice, hyperbaric specific training, experience, and competency standards are necessary for credentialing purposes within a healthcare facility. While stand alone wound care centers may not require that level of documentation, proof of training and experience is part of the UHMS and NBDHMT position statements.

References: Expert answers provided by Laura Josefsen, RN and Nick Bird, MD, MMM

This article was previously published in Wound Care & Hyperbaric Medicine magazine Volume 5 Issue 1.

About the Experts

Laura-Josefsen

Laura Josefsen, RN, ACHRN, is on the UHMS (Undersea and Hyperbaric Medical Society) Board of Directors as the current Nurse Representative on the Associates Council, and has been a member of the UHMS Accreditation Team as a nurse surveyor since its inception. She is a founding member of the (BNA) Baromedical Nurses Association, served as president from 1996-1998, and has been active on the executive board since 1985. She served for many years as an Executive Board Member of the NBDHMT (National Board of Diving and Hyperbaric Medical Technology), and is a previous member of the BNA Certification Board. She is currently on the Board of Directors of the TMAA (Texas Medical Auditors Association). She is a member of the Undersea and Hyperbaric Medical Society Associates, former member of DAN (Diver’s Alert Network), and HTNA (Hyperbaric Technologists and Nurses Association) of Australia. She has numerous publications and is  an internationally recognized speaker in the field of hyperbaric medicine.

 

Nick-Bird

UHM Nick Bird, MD, MMM, is a fellowship-trained, board-certified hyperbaric physician. He is the past CEO and Chief Medical Officer for Diver’s Alert Network (DAN) in Durham, North Carolina. Prior  to his position with DAN, he served as the Medical Director of Hyperbaric Medicine at Dixie Regional Medical Center in St. George, Utah. Additionally, Dr. Bird served in the United States Air Force as a flight surgeon and received his initial training and experience in hyperbaric medicine at Travis AFB while working as the Deputy Flight Commander of the hyperbaric /wound center. He was honorably discharged with the rank of Major, but not before serving as the final Commander of the Base Hospital in Jordan during Operation Iraqi Freedom.

Earning his Bachelor of Arts degree from the University of California at Santa Cruz in 1992, Dr. Bird went on to earn a medical degree from the Royal College of Surgeons in Ireland in 1999. He completed a residency in family medicine under the University of Washington and a fellowship in hyperbaric medicine at the University of California at San Diego. In addition to his fellowship training, he attended the US Air Force hyperbaric course, the International ATMO program, and the NOAA Diving Medical Officer course.

Dr. Bird has remained a clinical instructor in hyperbaric medicine and wound care. He is an active member of the UHMS, works as part of the UHMS accreditation team, has authored articles and book chapters in diving medicine, is a member of the UHMS Diving Medicine Committee, and he has both attended and presented at multiple conferences on diving and hyperbaric medicine. Additionally, he was the course director for the DAN DMT course and author of the revised series of DAN educational programs.

 

 

 

Clinic in Focus

  • Swedish Edmonds Center for Wound Healing and Hyperbarics
  • Volume 06 - Issue 2

Continuing our series of interviews featuring outstanding hyperbaric and wound care centers around the world, we spoke with Susan Lowber at Swedish Edmonds Center for Wound Healing and Hyperbarics, a UHMS-accredited facility in Edmonds, Washington.

How long has your clinic been in business?

The hospital site has been here for over 50 years and has offered wound healing services for over 10 years. We expanded to include hyperbaric medicine in the fall of 2008.

How has seeking UHMS accreditation affected your clinic?

In order to receive accreditation, our facility underwent an intense review by a team of UHMS experts. The team examined staffing and training, equipment installation, operations and maintenance of the facility, patient safety, and standards of care. Accreditation by the UHMS recognizes a center’s commitment to patient care and safety and is validation that the center meets the most rigorous industry standards.

The accreditation gives confidence to both the patient and other community providers that we are providing excellent care to the patient while up- holding the highest safety standards and clinical knowledge. We are one of only two centers in the state of Washington that are accredited.

What are the most common indicators treated at your clinic?

In the wound clinic: leg ulcers (both venous and arterial), wounds resulting from peripheral edema, diabetic foot ulcers, post-surgical wounds, decubitus ulcer, and infected wounds.

For HBO treatments: severe diabetic foot ulcers, compromised surgical flaps and grafts, medical conditions resulting from radiation injury (soft tis- sue radionecrosis and osteoradionecrosis), and refractory osteomyelitis.

What is the most memorable treatment success story that has come out of your clinic?

We have had many remarkable outcomes, particularly with hyperbaric medicine patients. But  recently we had a patient who had complications from radiation therapy after treatment for esophageal cancer, which resulted in soft tissue radionecrosis (STRN). She developed an esophageal cutaneous fistula, an opening where fluids would leak through her throat, and she was unable to swallow or eat and had constant drainage of saliva from her neck. After 50 hyperbaric oxygen therapy treatments, her fistula healed and was no longer draining. She was ecstatic as she was now able to eat and drink again after not being able to do so for several months.

Do you work with a management company?

No, we are independent.

CLINIC DETAILS
Swedish Edmonds Center for Wound Healing and Hyperbarics
21600 Highway 99, Suite 150, Edmonds, WA 98026
http://www.swedish.org/services/wound-healing- hyperbarics-edmonds
(425) 673-3380
Date of UHMS Accreditation: January
2013 Number of chambers: 2
Chamber type: Monoplace
On staff: 2 full-time physicians / 4 full-time RNs / 1 safety supervisor CHT / 1 CHT / several part-time RNs
Dr. Peter Ro, Medical Director

If you had to pick one thing to attribute your clinic’s success to, what would it be?

Caring. Our experienced clinical staff genuinely cares about the patients. Not only do we address the wounds, we also look at the condition of the patient as a whole for multiple factors that can affect wound healing, including nutrition, medications, insufficient blood flow to arteries, and other illnesses. When appropriate, our wound care team will refer patients for studies and collaborate with other medical specialties to ensure our patients are receiving comprehensive, quality care. We also assist patients in obtaining social services and home healthcare if they seem unable to make arrangements for themselves. We have many satisfied patients who have given us excellent reviews upon completion of their treatments.

What is one marketing recommendation that you can make to help clinics increase their patient load?

We believe that developing good relationships with our referring providers are key to growth for our center and would also benefit other wound healing centers. Both of our physicians regularly and pro- actively engage in personal communication with the referring providers, whether by phone or face- to-face contact, which is always appreciated by the medical community.

Are there any additional questions you'd like to answer, or is there any other information about your clinic you would like to showcase?

Both of our physicians are board certified in undersea and hyperbaric medicine. One of our physicians, James Wright, MD, FACS, is a board certified plastic surgeon and has also been involved in research in hyperbaric medicine during his tenure with the US Air Force. Darren Mazza, our Hyperbaric Safety Supervisor, has been the recipient of the monthly “Most Valuable Player” (MVP Award) from our hospital, Swedish Edmonds. He has also writ- ten several articles on hyperbarics in the clinical setting.

Last May, we moved into a state-of-the-art facility near our hospital, with 10 treatment rooms located on the ground floor level for ease of access for our patients. And finally, our patient satisfaction numbers are high: 92.9% in 2014 and 96.0% to date for 2015.

Pictured below: The staff of the Swedish Edmonds Center for Wound Healing and Hyperbarics in Edmonds, Washington.

clinic-in-focus-6-2

 

Give Me a Break

  • Darren Mazza, EMT, CHT
  • Volume 06 - Issue 2

Air Breaks During Hyperbaric Treatment

When treating patients with hyperbaric therapy in the monoplace chamber using 100% oxygen, the supervising hyperbaric physician may order air breaks to be provided to the patient at certain intervals during the treatment.

What is an air break? During a typical air break, the patient will be instructed to breathe medical air from a mask at certain intervals during the treatment for around five minutes at a time, depending on the provider’s written order. In my past working as an EMT, any time we had a patient with an inhalation injury such as from smoke inhalation or exposure to chemical fumes, the primary treatment guideline was to immediately get the patient on high flow oxygen and into a clean air environment. A saying we used to use was “the solution to pollution is dilution.” When providing air breaks to a patient, you dilute the oxygen concentration the patient breathes in the chamber from 100% down to around 21% via demand valve mask. This switch to air will in turn reduce the risk of CNS oxygen toxicity by giving the patient a break from the 100% oxygen concentration in the chamber.

The use of air breaks during treatment is dependent upon two key CNS oxygen toxicity potentiating factors: treatment depth/time and predisposing factors noted in the patient’s medical history.

  1. Treatment depth/time: Studies have shown that CNS oxygen toxicity occurrences are 1.3 in 10,000 patients at treatment depths >2.0 ATA.
  2. Prior medical history: Patients with hyperthyroidism or who are CO2 retainers are at greater risk for CNS oxygen toxicity due to vasodilation in the brain. Seizure disorders and certain medications, such as epinephrine and steroids, may also increase susceptibility.

It is important to be aware of the signs and symptoms of CNS oxygen toxicity, which are represented in the below acronym.

CON – Convulsions (seizure)
V – Vision changes
E – Ears (tinnitus)
N – Nausea
T – Twitching, facial
I – Irritability
D – Dizziness

Keep in mind that any of these symptoms can occur at any time, and the patient may only present with one of the symptoms such as nausea, dizziness, or even irritability. This is why it is essential to observe the patient during the entire hyperbaric treatment. I have found that the more I observe each patient during the course of the treatment, the easier it is for me to notice any changes in his or her demeanor, such as increased irritability. At the first sign of any symptoms of CNS oxygen toxicity during a hyperbaric treatment, the patient will be instructed to breathe from the mask while being brought to surface, and treatment will be aborted. If the patient begins to have a seizure, the treatment depth would not change until the provider determines the patient to be in a postictal state.

When providing patients with instruction on the use of the air break equipment, it is extremely important that they demonstrate competency in using the equipment so they can adequately provide themselves with an air break during treatment. Before every treatment, I instruct the patient to take two breaths from the air break line and mask and confirm two things: that the mask provides an adequate seal and the regulator provides proper air flow, allowing the patient to breathe freely with no resistance. Occasionally, when a patient is instructed to begin an air break, the patient places the mask carelessly without providing a proper seal to their mask. Risk of oxygen toxicity to the patient will be increased if they are not properly utilizing the equipment by sealing the mask and breathing appropriately from the regulator. Again, it is important to observe the patient during treatment to ensure the correct use of the equipment and to note any changes in demeanor that may point to possible CNS oxygen toxicity.

Final Note

Keeping patients safe during their hyperbaric treatment is my absolute focus; in the hyperbaric environment there is no room for complacency. Providing proper education to a patient about possible risks that may occur during treatment and corresponding safety guidelines will encourage the patient to become proactive in his or her care and understand the importance of correctly using equipment, such as air break equipment, during treatment.

 

About the Author

Darren Mazza is the CHT and Safety Director at the Center for Wound Healing and Hyperbarics at Swedish/Edmonds, located in the greater Seattle area. He has 20 years of experience in healthcare, which includes 8 years as an EMT in the greater Sacramento region. Darren also worked as a preceptor trauma tech in a Sacramento hospital for several years. After leaving California and moving to Idaho in 2005, his hyperbaric career began after becoming the department head of an outpatient wound care and hyperbaric center. His hobbies include fly fishing and fly tying.
 

 

Fox01Catcher

  • WCHM
  • Volume 06 - Issue 2

 

An Interview with Dr. Dana Graves on the Role of FOXO1 in Diabetic Patients

 

WCHM had the good fortune to land an interview with Dr. Dana Graves, who led a team of researchers investigating the FOXO1 molecule’s role in promoting healing in patients with chronic wounds and diabetes. We interviewed him about information on his recently published research. Dr. Graves is a professor in the Department of Periodontics, Vice Dean for Scholarship and Research, and Director of the Doctor of Science in Dentistry Program for Penn Dental Medicine under the umbrella of the University of Pennsylvania. Penn Dental Medicine is an ivy-league institution with a deep history in forging precedents in dental education, research, and patient care.

WCHM: Dr. Graves, can you please tell us about your background and what led to your interest in mucosal wound healing and diabetes?

DG: Well, I am a clinician. I am periodontist and I treat patients. One of the striking things about periodontal disease is that it is enhanced or increased by diabetes. Diabetes has effects on different tissues. As a  periodontal surgeon, I place implants and perform surgeries where the wound healing response is impaired by diabetes. I became interested in the molecular mechanisms by which diabetes affects different tissues. I have studied bone as well as soft tissue healing, and I’ve been interested in how diabetes slows the healing process.

WCHM: Would you please explain your research of diabetes and non-healing wounds and your findings?

DG: In diabetes, a non-healing wound results from a number of events. In the early aspects, the wound heals slowly. A slower healing wound then can become colonized by bacteria, which sets up a non-healing situation. The aspect that I’m interested in is the initial aspect, which is the diabetic wound heals more slowly. I’m interested in why the wound heals more slowly, and I have not focused on the second aspect, which is why a slowly healing wound converts to a non-healing wound.

So think of it as two processes, and they’re linked together. The more slowly healing wound allows a situation to develop where the wound becomes colonized and doesn’t heal.

WCHM: What do your findings suggest is the link between FOXO1 and diabetes?

DG: We were originally examining FOXO1 in normal wounds. And we deleted the FOXO1 gene keratinocytes, which are the cells that form the outer layer of skin and are involved in closing the wound. The goal of wound healing is to close the wound as rapidly as possible. And the cells that are really essential for that are the keratinocytes, which are the outer layer. So we deleted FOXO1 in this particular layer of cells, and in the normal wound we found that when this particular gene was deleted, healing was much slower. This shows that the gene is needed because when it was removed, the healing got worse.

Then we found out what FOXO1 was regulating and we figured out the mechanism. I was then interested in finding out what might happen in a diabetic wound. So we created a wound on a diabetic animal and it healed more slowly, which is what you would expect.

Then we deleted the FOXO1 in the diabetic animal and the odd thing was that it speeded up healing. This was a real surprise. So you delete FOXO1 in the normal wound and it behaves like a diabetic wound. You delete FOXO1 in the diabetic wound and it behaves like a normal wound.

So it seems like this particular factor is a good factor in a normal wound but becomes a bad factor in a diabetic wound. The reason we say this is that when you delete this particular gene in the outer layer of cells, healing in the diabetic wound speeds up.

So our interpretation of this observation is  that the FOXO1 molecule is interfering with healing because when you remove it, healing is faster and occurs at a more normal pace. What we then establish from this work is that FOXO1 plays an important role in promoting healing under normal circumstances, but in diabetic situations (or diabetic healing), this same molecule becomes a problem. So it becomes a “bad apple.”

WCHM: Can you talk about what these findings mean for the future of diabetes care?

DG: When you take a molecule that has gone from being a good factor to a bad factor, what you normally do is inhibit it under conditions where it’s harmful. This would suggest that if you can inhibit it in the diabetic wound, healing would be improved.

The next step is to try and develop a therapeutic factor. We have so far reduced the activity of the gene through genetic manipulation, so now we need to test what the impact of inhibiting it with a small molecule would be. These are experiments we have on the drawing board and will carry out very soon.

WCHM: I think you may have answered our next question. What are your future research plans for FOX01?

“We deleted the FOXO1 in the diabetic animal and the odd thing was that it speeded up healing. . . So you delete FOXO1 in the normal wound and it  behaves like a diabetic wound. You delete FOXO1 in the diabetic wound and it behaves like a normal wound.”

DG: The progression is to now perform experiments in a large animal model. We have established the concepts in mice and in order to do pre-clinical trials, we need to move in a  larger animal. We plan to do these experiments in a larger animal to see if we applied this therapeutic factor, which is to inhibit FOXO1 with a small molecule, can we improve the healing environment for the cells.

WCHM: A number of our readers practice both wound care and hyperbaric medicine, so can you tell us a little about the impact your research findings might have on hyperbaric medicine in the future and how this could affect hyperbaric practitioners?

DG: Well, the link between FOXO1 and wound healing is pretty clear, and it is possible that there are links to the hyperbaric question you asked. How- ever, at this point they’re not known, and I wouldn’t be able to provide any real insight to that.

WCHM: Is there anything additional about your research and findings that you would like to address?

DG: Yes, well there is something that I think is quite interesting. It’s a bit technical. And that is when we looked to see what caused FOXO1 to change from being a good factor that promotes healing to a bad factor that inhibits it, we found that glucose itself caused that change. There is something about the high glucose environment that modifies the activity of FOXO1 which determines its particular consequences.

WCHM: Dr. Graves, if any of our readers would like to find more details or follow the research you’re doing, where can they get more information?

DG: They could look up my name, Dana Graves, in PubMed, which is a website run by the government that lists all the published articles. I have a follow- up study coming out in April in the Journal of Cell Biology that describes the impact on skin. So the first set of studies were on mucosal wound healing and the second set of studies, which we’ll publish in April, deals with skin healing. And I think that it’s interesting that this particular molecule FOXO1 is important to both types of wounds.

WCHM: Do you have any plans for presentations at upcoming conferences that you’d like to tell our readers about for anyone who might be interested in connecting with you personally and hearing more about your research?

DG: Yes, I’ll be presenting on this in the June 2015 Diabetes Conference in Boston.

WCHM: Dr. Graves, thank you for joining us today and sharing your research and findings with our readers. We look forward to connecting with you again and finding out more about your research and your future studies.

DG: Thank you very much for having me and having this discussion.

 

Dr. Grave’s article is published in Diabetes. Xu F, Othman B, Lim J, Batres A, Ponugoti B, Zhang C, Yi L, Liu J, Tian C, Hameedaldeen A, Alsadun S, Tarapore R, Graves DT. Foxo1 inhibits diabetic mucosal wound healing but enhances healing of normoglycemic wounds. Diabetes. 2015 Jan: 64(1): 243-56. doi: 10.2337/db14-0589. Epub 2014 Sep 3.

 

ICD-10-CM Wound Care Review Part 1

  • Gretchen Dixon, MBA, CCS, CPCO
  • Volume 06 - Issue 2

Bolstering Your Documentation for the Four Most Common Wound Diagnoses in the Clinical Setting

Level of Acuity with Intensity of Services and Complexity of Care

As we draw nearer to the ICD-10-CM go-live date of October 1, 2015, now is the time to identify and address any weaknesses that may affect future reimbursement for provided services. As a provider, your documentation is the key source of information supporting the level of acuity with intensity of services and complexity of care for each of your patients. As we have discussed before, if your documentation is without details, inconsistent, ambiguous, or incomplete, your patient’s level of acuity and provided services may not be supported. It is anticipated that within approximately two years after the implementation of ICD-10-CM, through data mining, unspecified codes will be reimbursed at a lesser value. Why? Unspecified codes only support a low level of acuity with the intensity of services and complexity of care. The use of unspecified codes may affect your profiles, which are monitored by third party payers as well as the public. Third party payers can remove providers from their plans if they feel there is an over-reporting of services based on diagnoses reported.

Focus on ICD-10-CM and Wound Care

Take this time to revisit your use of selected un- specified codes. In the wound care environment, a good start would be to review documentation details required for the four most common types of ulcers/wounds treated in a wound clinic. Of course, this does not exclude the fact these types of wounds are diagnosed in all healthcare settings, thus the documentation information value is for all types of providers. This article breaks out the following wounds/ulcers and outlines their documentation requirements for this specificity:

  1. Diabetic foot ulcer
  2. Pressure ulcer
  3. Trauma wound (will be discussed in a future article)
  4. Arterial ulcer

REMINDER: Don’t forget to sequence diagnoses!

List your first diagnosis (called the principal diagnosis or PDX), which supports the reason for the encounter and services provided. Per ICD-10-CM Coding Manual directions: code first any associated underlying condition. Instruction examples are to code first diagnosis, such as atherosclerosis of lower extremities, diabetic ulcers, or associated gangrene.

List all other diagnoses (called secondary diagnoses), which describe any co-existing conditions which require or affect patient care treatment or management.

  1. First diagnosis: type 2 diabetes mellitus with foot ulcer of right planter foot
  2. Secondary diagnoses that affect the management of the patient's treatment:
  • Right foot plantar surface ulcer involves the necrotic subcutaneous tissue
  • Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (microvascular disease)
  • Hyperglycemia

GENERAL ICD-10-CM DOCUMENTATION GUIDELINES FOR ULCERS OR WOUNDS

When describing ulcers and wounds, it is necessary to include additional details in specific categories:

  • Anatomical location — be as specific as possible
  • Diagnosis — related complications (example: atherosclerosis of specified vessel involving the right lower extremity with ulcer)
  • Secondary diagnoses that affect the patient's treatment and/or management of care
  • Describe the severity (depth) of the non-pressure ulcers (wound descriptions provided later in this article)
  • Pressure ulcers are required to have the stage reported, not the severity of the wound tissue noted above

NOTE: Electronic health records can help the provider include specific information, thus improving clinical documentation. However, the point-and- click process of adding information can result in the use of pre-determined verbiage for general diagnoses rather than objective observations made during the patient visit. Therefore, documentation details may need to be added as free text for clarification. DO NOT rely on the same identical phases used for all patients during visits! The individuality of the patient is frequently eliminated and patient records all read the same.

WOUNDS MOST COMMONLY TREATED IN A WOUND CLINIC

Diabetic Foot Ulcer

Diabetic ulcers (DFUs) require detailed documentation and more than one ICD-10-CM code to accurately describe the patient’s condition. The first diagnosis is always the reason for the encounter, which would be the ulcer.

DFU Case Scenario: The patient’s diagnosis is ulcer on the plantar surface, involving subcutaneous tissue, of the right foot due to diabetes with circulatory complications and hyperglycemia. Patient’s blood glucose is not well controlled and ranges from 180 to 230 mg/dL on a regular basis as reported by the patient. Currently the patient is on the following medications: metformin, glipizide, and NPH insulin injections in the morning and at bedtime.

Documentation details of DFUs are often problematic and can result in the diagnosis being incorrectly coded. This is due to documentation that is ambiguous, inconsistent, vague, or incomplete, which can cause the question of which came first: the ulcer in a diabetic patient or a diabetic patient who developed an ulcer due to complications of the disease? Documentation needs to clearly identify the causative relationship since not all wounds/ ulcers have this relationship with diabetes.

So, what do you document? Looking at the above scenario, we can discuss the ICD-10-CM coding options that would need to be applied.

This is an established patient with an identified DFU of the plantar surface on the right foot. The ulcer involves the necrotic subcutaneous tissue and is due to diabetes microvascular disease. The patient exhibits hyperglycemia with blood sugar ranges from 180 to 230 mg/dL, with today at 190 mg/dL.

The first diagnosis would be type 2 diabetes mellitus with a skin ulcer. The following information relates to specific documented diagnoses of diabetes with complications related to wound care services. Note how the ICD-10-CM code description has been expanded as a combination code different from the broadness of ICD-9-CM diagnosis codes. Table 1 provides the specific coding description of options for type 2 diabetes mellitus with skin complications. Blue highlight represents the applicable code.

 

Table 1
ICD-10-CM Code ICD-10-CM Code Description
E11.620 Type 2 DM with diabetic dermatitis
E11.621 Type 2 DM with diabetic foot ulcer
E11.622 Type 2 DM with diabetic other skin ulcer
E11.628 Type 2 DM with diabetic other skin ulcer complications

DM=diabetes mellitus

Diabetes Mellitus-Related ICD-10-CM Codes

In ICD-10-CM, several changes are noted according to ICD-10-CM Draft Official Guidelines for Coding and Reporting. During the development of ICD- 10-CM, diabetes combination codes were created requiring the following three components to be reported:

  1. Type of diabetes (type 2 is the most common in wound clinics)
  2. Body system affected (nervous, circulatory, nephrology skin)
  3. Complication affecting a body system

NOTE:¹

  • ICD-10-CM coding guidelines: select or assign codes as necessary to describe all of the complications of the disease
  • Sequence diagnoses based on reason for the encounter
  • If the type of diabetes is not documented, the default diagnosis code to be selected is type 2 diabetes mellitus or ICD-10-CM code E11.XX
  • Document when the patient is on insulin versus oral hyperglycemic medications
  • In describing the patient's blood sugar control, the provider needs to avoid the use of terms controlled or uncontrolled and use the terms inadequately, out of control, or poorly controlled, which all code to hyperglycemia. If the patient has periods of low blood sugars then the term hypoglycemic should be documented.

The second diagnosis would be type 2 diabetes mellitus with diabetic foot ulcer located on the plantar ulcer of the right foot. The ICD-10-CM code is a combination code noting the anatomical location and the severity of the ulcer (DFU scenario documents involving subcutaneous tissue), so it is important to include in your documentation the depth of the non-pressure ulcer/wound. Table 2 lists the options available for selection based on the provider’s documentation. Blue highlight represents the applicable code.

Keep in mind the documentation of laterality and code selection changes. There is no selection for bilateral extremity for this category. However, there is a code for unspecified laterality and unspecified severity of the ulcer, which should never be coded in the wound care setting.

Diagnosis: type 2 diabetes mellitus with diabetic foot ulcer located on the plantar surface of right foot.

Severity (depth): fat layer exposed (subcutaneous tissue)

Table 2
Severity (depth) Documentation

ICD-10-CM Codes           

ICD-10-CM Descriptions
Is it limited to breakdown of skin? L97.411 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) limited to breakdown of skin
Is the fat layer exposed? L97.412 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with fat layer exposed
Is there necrosis of muscle? L97.413 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with necrosis of muscle
Is there necrosis of bone? L97.414 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with necrosis of bone
No severity specified (should not be used) L97.419 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface)

The third diagnosis would be type 2 diabetes mellitus with circulatory complications supporting the microvascular disease. Table 3 provides the specific coding description of options for type 2 diabetes mellitus with diabetic circulatory complications.

 

Table 3
ICD-10-CM Code ICD-10-CM Code Description
E11.51 Type 2 DM with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 DM with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 DM with diabetic with other circulatory complications

DM=diabetes mellitus

The diagnosis would be for type 2 diabetes mellitus with either hyperglycemia or hypoglycemia. Tables 4 and 5 illustrate the specific coding options for type 2 diabetes mellitus with management issues commonly occurring in a wound clinic.

Table 4
Hyperglycemia
ICD-10-CM Code ICD-10-CM Code Description
E11.65 Type 2 DM with hyperglycemia

DM=diabetes mellitus

Table 5
Hypoglycemia
ICD-10-CM Code ICD-10-CM Code Description
E11.641 Type 2 DM with hypoglycemia with coma
E11.649 Type 2 DM with hypoglycemia without coma

DM=diabetes mellitus

Possible Codes: If the patient also has peripheral neuropathy, Table 6 provides the specific documentation details and coding options for type 2 diabetes mellitus with diabetic neurological complications.

Table 6
ICD-10-CM Code ICD-10-CM Code Description
E11.40 Type 2 DM with diabetic neuropathy, unspecified (needs to be specific)
E11.41 Type 2 DM with diabetic mononeuropathy
E11.42 Type 2 DM with diabetic polyneuropathy
E11.43 Type 2 DM with diabetic autonomic (poly) neuropathy
E11.49 Type 2 DM with other diabetic neurological complications

DM=diabetes mellitus

Based on the case scenario, the following ICD-10-CM codes should be selected for this patient:

  • E11.621 — Type 2 diabetes mellitus with diabetic foot ulcer
  • L97.412 — Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with fat layer exposed (reason for the wound care department encounter)
  • E11.51—  Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
  • E11.65 — Type 2 diabetes mellitus with hyperglycemia

Pressure Ulcer

Pressure ulcers are frequently treated in the wound care setting. Therefore, ICD-10-CM includes in the description the combination of laterality with the anatomical location of the ulcer as well as the stage of the pressure ulcer. The ulcer staging can be documented by either the provider or the clinician. However, the documentation must consistent.

Pressure Ulcer Case Scenario: An established patient with a pressure ulcer of the right heel now presents with necrosis of soft tissue involving the tendon. The tissues of this ulcer continue to  deteriorate due to non-compliance of pressure relief. This pressure ulcer is now at stage 4.

 

Table 7

Anatomical LocationLaterality
Elbow Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Back Right upper or lower
Left upper or lower
Unspecified part of back—should not be a coding option selected in a wound care setting
Hip Right
Left
Sacral region does not have any additional specificity other than to include staging Unspecified—should not be a coding option selected in a wound care setting
Buttock Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Contiguous site of back, buttock, and hip Document ulcer staging
No laterality required with this code
Ankle Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Heel Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Other site –head Document ulcer staging
No laterality required with this code
Other site not listed above Document ulcer staging
No laterality required with this code
Unspecified site Should not be a coding option selected in a wound care setting

NOTE: Pressure ulcer ICD-10-CM code descriptions do not require reporting tissue severity as with non-pressure ulcers. However, laterality and staging of the pressure ulcer are required. The broad ICD-10-CM category for pressure ulcers begins under L89.XXX and is broken down by anatomical locations and staging. Anatomical descriptions for pressure ulcers are listed in Table 7.

Staging descriptions for pressure ulcers are listed in Table 8.

Table 8
Stage 1 ulcers consist of but are not limited to:

Intact skin with non-blanchable redness of localized area

Usually located over bony prominences

Stage 2 ulcers consist of but are not limited to:

Partial thickness loss of dermis

Shallow open ulcer with a red-pink wound bed

No slough in wound bed

May also present as intact or open/ruptured serum-filled blister

Bruising indicates suspected deep tissue injury

Stage 3 ulcers consist of but are not limited to:

Subcutaneous tissue may be visible

No exposed muscle/tendon/bone

Slough may be present

May include undermining & tunneling

Shallow ulcer on nose/ear/occiput/malleolus due to lack of subcutaneous tissue

Stage 4 ulcers consist of but are not limited to:

Full thickness loss with exposed muscle/tendon/bone

Slough/eschar may be present on some parts of wound bed

Often includes undermining and tunneling

May extend into muscle/supporting structures/fascia/tendon/joint capsule

 

NOTE: ICD-10-CM coding requires documentation of laterality (right or left or both) along with the pressure ulcer staging to avoid unspecified codes. Without specifying laterality, the code description includes “unspecified heel.” The codes in Table 9 note the documented location of the right heel along with the applicable stages. The code that applies to the pressure ulcer described in the case scenario, a stage 4 pressure ulcer of the right heel, is highlighted.

Table 9
ICD-10-CM Code ICD-10-CM Code Description
L89.610 Pressure ulcer of right heel, unstageable
L89.611 Pressure ulcer of right heel, stage 1
L89.612 Pressure ulcer of right heel, stage 2
L89.613 Pressure ulcer of right heel, stage 3
L89.614 Pressure ulcer of right heel, stage 4
L89.619 Pressure ulcer of right heel, unspecified stage—should not be a coding option selected in a wound care setting

Arterial Ulcer

Lower extremity arterial disease (LEAD) is most commonly caused by atherosclerosis, particularly in patients with high risk lifestyle factors such as advanced age, diabetes mellitus, hyperlipidemia, hypertension, obesity, and smoking as well as a family history of cardiovascular disease. With ICD-10-CM, a patient with an arterial ulcer will require more than one diagnosis code to accurately reflect the level of acuity with complexity of care and intensity of services. However, these new ICD-10-CM codes for arterial ulcers encompass the following details, which are required in a provider’s clinical documentation:

The disease of atherosclerosis

  • Anatomical specific location
  • Laterality (right or left)
  • Type of arteries involved
    • Native arteries
    • Unspecified type of bypass graft(s)
    • Autologous vein bypass graft(s)
    • Non-autologous biological bypass graft(s)
    • Other type of bypass graft(s)
    • Type of bypass vein

Arterial ulcers have associated common characteristics that include:

  • Wound margins well-demarcated and
    • Wounds are often full-thickness, deep, and painful
    • Wound bed may have nonviable gray-yellow tissue or eschar with a pale coloration due to compromised blood flow
    • Gangrene may be present
  • Typical locations such as the following:
    • Ankles
    • Feet, including toes, tip of toes, or over the phalangeal heads
    • Lateral malleoli
    • Areas of trauma
  • The severity of the ulcer requires an additional code
Arterial Ulcer Case Scenario: A new patient presents with right lower extremity ulcers on the right great and third toes. The physician documents a diagnosis of atherosclerosis of native vessel, which had a non-autologous biological bypass graft inserted during a femoropopliteal bypass performed on the right leg to improve circulation six weeks prior. The right great toe has a gangrenous ulcer with necrotic bone exposed, and the right third toe has eschar present over half of the ulcer with subcutaneous tissue exposed. Both ulcers will require debridement and an aggressive wound care treatment regimen.

The following ICD-10-CM code options listed in Tables 10 through 12 are based on the details contained in the provider’s documentation. The applicable codes are highlighted in blue.

 

Table 10
Diagnosis: Atherosclerosis of native arteries of right leg with ulceration of other part of foot
ICD-10-CM Code ICD-10-CM Code Description
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg

 

Table 11
Diagnosis: Atherosclerosis of native arteries of right leg with ulceration of other part of foot
ICD-10-CM Code ICD-10-CM Code Description
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot (toes)
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot (toes)

 

Table 12

Diagnosis: Severity of each ulcer is to be coded separately
ICD-10-CM Code ICD-10-CM Code Description
L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone
L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed

Based on the case scenario, the following ICD-10-CM codes should be selected for this patient:

  1. I70.261 — Atherosclerosis of native arteries of extremities with gangrene, right leg
  2. I70.235 — Atherosclerosis of native arteries of right leg with ulceration of other part of foot (toes)
  3. L97.514 — Non-pressure chronic ulcer of other part of right foot with necrosis of bone (reason for the wound care department encounter)
  4. L97.512 — Non-pressure chronic ulcer of other part of right foot with fat layer exposed (reason for the wound care department encounter)

Conclusion

This article has focused specifically on examples related to the most common wounds encountered in the clinical setting, along with the clinical documentation elements necessary to avoid the use of unspecified codes. Keep in mind, when treating wounds it may be necessary to report the wound with a level of severity of tissue destruction code. This L97.XXX code (level of wound severity) supports your level of acuity with intensity of services and complexity of care decisions necessary, such as additional workup evaluations, tests, procedures, and debridements, to provide your patient with the appropriate care. It is the details of your documentation that will tell the most complete and accurate story of your patient’s medical care, so be sure to make the necessary documentation preparations to survive the transition to ICD-10-CM this fall.

References

  1. ICD-10-CM Draft Official Guidelines for Coding and Re- porting 2015. Chapter 4, Sections 1-6

  2. CMS: Billing and Coding with Electronic Health Records, 2013, May 3. (Scanned document)

  3. Optum ICD-10-CM Expert for Hospitals Manual.2015.

  4. Optum ICD-10-CM Mappings Manual.2015.

  5. Wound Management and Healing Manual. 2nd Edition. Western Schools

  6. Optum ICD-10-CM / PCS Coding Readiness Assessment.2015.

  7. Optum ICD-10-CM Clinical Documentation Improvement Desk Reference. 2015. 


Free Mini-Course: The Business of Wound Care and Hyperbaric Medicine

Join us for this free 4-part mini-course and jump start your clinic business today! 
  • Are you a clinic manager or medical director who wants to increase patient load and referrals but has no money for marketing?
  • Could you be losing money due to incorrect billing and coding?
  • Do you want to become a profit center for the hospital but inefficient business operations are holding your clinic back?

If you don't know where to start, how to start, or what you need to know to take your clinic to the next level, this free 4-part mini-course is for you.

This mini-course is taught by Dr. Michael White, MD, MMM, CWS, UHM and course director for the live two-day workshop, The Business of Wound Care and Hyperbaric Medicine.

You Will Learn:

Lesson 1: [Video] How to create a strong (or stronger) foundation for your clinic business

  • How to identify where your patient referrals are coming from (or should be coming from).
  • How to create an action plan for effective, efficient marketing.
  • How to become a profit center for the hospital.

Lesson 2: [Video] The explosion of chronic wounds in the U.S. and the opportunity for wound care and hyperbaric medicine clinics to serve more patients.

Lesson 3: 4 Easy steps to market your clinic.

Lesson 4: How key are front office operations to the wound clinic business?

  • Learn the two key considerations for creating efficient front office operations that contribute to the achievement of your clinic's overall financial goals.
Join us for this free 4-part mini-course and jump start your clinic business today! 

SIGN UP HERE 


 

About the Author

Gretchen-Dixon
Gretchen Dixon is the owner of Professional Compliance Strategies LLC and consults on outpatient departments and physician services. She has pro- vided revenue cycle compliance reviews of services with the focus on wound care department operations for over 9 years. She holds several credentials: MBA in Healthcare Management, Registered Nurse with practicing licenses in NY and a multi-state license from Virginia, AHIMA Certified Coding Specialist (CCS), AAPC Certified Professional Compliance Officer (CPCO), and is an AHIMA Approved ICD-10-CM/PCS Trainer/Ambassador. Being a longtime internal health- care compliance auditor, she identifies issues through audits of D, C, Bs (documentation, coding & billing) of provided services. The outcomes of each audit determines the topics of education to be provided to staff and physicians as she believes education is the KEY to having accurate, complete and consistent documentation for accurate reimbursement of billed services. Contact at This email address is being protected from spambots. You need JavaScript enabled to view it. or 615.210.7476.
 

 

  • 1
  • 2

Contact Us

Best Publishing Company
631 US Highway 1, Suite 307
North Palm Beach, FL 33408

Email:
This email address is being protected from spambots. You need JavaScript enabled to view it.

Phone:
561.776.6066

Fax:
561.776.7476


Copyright © 2018 Best Publishing Company, a company of WCHMedia Group, Inc | All rights reserved
Find more information at www.WCHMediaGroup.com