Practice Management Pearls

Getting Leg Ulcers Healed and Keeping Them Healed This debilitating condition is common among the elderly, yet little has been published on protocols and treatment.

By Jonathan Moore, DPM

Practice Management Pearls is a dressings and Velcro gradient compres- leg ulceration, it is imperative that your regular feature that focuses on prac- sion garments. While both of these tools management plan for these patients in- tice management issues presented by are considered “surgical dressings”, they volve an early strategic and coordinat- successful DPMs who are members of can be used adjunctively and both have ed approach to delivering the correct the American Academy of Podiatric A-codes that can afford the physician treatment option for each individual 59 Practice Management. favorable reimbursement. patient, based on accurate assessment Venous ulcers are the most common of the underlying pathophysiology.5 The AAPPM has a forty-plus year his- type of leg ulcers, accounting for approx- Implementation of immediate tory of providing its member podiatrists imately 70% of cases while arterial dis- compression therapy along with ap- with practice management education ease accounts for another 5% to 10%.2 propriate wound care is critical. Pa- and resources they need to practice effi- Venous ulcers arise from ve- tients should be educated regarding the ciently and profitably, through personal nous valve incompetence in the deep pathophysiology of their venous insuf- mentoring and sharing of knowledge. To veins, thereby causing the vessels to ficiency and their most certain need for contact AAPPM visit www.aappm.com. become distended and stretched to long-standing leg compression. accommodate the additional blood hronic leg ulcers are a flow. As the valves are not able to ef- Immediate Compression and common finding among fectively close, retrograde blood flow Wound Care patients presenting to po- and venous hypertension occur, cre- While compression therapy is often diatric physicians and yet ating a leakage of fluid out of the sufficient to heal venous ulcers, espe- little has been published veins into the tissues resulting in the cially when treated with Unna , Cregarding protocols and effective tools deposition of a brownish/red pigment addressing the needs of the ulcer with to address this complicated condition. in the gaiter area of the leg.3 additional tools is also essential. As Chronic ulceration of the lower Venous ulcerations differ consider- most venous ulcers are moist (produc- legs is a relatively common presenta- ably from arterial in that venous ulcers ing at least a moderate amount of ex- tion amongst adults, impacting 1% of are typically shallower and more pain- udate) appropriate topical wound care the adult population and 3.6% of peo- ful and are associated with an older pa- dressings should be considered along ple older than 65 years. Not only do leg tient population. Additionally, venous with compression therapy to maximize ulcers reduce the quality of life among ulcers are irregular in shape and occur healing. The author likes the use of the elderly, they are debilitating and predominately over the medial mal- collagen powders (Helix 3™) for venous are often treated poorly or not at all.1 leolus area, among other bony prom- ulcers because of their absorption ca- The common causes are venous dis- inences. Venous ulcers present often pability and the bioavailability of the ease, arterial disease, and neuropathy, with at least some granulation tissue powder. Collagen-based wound - yet many factors typically exist creat- with exudate. In most cases where a ings are ideal for chronic wounds by ing the need for an interdisciplinary ap- venous ulcer develops, edema, venous addressing not only excess exudate, proach to the systematic assessment in dermatitis, varicosities and lipoderma- but also elevated levels of MMPs (Ma- order to ascertain the pathogenesis, di- tosclerosis are also present.4 trix Metalloproteases) which degrade agnosis, and an effective treatment. Two both viable and non-viable collagen. effective tools will be discussed that to- Management of Chronic Venous Without the proper formation of gether create an effective treatment plan Leg Ulcers the scaffold needed for cell migra- that can not only heal the ulceration, but Considering that venous leg ulcers tion, formation of the extracellular keep it healed: Collagen Powder wound are by far the most common type of Continued on page 60

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Leg Ulcers (from page 59) lored to the specific needs of an indi- Graduated compression is vidual patient. When surgical dress- achieved by the end stretch of the matrix (ECM) and granulation tissue ings are provided in kits, only those material, as well as the shape of the will be significantly altered. Collagen components of the kit that meet the limb. The beauty of this kind of sys- based dressings also have the abili- definition of a surgical dressing, that tem is that the user is allowed to vary ty to absorb excess wound exudate are ordered by the physician, and that the degree of compression to the limb, while maintaining a moist environ- are medically necessary are covered. depending on his/her needs. Systems ment for wound healing.6 like this typically include a foot , Compression Therapy a lower leg piece, and the option of Billing Pearls for Collagen Powders Although not new, Velcro Gradient a thigh wrap, which interconnects to Collagen Powders are reimbursed by Compression Garments can provide the the below-knee garment with Velcro. Medicare with the code A6010. Products practitioner an effective and innovative While there has been minimal re- like Collagen Powders are covered when tool to address venous disease and ve- search into the effectiveness of Velcro either of the following criteria is met: nous ulceration. Additionally, as of 2013 Wrap compression systems, the au- 1) They are required for the treat- these compression devices are reimburs- thor has had tremendous success with ment of a wound caused by, or treat- able under the HCPCS Code: A6545— patients who are poor candidates for ed by, a surgical procedure; or Gradient compression wrap, non-elastic, “traditional” compression . 2) They are required after de- bridement of a full thickness wound. When billing for any compression garment Surgical dressing codes require the use of modifiers A1-A9 (A1 = 1 (traditional or Velcro Wrap), the documentation of wound; A2 = 2 wounds, etc). Up to 60 30 units (1 unit = 1 gram) may be a venous stasis ulcer is mandatory. dispensed per wound every 30 days as needed. As any wound dressing being billed to insurance will be sent home below knee 30-50 mmHg, each. Pearls for Billing a 30-40mmHg with the patient, claims submitted to The key to keeping patients utiliz- Velcro Gradient Compression Wrap: the DMERC will use the place of service ing an adequate graduated compres- When billing for any compression corresponding to the patient’s residence sion garment is not only compliance, garment (traditional or Velcro Wrap), (POS=12); Place of Service Office but also the availability of suitable gar- the documentation of a venous stasis (POS=11) must NOT be used. Addi- ments for the affected limb that older ulcer is mandatory. tionally, patients that are under ANY and often obese patients can don and Additionally, the prescribed gar- home health status (even services not doff. Although the range of “tradition- ment must achieve a minimum of 30- related to the wound) are not eligible al” compression garments and appli- 40mmHG. When a gradient compres- for the billing of wound care products to cators (don/doffing devices) has im- sion wrap is used for an open venous DMERC. Claims for wound care related proved in recent years, there are still stasis ulcer, the A6545 code must be dressings (even compression garments) many people who can’t deal with the billed with the AW modifier. If there will be denied if the patient is still under application of these devices: patients is no open ulcer, the AW modifier any Home Health designation. It is al- with weak hand strength, back prob- must not be used. Claims for code ways wise to confirm the patient’s sta- lems, obesity, or abnormal limb shape, A6545 without an AW modifier will tus before billing wound dressings. and elderly or palliative patients. be denied as statutorily non-covered. Dressing size and quantity must The development of Velcro grad- The right (RT) and left (LT) mod- be based on and appropriate to the uated compression systems like the ifiers must also be used with this size of the wound. Dressing needs may Farrow Wrap are designed to address code. When the same code for bilat- change frequently (e.g., weekly/daily) the needs of this group of patients eral items (left and right) is billed on in the early phases of wound treatment utilizing the principles of short-stretch the same date of service, bill both and/or with heavily draining wounds. bandaging, providing a low resting/ items on the same claim line using Suppliers are also expected to have a high working pressure garment. LTRT modifiers and the quantity of mechanism for determining the quanti- These systems consist of a pro- the dressings being dispensed. Claims ty of dressings that the patient is actu- tective liner, over which the filed without RT and/or LT modifi- ally using and to adjust their provision wrap is applied along with multiple ers will be denied as incorrect cod- of dressings accordingly. No more than overlapping short-stretch in- ing. While the posted fee schedule a one-month’s supply of dressings may terconnected by a spine. The bands for A6545 is $92.23 for all states, cov- be provided at one time, unless there are secured by using Velcro®, and the erage is limited to one compression is documentation to support the neces- degree of compression is determined garment per leg every six months. sity of greater quantities in the home by the user applying the wrap at near While the LCD for the utilization setting in an individual case. An even end stretch of the material, as well as of these devices requires the presence smaller quantity may be appropriate. by the circumference of the leg and of a venous ulcer, the author will of- Surgical dressings must be tai- the position and activity of the user. Continued on page 62

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Leg Ulcers (from page 60) long-standing duration are vital to im- Journal, vol. 76, no. 901, pp. 674–682, 2000. prove quality of life and reoccurrence. 3 M. H. Meissner, G. Moneta, K. Burnand tentimes start with an Unna with Training your staff on how to measure et al., “The haemodynamics and diagnosis of local wound care to address the initial and provide these services is funda- venous disease,” Journal of Vascular Surgery, needs of the venous ulcer, then transi- mental yet not difficult. Measuring for vol. 46, no. 6, supplement, pp. S4–S24, 2007 4 H. Newton, “Leg ulcers: differences tion to a Velcro graduated compression any compression garment is essential between venous and arterial,” Wounds garment before the ulcer is healed. to get the right size and fit. Sending Essentials, vol. 6, no. 1, pp. 20–28, 2011 your patients to a pharmacy or medical 5 A. S. K. Ghauri and I. K. Nyamekye, Conclusion supply location to get a device without “Leg ulceration: the importance of treating Leg ulcers due to chronic venous a thorough measurement and education the underlying pathophysiology,” Phlebolo- insufficiency can be difficult to heal, regarding the proper donning and doff- gy, vol. 25, supplement 1, pp. 42–51, 2010. and lymphedema (or anything else ing techniques usually results in failure. 6 Holmes, Wrobel, et al Diabetes, Met- that causes fluid retention) can in Additionally, recommending or allow- abolic Syndrome and Obesity: Targets and itself be challenging. Utilizing the ing your patients to use a compression Therapy 2013:6 17–29. right tools in order to achieve quick garment used previously by a family or healing is fundamental. Collagen friend isn’t recommended, nor is recom- Dr. Moore is board certified by the American powders, among other granulation mending the use of an “anti-embolic” Board of Podiatric Medicine and is Fellowship tissue-building dressings that also re- compression garment (Ted ). PM trained in Diabetic Foot duce exudate, can significantly en- Salvage from UTHSC. He References hance healing times. is on the Board of Trustees 1 R. Rayner, K. Carville, J. Keaton, J. of the American Board of Moreover, providing compression Prentice, and X. N. Santamaria, “Leg ul- Podiatric Practice Manage- garments in your office is something cers: atypical presentations and associated ment and is a Fellowship that can be rewarding for your pa- co-morbidities,” Wound Practice and Re- Director, author and 62 tients and your practice. While Unna search, vol. 17, no. 4, pp. 168–185, 2009. frequent lecturer. Dr. Boots can provide immediate swelling 2 P. K. Sarkar and S. Ballantyne, “Man- Moore is a consultant for reduction, compression garments of agement of leg ulcers,” Postgraduate Medical Amerx Health Care.

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