Cutting Through The Confusion

The TWC Editorial Board labored over how to address the important, controversial, and confusing topic of debridement. An integral part of the day-to-day care provided in hospital-owned outpatient wound care departments (HOPDs), debridement removes devitalized tissue from a wound that otherwise would be slower to heal, at higher risk for infection, and not receptive to more advanced topical treatments such as wound matrix technology, negative pressure wound therapy, growth factors, and bioengineered tissues.

Surgical wound debridement is not a technically difficult skill to learn once you understand the principles. Choosing a method for removal of devitalized tissue from among the various approaches available is a matter of patient factors, resources, urgency of the need, pain control, and the type of practitioner. Describing what you have done is more challenging. Medical school students rarely find it difficult to identify tissue type yet we doubt there is a wound care physician of any specialty who has not held a piece of tissue in a pair of pick-ups and thought,“I wonder exactly what that used to be.”

From a purely visual standpoint, it is sometimes impossible to name the tissues being removed with absolute histological certainty. The practitioner must look at the anatomy involved and the depth of the defect in the skin and soft tissues, mindful of the fact that the processes of necrosis and infection can essentially liquefy tissues. Some tissue layers thin out while others hypertrophy. Inflammation may turn normally pliable tissues into the consistency of an unripe pear. Making your way through hyperkeratotic tissue that might be full-thickness skin and moving on to the next layer is like the reverse of a map. Rather than beginning with, “You are here,” when you get to a tissue you recognize, you know where you must have started.
This problem exponentially complicates the proper use of debridement codes. The physician’s billed level of service not only has to agree with what he or she documented, but also with what the facility charged. This may engage the entire staff in game of “Name that Tissue” in order to establish the proper code. It would be so much easier for practitioners in our specialty if tissues had color-coded or clearly marked levels of demarcation between all tissue layers regardless of their condition.

To further complicate matters, we cannot deny that economic issues are at play. Wound centers and wound care practitioners must remain economically viable. As documentation requirements increase in complexity and detail and payments correspondingly decrease, the wound center’s economic margin can begin to look like the fine edge of a scalpel. Plus, not only have surgical debridement codes unique to advanced practitioners been created, but also new codes, some of which describe activities once considered “dressings.” Because we face the potential for providing wound care with far less reimbursement due to an increase in and potential abuse of debridement and other wound care-related codes, we need to make it our business to understand the directives, realistically and fairly evaluate the care/procedures we are providing, and examine our methods of coding and billing. At the same time, the CMS and other payors need to understand that wound care is not always a clear and exact science.For this issue of TWC, we have taken a multilevel look at debridement. As we asked experts in the field to weigh in on debridement from their specific viewpoints on reimbursement, coding, documentation, and technology, it became evident that this subject generates a great deal of confusion among clinicians, even those we designate experts.The issue begs us to ask the hard questions: Do I know what type of debridement I just did? How do I document it properly? How do I code for it correctly? To begin to assess your knowledge, we invite you to take a debridement quiz and determine how you would handle and code the theoretical but real-life situations presented. Our wish is to reach out to our readers and gather and cull the answers to the questions posted to show either all is well understood or this is an issue confusing to the masses.
Additionally in this issue,we look at a new technology in water jet debridement, as well as how to educate staff on debridement and other wound clinic concerns.

We had hoped this issue of TWC would clear some of the fog around the debridement dilemma. For the short term however, we may have added to the confusion. Debridement is a process that inadvertently may have become second nature but now requires critical thinking, especially in these regulatorily challenging times. We have realized that this is not a cut-and-dry issue (pun intended). Rather, it is a subject that requires us to continuously strive for clarity and understanding so that we may provide the best care for our patients within the guidelines set by payors.We acknowledge with certainty the need for debate and encourage you to not only send your responses to the questions we pose in the debridement quiz, but also letters to the editor about your experiences (and frustrations). Together, we can cut through the confusion that surrounds debridement.