The Debridement Dilemma

A chance to cut is a chance to cure. — Medical proverb

Non-viable (necrotic) material within a chronic wound has been shown to inhibit the development of vascular tissue (granulation) and the formation of skin (epithelialization). Devitalized material enhances bacterial growth while at the same time decreasing resistance to infection. The removal of such material is called debridement.

General consensus dictates that devitalized tissue should be removed from non-healing wounds (rare exceptions may include eschars on ischemic feet). In a randomized controlled trial of becaplermin, Steed1 showed that healing improved in diabetic foot ulcers in relation to the frequency of debridement in both the placebo and the treatment arms of the study. Ennis2 demonstrated in a variety of wound types that sharp debridement significantly increases healing when other factors are controlled. Saap3 showed that the adequacy of debridement is an independent predictor of wound healing.

Recognizing the importance of chronic wound debridement, the American Medical Association (AMA) has provided Common Procedural Terminology (CPT®) codes to represent the variety of surgical excisional and non-surgical debridements performed for initial and maintenance debridement. The Centers for Medicare and Medicaid Services (CMS) has assigned payment rates to these codes (see “In Business” in this issue).

At the intersection of clinical concepts and actual patient care lives economic reality. Wounds need debridement performed by a caregiver who must be compensated for services and/or expertise or this care will not continue to be available. This article explores the health, economic, and clinical impact of various debridement protocols by addressing the following questions:

1. What type of debridement is needed?
2. What type of debridement is performed?
3. What type of debridement is documented?

Types of Debridement
Clinically, debridement may be classified as surgical excisional, sharp, mechanical, autolytic, chemical, and biological.
Surgical excisional debridement and non-surgical sharp debridement describe the use of instruments such as scissors, scalpels, or curettes to remove devitalized tissue. Although they can be performed quickly, these methods are invasive, potentially painful, may require hospitalization, may require anesthesia, require control of bleeding, and must be performed by a qualified professional.

Mechanical debridement may include the use of wet-to-dry gauze dressings, water jet, or ultrasound. It may not discriminate between viable and non-viable tissue. Although the published literature overwhelmingly subscribes to better methods of debridement, data show that physicians are still more likely to choose gauze over other options.

Wet-to-dry gauze treatment is subject to various interpretations. Because it is painful, it is not uncommon for patients (or merciful caregivers) to moisten the gauze before removing it, thus reducing the efficiency of mechanical debridement. Various gauze types are used — most commonly, open weave and woven. Linting and pain are factors; cost is not. Physicians also still think wet-to-dry helps prevent infection, despite the fact that the literature suggests that moist gauze is a fertile culture media.

Autolytic debridement is the process through which the wound bed clears itself of devitalized tissue using phagocytic cells and proteolytic enzymes (the body’s own natural enzymes) to liquefy necrotic tissue. This is accomplished by keeping the wound moist with occlusive or semi-occlusive dressings. Eschar and necrotic debris are softened, liquefied, and separated from viable tissues. If the wound does not stay moist, autolytic debridement will not occur. Clinically, autolytic debridement is effective but slower. It can be used in patients whose medical and nutritional status are fairly stable and may be appropriate for patients who are on anticoagulant therapy and for whom surgical excisional and non-surgical sharp debridement are contraindicated. It should not be used when the wound is infected.

Chemical debridement can be facilitated by applying topical agents that disrupt or digest extracellular proteins. The enzyme collagenase, derived from the fermentation of Clostridium histolyticum, has the unique ability to digest collagen in necrotic tissue. Papain, the proteolytic enzyme from the fruit of carica papaya, is a potent digestant of non-viable protein matter. When combined with urea, studies have shown it has twice as much digestive activity.

Biological debridment involving maggot therapy is a relatively painless form of biological debridement and specific to necrotic material. The Food and Drug Administration classifies maggots as “medical devices.” Maggots have bacteriocidal properties (even against methicillin-resistant Staphylococcus aureus) and secrete substances that promote healing. Patient perception can be a significant disadvantage. Note: CPT/HCPCS codes are not currently available for this procedure.

What Debridement Technique is Needed?
Chronic non-healing wounds may require multiple debridement procedures of different types. Not only must the wound base repeatedly be cleaned of devitalized tissue and senescent cells, but also wound edges must be kept “open,” allowing for epithelial migration and any “undermining” (the “ledge” created when the skin partially migrates over a three-dimensional tissue defect) removed. This is important because wounds must not be allowed to close with a three-dimensional defect (that creates a potential space for infection) in place. Granulation tissue must completely fill the defect so again, epithelial cells can migrate from the wound edges to cover and close the wound.
The debridement technique needed for a given wound at a given time continues to be the subject of much debate and is not really the focus of this article. Many scholarly articles have been published to assist the clinician in making these decisions. Suffice it to say that all debridement techniques might be appropriate in the same patient at different times depending on the type and extent of devitalized tissue present, pain control, infection or bleeding risk, cost, access to care, underlying nutritional status, and a host of other complex factors.

What Type of Debridement is Performed AND DOCUMENTED?
The appropriate type of debridement performed is determined by the needs of the wound. The provider must state exactly what and why the work is being done, including proper documentation of
1) the type of tissue that was excised or debrided,
2) the depth of the excision or debridement,
3) the device, drug, or dressing used for the excision or debridement,
4) the size of the wound before and after the excision or debridement, and
5) the condition of the wound after the excision or debridement.

Take Home Message
Perhaps the medical proverb should be updated to read, “To debride is to cure.” Providers need to incorporate advanced procedures into their practices. This allows wound care professionals to perform the most appropriate debridement technique, regardless of whether it is surgical excisional debridement or non-surgical maintenance selective/non-selective debridement.

Wound care professionals must clearly document the type of debridement that was performed. The documentation should include the method (instruments, modalities, dressings, drugs, and the like) used to debride the wound, the level of tissue removed, and the character of the wound before and after debridement. Documentation needs to paint a clear picture for coders, auditors, payors, and others. Medical necessity is determined not only by what was performed, but also by what was documented. Proper documentation and coding benefits both clinicians and patients.

Acknowledgment
The author is grateful to William Ennis, MD, who generously provided material for this article, and to Kathleen Schaum and Dot Weir for invaluable input. n

*CPT is a registered trademark of the American Medical Association.