Transforming Skin Integrity in the Acute Setting: Clinical and Coding Insights

Catherine T. Milne, APRN, MSN, ANNP/ACNS-BC, CWOCN-AP, emphasized the importance of differentiating skin conditions. As she noted, moisture-associated skin damage (MASD), a concept introduced in 2011, includes incontinence-associated dermatitis (IAD), intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis.
 
Peristomal MASD, said Milne, consists of problem stomas, poor stoma location, and high-volume output (especially liquid stool). She said this can contribute to skin injury that could rapidly progress to erosion.
 
Periwound MASD is often associated with wounds that produce large quantities of drainage, such as venous ulcers or infected wounds, according to Milne.
 
IAD, which Milne noted is a worldwide problem, entails skin breakdown caused by repeated or prolonged exposure to moisture from caustic agents such as urine, liquid stool, or other bodily fluids.
 
Intertriginous dermatitis is skin damage between skin surfaces due to the interaction of friction and moisture, noted Milne.
 
Medical adhesive–related skin injury (MARSI) occurs when erythema and/or another manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion, or tear) persists for 30 minutes or more after adhesive removal, noted Milne. She noted MARSI can manifest as blisters, skin tears, or an allergic reaction. She added that the condition is underreported, and can affect patient quality of life and health care costs.
 
A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device. Milne advised that if you can see redness, it’s too late to prevent a pressure injury. She emphasized the impact of mechanical loading in pressure injuries, and that while these injuries may have different etiologies, they have the same result—disruption of the skin barrier.
 
Milne also addressed the effects of microclimate in skin damage. Underhydration, she noted, makes skin more susceptible to mechanical damage, cracks, fissures, and inflammation, due to increased structural stiffness in the epidermis. As she notes, dry skin is a contributory factor in pressure injury development. Milne said overhydration leads to softening of the stratum corneum, increased permeability, susceptibility to irritants, barrier disruption of the intracellular lipid lamellae, and tissue breakdown by fecal/urine enzymes.

Protecting and Managing Skin Injuries

As for how to protect skin and manage injuries, Karen Laforet, RN, MCISc-WH, RN, CCHN(C), VA-BC(TM) CVAA(c), presented an algorithmic approach. The goals include early identification and treatment of skin irritation; identifying and addressing the cause; reducing pressure, friction, shearing, and moisture; minimizing contact with irritants; managing pain and patient-centered concerns; and restoring and maintaining the skin’s protective capacity.
 
Laforet described her ACCPR algorithm—Assess, Confirm, Cleanse, Prevent, Restore.
 
Assess. This entails assessing patient risk and health care professional competency. Laforet notes one should anticipate a potential risk of skin injury, with factors including age extremes, chemotherapy, nonsteroidal anti-inflammatory drugs, steroid use, and autoimmune disorders. One should also educate, confirm, assess competency in skin health and wound assessment, product application, and removal.
 
Confirm. One should confirm the wound etiology to develop a prevention or management plan. Laforet says this involves confirming wound etiology (diagnosis). She cautioned that misdiagnosis of skin injury delays appropriate intervention and treatment, reimbursement, and data accuracy.
 
Cleanse. Choose the right cleansing product and develop a structured, individualized plan for prevention or management. Laforet said one should avoid soaps and cleansers with an alkaline pH, use a gentle liquid cleanser (spray or wipe), use minimal rubbing on skin, and pat skin dry to avoid mechanical injury. One should consider a pH-balanced surfactant cleanser to help remove water-soluble proteins and lipids.
 
Prevent. Laforet advised prevention of skin injury entails protecting compromised skin from further trauma. She said one should apply a barrier to vulnerable skin in the form of ointment, cream, film, or dressing, and use adhesives with caution. She noted silicone-based adhesives are gentler than acrylate and need to apply on intact skin.
 
Remove. On fragile and moistened skin, Laforet said one should remove dressings with caution and apply a skin barrier. Use absorbent dressings with lateral wicking properties for exudating wounds, she advised. For people with MASD, Laforet suggested applying emollients and moisturizers before soiling and after cleansing. Those with MARSI should use the appropriate skin barrier to protect damaged skin and continue to use once skin integrity is restored.

A Closer Look at New MASD Diagnosis Codes

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, addressed the new ICD-10-CM diagnosis codes for MASD as developed by the Wound, Ostomy and Continence Nurses (WOCN) Society.
 
The following are the new irritant contact dermatitis codes, which took effect in October 2021:

L24A0 Irritant contact dermatitis due to friction or contact with body fluids, unspecified

• Add: L24A1 Irritant contact dermatitis due to saliva
• Add: L24A2 Irritant contact dermatitis due to fecal, urinary or dual incontinence
• Add: L24A9 Irritant contact dermatitis due to friction or contact with other specified body fluids
• Add: L24B0 Irritant contact dermatitis related to unspecified stoma or fistula
• Add: L24B1 Irritant contact dermatitis related to digestive stoma or fistula
• Add: L24B2 Irritant contact dermatitis related to respiratory stoma or fistula
• Add: L24B3 Irritant contact dermatitis related to fecal or urinary stoma or fistula

As Cartwright explains, since ICD-11—used internationally—may be a long way from implementation in the United States, the WOCN Society decided to propose a change to the codes now so data collection could begin for irritant contact dermatitis. As she noted, the ICD-11 codes are primarily used to enable sharing of health-related information using common terminology and support research in other countries.
 
Cartwright noted the existing code for irritant contact dermatitis (ICD 10-CM Code L24) covered a variety of potentially irritating substances, such as detergents, oils and greases, solvents, drugs, plants, and metals. However, she said the code did not cover the clinically relevant and prevalent forms of irritant contact dermatitis caused by exposure of the skin to the body fluids associated with MASD. Currently, Cartwright said if these conditions were documented in the medical record, inappropriate, non-specific, or miscellaneous diagnostic codes were used by clinicians to document MASD conditions.
 
Cartwright noted the following tablular modifications for the ICD-10-CM code:

• L24 Other and unspecified dermatitis
• New subcategory

       – L24.A Irritant contact dermatitis due to friction or contact with body fluids
                    Add Excludes1: Irritant contact dermatitis related to stoma or fistula (L24.B-)
                    Add Excludes2: Erythema intertrigo (L30.4)
                    New code L24.A0 Irritant contact dermatitis due to friction or contact with body fluids, unspecified
                    New code L24.A1 Irritant contact dermatitis due to saliva
                    New code L24.A2 Irritant contact dermatitis due to fecal, urinary or dual incontinence
                           ─Add Excludes1: diaper dermatitis (L22)
                    New code L24.A9 Irritant contact dermatitis due to friction or contact with other specified body fluids
                    Add Wound fluids, exudate
 

• New subcategory L24.B Irritant contact dermatitis related to stoma or fistula

          Note: Add Use additional code to identify any artificial opening status (Z93.-), if applicable, for contact dermatitis related to stoma or secretions
          – New code L24.B0 Irritant contact dermatitis related to unspecified stoma or fistula
             • Add Irritant contact dermatitis related to stoma NOS
             • Add Irritant contact dermatitis related to fistula NOS
          – New code L24.B1 Irritant contact dermatitis related to digestive stoma or fistula
             • Add Irritant contact dermatitis related to gastrostomy
             • Add Irritant contact dermatitis related to ileostomy
             • Add Irritant contact dermatitis related to saliva or spit fistula
 

• New code L24.B1 Irritant contact dermatitis related to digestive stoma or fistula

          Add Irritant contact dermatitis related to gastrostomy
          Add Irritant contact dermatitis related to ileostomy
          Add Irritant contact dermatitis related to saliva or spit fistula

• New code L24.B2 Irritant contact dermatitis related to respiratory stoma or fistula

          Add Irritant contact dermatitis related to endotracheal tube
          Add Irritant contact dermatitis related to tracheostomy
 

• New Code L24B3 Irritant contact dermatitis related to fecal or urinary stoma or fistula

          Add Irritant contact dermatitis related to colostomy
          Add Irritant contact dermatitis related to ileostomy
          Add Irritant contact dermatitis related to enterocutaneous fistula

Implementing Evidence-Based Skin Treatment

Emily Greenstein, APRN, CNP, CWON-AP, FACCWS, discussed evidence-based treatment for skin. As she noted, the evidence base for practice is rapidly expanding and growing in complexity. However, Greenstein pointed to a mismatch between what we know to be quality care and the quality of care that is delivered. She said quality problems occur even in the hands of dedicated, conscientious professionals.
 
Greenstein suggested several steps: Identifying a patient-oriented goal, implementing an evidence-based action plan, and measuring progress.
 
To manage pressure injuries, Greenstein notes an evidence-based approach entails correcting the cause of tissue damage, which can include prolonged pressure, friction, shear, and nutritional deficiencies. One should debride necrotic tissue, treat local or distant infection. In addition, she suggested protecting skin from excess moisture or dryness, and from chemical or physical trauma.
 
For MASD, Greenstein suggests correcting the cause(s) of tissue damage, such as incontinence or sweating. An evidence-based approach also includes treating infection, protecting skin from excess moisture or dryness, and from chemical or physical trauma, noted Greenstein.
 
Greenstein also enumerated several principles for implementing evidence-based practice for wounds, including the use of a multidisciplinary wound care team and identifying practices and outcomes to improve. One should make a facility plan based on current and future patients and wounds, and on current and projected costs and revenues. Greenstein said one should provide training in evidence-based protocols, motivate patients, staff, and management with feedback on evidence-based practices. She said one should measure and communicate utilization and outcomes.