Eli's Rehab Report

According to the federal Agency for Health Care Policy and Research, more than 60,000 people die from bedsore (also known as pressure ulcers/sores, 707.0) complications each year, and as many as 60 percent of quadriplegic patients have pressure sores. Depending on the size and severity of each patients ulcers, clinicians can use various types of treatments for bedsores, ranging from simple saline cleansing to debridement and operation.

A recent decision by the Health Care Financing Administration (HCFA) to revise its coverage of pressure-reducing therapy in the home setting may help the rehabilitation community increase reimbursement for air-fluidized bed therapy (E0194), which is classified as a Group III support surface. According to Fran Menard, product manager for the Clinitron-At-Home Air Fluidized Therapy at Hill-Rom Home Care in Charleston, S.C., one of the companies that manufactures air-fluidized therapeutic beds, Air fluidized therapy creates a very warm and buoyant environment, so the patient is almost in suspension, as if floating. And its a very low-friction environment where patients can recover.

HCFAs decision, which was issued on June 12, states that air-fluidized bed therapy is only covered after a physician evaluates a patient who has not successfully progressed toward healing after at least one month of conservative treatment. The decision memorandum (CAG-00017) lists six criteria that should be included in the patients conservative therapy:

1. Frequent repositioning of the patient with particular attention to relief of pressure over body prominences, usually every two hours. Two hours is the general rule for patients confined to a bed, but those in a chair should be moved every hour, says Angela Rosati, RN, who served as a rehabilitation center supervisor for 27 years in Bergen County, N.J., before retiring in May. Some patients, who are in a chair or wheelchair, can reposition themselves by shifting their weight, and its recommended that they do so about every 15 minutes.

2. Use of a specialized Group II support surface designed to reduce pressure and sheer forces on healing ulcers to prevent new ulcer formation. Before moving to an air-fluidized bed, the patient usually will have used something like low-airloss therapy (E0193), which is classified as a Group II support surface, says Rosati.

3. Necessary treatment to resolve any wound infection. Each wound ulcer is treated differently, depending on the size, the amount of drainage, how deep it is, and whether its infected, says Audrey Torres, a clinical nurse specialist at the Rehabilitation Hospital of the Pacific in Honolulu. On early stage pressure ulcers, saline [A4214] and topical antibiotics [such as Neomycin] are sometimes enough to promote healing.

4. Optimization of nutrition status to promote wound healing. Undernourished patients, or those with poor nutrition, dont heal as quickly or easily as those whose diets are complete, says Rosati. The malnourished patients often need supplements to ensure that their diets are balanced with the right combination of calories, proteins, vitamins, etc., and sometimes, a feeding tube is even required.

5. Debridement by any means (including wet to dry dressings) to remove devitalized tissue from the wound bed. Our patients are often treated using mechanical debridement with a wet-to-dry dressing, says Torres, and the physicians sometimes perform surgical debridement.

Editors note: Debridement is covered under codes 11000-11044. Many Medicare carriers will allow physical therapists to perform and bill for debridement under a physicians order (G0169), including sharp debridement using a scalpel, laser, etc., if medically indicated for the wound care. Check your local carriers regulations to determine if physical therapists are eligible to perform this in your region.

6. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering while the wound heals. One of the most important things to remember when treating pressure ulcers is that the wound should stay moist, but the surrounding skin should stay dry, says Rosati. Normally, after cleaning the wound with saline, it should be covered with something like Alginate dressing [A6196-A6199].

Air-fluidized therapy is ideal for patients in need of treatment for multiple or advanced pressure ulcers, flaps, grafts, burns or intractable pain, says Menard. Flaps, grafts and intractable pain are not covered under the Medicare regulations for the E0194 classification, but in the managed care or hospital environment, where the bed doesnt have to be restricted to certain diagnoses, it can be useful for those conditions as well.