July 2013

A recent study published in the Journal of the American Podiatric Medical Association concluded that podiatric surgeons should consider split-thickness skin grafting (STSG) as a wound closure option for patients with diabetes who do not have exclusionary comorbidities.

   The retrospective study looked at 203 patients, including patients without diabetes and patients with diabetes, both with and without preexisting comorbidities. All patients received STSGs to help facilitate wound closure. The study concluded that STSG patients with diabetes and preexisting comorbidities experienced the highest risk of delayed healing, post-op infection and a higher need for revisional surgery in comparison to the other two groups. Study authors did not find any significant differences in outcomes between patients with diabetes who had no comorbidities and patients without diabetes. Comorbidities included cardiovascular disease, neuropathy, retinopathy and nephropathy.

   David G. Armstrong, DPM, MD, PhD, is a strong proponent of split-thickness skin grafts, which he and his operating staff apply up to four times a week.

   “(Split-thickness skin grafts are) an integral part of our ‘vertical’ and ‘horizontal’ strategy. We advocate using STSGs to resolve epithelialization horizontally once we have resolved depth vertically with negative pressure wound therapy (NPWT),” explains Dr. Armstrong, a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz.

   Dr. Armstrong offers the following surgical pearls when utilizing STSGs on patients with diabetes.
• Use thicker STSGs in this population, especially on plantar wounds where one would normally see “glabrous skin.” He will go to 20/1000ths of an inch or even higher in high use areas.
• If the wounds are small and especially on the bottom of the foot, “pie crust” the STSGs rather than using 1.5:1 mesh.
• Apply NPWT to bolster the STSG. However, only use NPWT for three to four days. Then apply a simple compressive/bolster dressing.

   According to Dr. Armstrong, he and his staff use NPWT most frequently as a “vertical strategy” to fill the wound.

   “We use STSG most frequently as part of our ‘horizontal’ strategy to facilitate epithelialization. We have absolutely no problem repeating a STSG if it takes less than 100 percent,” adds Dr. Armstrong, the Director of the Southern Arizona Limb Salvage Alliance.

Could EMR Open The Door To Upcoding?

By Brian McCurdy, Senior Editor

With the Centers for Medicare and Medicaid Services (CMS) looking into the possibility that electronic medical records (EMR) could lead to physicians coding for higher level services, does a real danger of upcoding exist?

   As Barbara Aung, DPM, notes, most physicians “are quite aware” of the dangers of upcoding. She says the use of EMR does present some risks in instances in which the physician may “copy or push forward” the history and physical information from the previous visit’s exam.

   “When there is more documentation found in the note or the note looks more complete, oftentimes we can think and/or feel that we are justified in billing a higher level of service so this can lead to the danger of billing a higher level evaluation and management (E/M) code,” says Dr. Aung, a Certified Professional Medical Auditor, a Certified Surgical Foot and Ankle Coder and member of the American Association of Professional Coders. “What we all should keep in the forefront is that the documentation should support what we did for the patient on the particular encounter. It should stand alone to give us a picture of the particular event, answering all of the questions of who, what, where, when, how and why.”

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