Post on 07-May-2015
description
1
Wound CareWound CareDocumentation Documentation Documentation Documentation
IssuesIssues
Tracey Goessel, M.D.CEO
FairCode AssociatesFairCode Associates
2
General Wound Issues We Will Discuss
What is the Nature of the Wound?
What is the Origin of the Wound?
Was the Wound Present on Admission?
What is the Treatment of the Wound?(Including everyone’s favorite: excisional debridement!)
22010 Intersect Healthcare, Inc. FairCode
3
What is associated with the wound?
Open Wounds -- Lacerations
What is associated with the wound?Be certain to capture associated injuries
Does the wound meet the definition of complicated?
Delayed healingDelayed treatmentForeign body orMajor Infection
How was the wound treated?Dermabond coded as application of tissue Dermabond coded as application of tissue adhesivesCapture length of wound and layers closed
32010 Intersect Healthcare, Inc. FairCode
4
Decubitus (Pressure Ulcers)
“A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.”
The National Pressure Ulcer Advisory Panel (NPUAP)
42010 Intersect Healthcare, Inc. FairCode
5
Decubitus Ulcers: Describe Location and Stage!Stage I
Persistent, focal erythema
Stage IIPressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis
2010 Intersect Healthcare, Inc. 5FairCode
6
Decubitus Ulcers, Continued
Stage IIIFull thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage IVNecrosis of soft tissues through to underlying muscle, tendon or bone
tissue
2010 Intersect Healthcare, Inc. 6FairCode
7
Are they diabetic in origin or decubitus?
Skin Ulcers: Describe Source
Are they diabetic in origin, or decubitus?Toe ulcer: likely diabetic
Heel ulcer: likely decubitus
Coding Clinic, Third Quarter 1991, pages 7-8, "Conditions listed with a diagnosis of diabetes mellitus or in a diabetic patient are not necessarily complications of the diabetes. The condition should be coded as such only when the physician identifies it as a diabetic physician identifies it as a diabetic complication."
Query, query, query!
72010 Intersect Healthcare, Inc. FairCode
8
Coding Clinic Second Quarter 1994
Skin Ulcers: Describe Source
Coding Clinic, Second Quarter 1994, Page: 17
“Do not assume a cause-and-effect relationship between diabetes and peripheral vascular disease if one is not stated by the physician Therefore if one is not stated by the physician. Therefore, category 250.7X, Diabetes with peripheral circulatory disorders, would not be used unless the physician so stated that the peripheral vascular disease was diabetic or due to diabetes. The conditions would be coded separately.”
Query, query, query!
82010 Intersect Healthcare, Inc. FairCode
9
Skin Ulcers: Determine if POA!
Coding Clinic, Third Quarter 2008, Pages: 20-21
“There is no required timeframe as to when a provider (per the definition of "provider" used in the Official Guidelines for Coding and Reporting) must identify or document a condition to be present on admission.”
Q ! Query, query, query!
92010 Intersect Healthcare, Inc. FairCode
10
Wound Treatment: Excisional Debridement
“Excisional debridement is the surgical removal or cutting away of devitalized tissue, necrosis, or slough. Depending on circumstances such as the patient's condition, availability of a surgical suite, or extent of area to be debrided, excisional debridement can be performed in the operating room, emergency room, or at the patient's bedside.”
“The attending physician must document in the medical eco d that an e cisional deb idement as medical record that an excisional debridement was performed.”
Coding Clinic, Fourth Quarter 1988 Page: 5
102010 Intersect Healthcare, Inc. FairCode
11
Wound Treatment: Non-Excisional Debridement
“Nonexcisional debridement is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, or slough. Nonexcisional debridement includes snipping of tissue followed by Hubbard tank therapy. Nonexcisional debridement may be performed by a nurse, therapist, or physician.”y , p , p y
“The use of a sharp instrument does not always indicate that an excisional debridement was performed. Unless the documentation describes sharp debridement as a definite cutting away of tissue and not the minor removal of loose fragments with scissors or scraping away tissue of loose fragments with scissors or scraping away tissue with a sharp instrument, assign code 86.28, Nonexcisional debridement of wound, infection, or burn.
Coding Clinic, Second Quarter 2004 Page: 5
112010 Intersect Healthcare, Inc. FairCode
12
Wound Treatment
h lOasis matrix burn dressing
Code as application of wound dressing
Escharotomy no longer excisional debridement of skin
is now re-indexed to code 86.09, Other incision of skin and subcutaneous ti etissue.
2010 Intersect Healthcare, Inc. 12FairCode
13
Maggots!
Wound Treatment
Maggots!“Assign code 86.28, Nonexcisional debridement of wound, infection or burn, for maggot therapy.”
Coding Clinic, Second Quarter 2001 Page: 18
132010 Intersect Healthcare, Inc. FairCode
14
Sample Queries
The medical record documentation requires clarification. The patient is documented in your progress notes to have pressure sores on the sacrum, identified as stage III in the nursing notes. Please provide clarification whether this problem was present on admission.
142010 Intersect Healthcare, Inc. FairCode
15
Sample Queries
You noted on day 3 of admission that the patient’s ulcer was debrided. Could you please specify and clarify the nature of the debridement, including whether or not there was actual surgical removal of devitalized tissue, or merely a scraping away of necrotic tissue?
152010 Intersect Healthcare, Inc. FairCode
16
Sample Queries
The patient, who is a diabetic, is noted to have lower extremity ulcers due to peripheral vascular disease. Please specify the relationship, if any, between the patient’s peripheral vascular disease and his diabetes.
162010 Intersect Healthcare, Inc. FairCode
1
Excisional DebridementExcisional DebridementExcisional DebridementExcisional Debridement
Charmira Orr BS,LPN,CCS,CPC,CCDS, Director of Coding and Auditing
Intersect Healthcare
2
Participants will understand how to utilize
Learning Objectives
Participants will understand how to utilize the RAC demonstration area target on Excisional Debridement to perform internal auditsParticipants will review and understand highlights to include in audits when focusing on excisional debridementParticipants will review and understand the ICD-9 CM guidelines for assigning 86 22 Excisional Debridement86.22 Excisional Debridement
22010 Intersect Healthcare, Inc.
3
86 22 Excisional Debridement #1
The RAC Demonstration
86.22 Excisional Debridement #1 procedure code that was coded incorrectly
Coding errors directly contributed to understanding guidelines, documentationg g ,
Two of the highest recoupment DRG’s for 86.22 were DRG 217 and DRG 263 collectively $17.8 million in 2006
32010 Intersect Healthcare, Inc.
4
MS‐DRG 573,574,575 Formerly DRG 263,264Issue Name:
Skin Graft and/or Debridement for Skin Ulcer or Cellulitis with CC: MS‐DRG 574 (At this time Medical Necessity excluded from review)
D i i DRG V lid i i h di i d d l i f i d h di h f hDescription: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS‐DRG 574, previously DRG 263 and 264, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.Provider Type Affected: Inpatient Hospital
Date of Service: 10/01/2007 ‐ Open
States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only)
Additional Information: Additional information can be found in the following manuals/publications:
1) ICD‐9‐CM Addendums and Coding Clinics
2010 Intersect Healthcare, Inc. 4
1) ICD 9 CM Addendums and Coding Clinics 2) ICD‐9‐CM Vol. 1, 2 & 3, coding manuals 3) PIM Ch 6.5.3, Section A‐C DRG Validation Review
Connolly Healthcare © 2010
5
MS-DRG 465 Formerly DRG 217
Issue Name: Wound Debridement and Skin Graft Except Hand, for Musculo‐Connective Tissue Disorders without CC/MCC: MS‐DRG 465 (At this time Medical Necessity excluded from review)MS DRG 465 (At this time Medical Necessity excluded from review)
Description: DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS‐DRG 465, previously DRG 217, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
Date of Service: 10/01/2007 ‐ Open
States Affected: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only)
2010 Intersect Healthcare, Inc. 5
Additional Information: Additional information can be found in the following manuals/publications:1) ICD‐9‐CM Addendums and Coding Clinics 2) ICD‐9‐CM Vol. 1, 2 & 3, coding manuals 3) PIM Ch 6.5.3, Section A‐C DRG Validation Review
Connolly Healthcare © 2010
6
86.22 Target of Other RAC MS-DRG’s
264 622
357
356
358
424 576
623
624
673
957 674
423
424
425
576
577
2010 Intersect Healthcare, Inc. 6
901
957
958
674
675
7
Excisional vs. Nonexcisional Debridement
• Surgical Removal or cutting away of devitalized tissue, necrosis , slough
• Performed at pt bedside, the operating, or emergency room
• Only applies to skin and subcutaneous tissue, can be performed on any part of the body
86.22 Excisional
Debridement
• Nonoperative brushing, scrubbing, or washing away of devitalized tissue, necrosis, or slough
• Can include Maggot and Water jet therapy, lavage, whirlpools, scrapings, irrigation
86.28 Nonexcisional g , p , p g , g
• Applies to only skinDebridement
2010 Intersect Healthcare, Inc. 7
8
What’s All the Fuss About What s All the Fuss About with Excisional Debridement
9
DocumentationDocumentation must support the translationpp
Terms “ Excisional debridement”, “Debridement of wound”, “Sharp debridement”, and etc. Are not enough to assign 86.22
Should note if the excision is beyond the wound margin, the Should note if the excision is beyond the wound margin, the type of area that was debrided, the type of instruments utilized in procedure, the number of areas debrided, specify location, and depth of the procedure
If debridement is part of another procedure- check to see if include or excluded from separate coding
10
Documentation
If documentation supports an extension beyond the skin or subcutaneous layer- 86.22 is the inappropriate code
Use of scissors is not enough – can be used just to loosen f l k f l l bl d l “R l f fragments, look for scalpel, blade, lasers- “Removal of tissue”
Measurements and appearance before and after
Note any documentation that states debrided down to vitalized or healthy tissue
2010 Intersect Healthcare, Inc. 10
11
Auditing Cases for Excisional Debridement
2010 Intersect Healthcare, Inc. 11
12
Retrospective or Concurrent
ExcisionalDebridement
Diagnosis
Case Mix Index
Documentation
Debridement
2010 Intersect Healthcare, Inc. 12
Documentation
13
Worksheet1. Diagnoses of the patient: ( All current diagnoses and treatments)
2. Initial Size, Depth, and Location of Wound:
3. Debridement Type: Wound, Infection, Burn
4. Date of Order: ( Make note of exact order)5. Is there any documentation that states the area is infected? Yes/No
6. Location of Procedure: Operating roomPatient bedsideEmergency room
7 Clinical Title of professional performing the procedure7. Clinical Title of professional performing the procedureNurseNurse PractionerTherapistPhysician AssistantPhysician
2010 Intersect Healthcare, Inc. 13
14
Worksheet Continued7. Number of locations debrided: __________________________
8. Post size and depth of areas:____________________________
9. Type of tissue to that was debrided: Cutaneous a. necroticSubcutaneous b. slough
c devitalizedc. devitalized10. Was the area debrided beyond the dead or damaged tissue down to healthy, viable tissue?Yes/ No
11. Instruments utilized during procedurescalpelscissorsscissorslaserblade
15
Worksheet Continued12.Is there evidence of other procedures that include procedure code 86.22: YesNo
13. What type of dressings were applied to the debrided area?
14. Were any specimens sent to pathology? Yes/No
15. Discharge status:
Home or Self Care -01Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03Discharged/Transferred to an Intermediate Care Facility - 04Di h d/T f d t A th T f H lth C F ilit N t l h i th C d Li t 05Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05Discharged/ Transferred to Home Care- 06AMA -07Expired-20
16
Highlights
If it doesn’t meet the criteria- look for another more appropriate code
Remember “ Cutting away of tissue”
Translate within the guidelines
2010 Intersect Healthcare, Inc. 16
Use the AHA Coding Clinics for guidance
17
DEBRIDEMENT THROUGH MULTIPLE LAYERS
AHA Coding Clinics on 86.22
DEBRIDEMENT THROUGH MULTIPLE LAYERSDEBRIDEMENT OF MULTIPLE LAYERS (SKIN, MUSCLE, BONE) OF THE SAME SITE IS CODED ONLY TO THE DEEPEST LAYER DEBRIDED. DO NOT ASSIGN TWO OR MORE CODES WHEN THE DEBRIDEMENT EXTENDS PAST THE SKIN AND SUBCUTANEOUS TISSUE INTO THE MUSCLE OR BONE (AHA CODING CLINIC FOR ICD-9-CM, 1999, FIRST QUARTER, PAGES 8-9).
DEBRIDEMENT INTEGRAL TO PROCEDUREDEBRIDEMENT OF THE SKIN THAT IS PREPARATORY TO FURTHER SURGERY DEBRIDEMENT OF THE SKIN THAT IS PREPARATORY TO FURTHER SURGERY SHOULD NOT BE CODED AS A SEPARATE PROCEDURE (AHA CODING CLINIC FOR ICD-9-CM, 1991, THIRD QUARTER, PAGES 18-19). IN ADDITION, DO NOT ASSIGN CODE 86.22 WHEN DEBRIDEMENT OF AN OPEN FRACTURE SITE IS PERFORMED. DEBRIDEMENT OF THE SKIN IS CONSIDERED INHERENT FOR THIS PROCEDURE (AHA CODING CLINIC FOR ICD-9-CM, 1995, THIRD QUARTER, PAGE 12).
WHO CAN PERFORMAN EXCISIONAL DEBRIDEMENT CAN BE CODED WHEN PERFORMED BY A NURSE AN EXCISIONAL DEBRIDEMENT CAN BE CODED WHEN PERFORMED BY A NURSE, THERAPIST, PHYSICIAN ASSISTANT OR PHYSICIAN. (SEE CODING CLINIC, SECOND QUARTER 2004, PAGE 5, CODING CLINIC, SECOND QUARTER 2000, PAGE 9, AND CODING CLINIC, FOURTH QUARTER 1988, PAGE 5.)
2010 Intersect Healthcare, Inc. 17
18
AHA Coding Clinics Cont’dLaser debridement of wound
Laser debridement of wound down to bone is coded 86.22, excisional debridement of wound, infection or burn, if this is not an open bone fracture or fracture/dislocation. Excisional debridement of an open fracture site is coded to 79.60‐79.69. When there is no specific “destruction” code for laser, laser technique is coded to the excisional codes (excluding those assignments under photocoagulation of eye.) (See Coding Clinic, second quarter 1992, page 17, and Coding Clinic, third quarter 1989, page 1 q , p g
Laser debridement of ulcer/repair/closure
Laser debridement of ischial decubitus ulcer down to bone with subsequent repair with skin flap creation and closure is coded 86.22, excisional debridement of wound, infection or burn, and 86.89, other repair and reconstruction of skin and subcutaneous tissue. The closure is included in the repair and not coded separately. The repair procedure code needs to be based on the documentation in the patient’s record. Code 86.89 indicates a nonspecific repair of the ulcer. (See Coding Clinic, second quarter 1993 page 11 and Coding Clinic second quarter 1992 page 17 )quarter 1993, page 11, and Coding Clinic, second quarter 1992, page 17.)
19
http://racmonitor.com/news/43-special-bulletin/174-racs-how-excisional-debridements-may-t d ht l
References
cut-deep.html
http://www.fortherecordmag.com/archives/091409p30.shtml
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036237.hcsp?dDocName=bok1_036237
http://med.stanford.edu/shs/update/archives/DEC2006/coding_corner.htm
192010 Intersect Healthcare, Inc.
1
Appealing an Appealing an Excisional Excisional
Debridement Debridement Inpatient DenialInpatient Denial
Denise Wilson, MS RN RRTDirector, Client Education and Performance
ImprovementIntersect Healthcare, Inc.
2
Understand how to create a successful
Learning Objectives
Understand how to create a successful coding or medical necessity appeal for Excisional Debridement or Wound Care denials by:
Understanding the Issue at HandProviding a Road Map for the ReviewerPresenting a Preponderance of Best Evidence
Understand how to tailor appeals to the Administrative Law Judge
22010 Intersect Healthcare, Inc.
3
From the RAC demonstration project:
Understanding the Issue at Hand
From the RAC demonstration project:
Top Services With RAC-Initiated Overpayment Collections (Net of Appeals):Cumulative Through 3/27/08
#2 on the list: Incorrect Coding of Excisional DebridementResulted in $66.8 million in collected overpayments (less cases overturned on appeal)cases overturned on appeal)
Top Services With Underpayments Refunded to Providers: Cumulative Through 3/27/08
#2 on the list: Incorrect Coding of Wound DebridementResulted in $3 million in amount refunded
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:An Evaluation of the 3-Year Demonstration, June 2008
https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf
32010 Intersect Healthcare, Inc.
4
Claim Facts
Understanding the Issue at Hand
The hospital coder assigned a procedure code of 86.22.In the medical record, the physician writes “debridement was performed.”Coding Clinic 1991Q3 states “Unless the attending physician documents in the medical record that an excisional debridement was performed (definite cutting away of tissue, not the minor scissors removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional debridement of skin… Any debridement of the skin that does not meet the criteria noted above or is described in the medical record as debridement and no other information is available should be coded as 82 26 ”available should be coded as 82.26.The RAC determined that the claim was INCORRECTLY CODED and issued a repayment request letter for the difference between the payment amount for the incorrectly correctly coded procedure and the payment amount for the correctly coded procedure.
Corrective ActionsHospitals can be more careful when submitting claims for excisional debridement.Medicare claims processing contractors can remind hospitals about the importance of following the coding clinic guidelines when submitting claims for importance of following the coding clinic guidelines when submitting claims for excisional debridement.
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:An Evaluation of the 3-Year Demonstration, June 2008
https://www.cms.gov/RAC/Downloads/RACEvaluationReport
42010 Intersect Healthcare, Inc.
5
Definition of Excisional Debridement
Understanding the Issue at Hand
Definition of Excisional Debridement86.22: Excisional debridement of wound, infection, or burnRemoval by excision of:
devitalized tissuenecrosis slough
86.22 excludes:debridement of: debridement of:
abdominal wall (wound) (54.3) bone (77.60-77.69) muscle (83.45) of hand (82.36) nail (bed) (fold) (86.27) nonexcisional debridement of wound, infection, or burn nonexcisional debridement of wound, infection, or burn (86.28) open fracture site (79.60-79.69) pedicle or flap graft (86.75)
ICD 9 CM Procedure Codes
52010 Intersect Healthcare, Inc.
6
Coding of debridement of wound infection
Understanding the Issue at Hand
Coding of debridement of wound, infection, or burn
Excisional debridement involves surgical removal or cutting away, as opposed to a mechanical (brushing, scrubbing, washing) debridement.For coding purposes excisional debridement is For coding purposes, excisional debridement is assigned to code 86.22.Nonexcisional debridement is assigned to code 86.28.
Official ICD-9-CM Guidelines for Coding and ReportingOfficial ICD 9 CM Guidelines for Coding and ReportingEffective October 1, 2009
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
62010 Intersect Healthcare, Inc.
7
Documentation of Excisional Debridement
Understanding the Issue at Hand
Documentation of Excisional DebridementWhat:
Excisional debridement is the definite cutting away of devitalized tissue, necrosis, or slough that includes cutting outside or beyond the wound margin.
Where:Excisional debridement can be performed in the operating room, p p g ,emergency room or at patient’s bedside depending on circumstances such as patient’s condition or location availability.
Who:An excisional debridement can be coded when performed by a nurse, therapist, physician assistant or physician.
How:Documentation should note if the excision is beyond the wound Documentation should note if the excision is beyond the wound margin, the type of area that was debrided, the type of instruments utilized in procedure, the number of areas debrided, the specific location, and depth of the procedure.
72010 Intersect Healthcare, Inc.
8
Providing a Road Map
82010 Intersect Healthcare, Inc.
9
Providing a Road Map
92010 Intersect Healthcare, Inc.
10
Providing a Road Map
102010 Intersect Healthcare, Inc.
11
SURGICAL TREATMENT OF BURNS
Preponderance of Evidence
SURGICAL TREATMENT OF BURNS Escharotomy
Definition, Purpose, Technique
Debridement of Burn WoundsDefinition Purpose TechniqueDefinition, Purpose, Technique
Excision of Burn WoundsDefinition, Purpose, Technique
American Burn Association. (2009) White Paper.S i l M t f th B W d d U f Surgical Management of the Burn Wound and Use of
Skin Substitutes. http://www.ameriburn.org/WhitePaperFinal.pdf?PHPSESS
ID=fa7087753db2caaa8c5b21f53869457d
112010 Intersect Healthcare, Inc.
12
Wound Care Associations:
Preponderance of Evidence
Wound Care Associations:The American College of Certified Wound Specialists —http://www.theccws.org/index.htmlAmerican Professional Wound Care Association (APWCA) —www.apwca.orgAssociation for the Advancement of Wound Care (AAWC) —www aawconline orgwww.aawconline.orgNational Alliance of Wound Care® (NAWC®) —www.nawccb.orgWound Ostomy Continence Nurses (WOCN) — www.wocn.orgDermatology Nurses’ Association (DNA) —www.dnanurse.orgThe Wound Healing Society — http://www.woundheal.orgThe Wound Healing Society http://www.woundheal.org
Free Access To The Chronic Wound Care Guidelines Free Access to the Acute Wound Care Guidelines
122010 Intersect Healthcare, Inc.
13
Use the guidelines that were available and in effect at the
Parting Thoughts
Use the guidelines that were available and in effect at the time the services were provided, coded, and billed!
Provide clear and accurate reference information, including URLs.
Include all supporting guidelines in full text documents pp g g(the pertinent pages) as attachments to your appeal.
132010 Intersect Healthcare, Inc.
14
Best Practice for Appeal
Summary
Best Practice for AppealDetermine if documentation in the chart supports an appealSupport the coding decision with:
ICD‐9‐CM Coding Guidelines
ICD‐9‐CM Official Guidelines for Coding and Reporting IC 9 CM Official Guidelines for Coding and Reporting
American Hospital Association's (AHA) Coding Clinic for ICD‐9‐CM
Support the physician’s decision making process with evidence based guidelinesUse CMS’s coverage policies and guidelines
142010 Intersect Healthcare, Inc.
15
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
Resources
An Evaluation of the 3-Year Demonstration, June 2008https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf
Official ICD-9-CM Guidelines for Coding and ReportingEffective October 1, 2009http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
American Burn Association. (2009) White Paper.Surgical Management of the Burn Wound and Use of Skin Substitutes.http://www.ameriburn.org/WhitePaperFinal.pdf?PHPSESSID=fa7087753db2
caaa8c5b21f53869457d
Guidelines to decrease the impediment to acute wound healing caused by nonviable tissuenonviable tissue
Wound Rep Reg (2008) 16 723–748 _c 2008 by the Wound Healing Societyhttp://www.woundheal.org
152010 Intersect Healthcare, Inc.