Lisa,

Thanks for your question. Per our conversation, the patient had a total of 5,440 cGy in 17 fractions following the excision of a lower extremity squamous cell carcinoma, resulting in a wound that has been present for 72 weeks.

Delayed radiation complications often manifest as non-healing wounds in previously irradiated areas. The wounds can be precipitated by an external insult such as surgery, trauma, or even minor trauma. Some of these wounds are visible, and some are not (e.g., radiation cystitis, vaginitis, proctitis, and urethritis). Hyperbaric oxygen has been shown to induce neovascularization and increase cellularity in irradiated and other hypoxic tissues.

Regarding criteria or qualification as a candidate for HBOT for Soft Tissue Radiation Necrosis:

• Non-healing wound within a previously irradiated area with at least six months since last radiation exposure
• History of radiation treatment (usually in excess of 40 Gray or 4,000 cGy) to the region of the documented injury
• Wound that is non-responsive to conservative standard treatment.

Also, documentation of a comprehensive history and physical exam should include the following details: The date of cancer diagnosis, the date when radionecrosis was diagnosed, the specific type of radiation source used, the total dosage administered over the entire course of treatments, the radiation fraction applied (for example, "Thirty sessions of electron beam radiation targeting the prostate gland, with each session delivering 200 cGy fractions, resulting in a cumulative total of 6,000 cGy"), the span of dates during which radiation was administered, and any preceding treatments or therapies.

Again, thanks for your question. Please let us know if you have any additional thoughts or questions.

Have a great day! Jeff

Lisa,

I would agree with Jeff. I am getting the idea that you may be hesitant to treat either because you are not sure that the type of radiation used would fall under the NCD guidelines or within the UHMS "Delayed Radiation Injury" indication. As far as coding goes, currently the NCD only covers L59.8 - Other Specified Disorders of the Skin and Subcutaneous Tissue Related to Radiation. In the current ICD-10 manual you can an additional code that could be used is L59.9 - Disorder of the Skin and Subcutaneous Tissue, Unspecified. L59.9 is not on the list of approved HBO codes per the NCD. Additionally, why would you choose one code over the other. Most coders will tell you to use L59.8 for soft tissue radiation damage. In your case, since the patient has an ulcer related to radiation then the only L59.8 is applicable and L59.9, per the CPT manual, would not be work here, because there is no ulcer reference in the diagnosis index for L59.9. So now that the coding is out of the way and we have an HBO appropriate code, L59.8, what about the types of radiation. I would not get hung up on the term "ionizing". Your patient had external beam radiation for a therapeutic purpose. On page 193 of the UHMS Indications Manual, 15th edition, Dr. John Feldmeier and Laurie Gesell have a nice review of Radiation Induced Skin Necrosis and I think that it will make you more comfortable treating your patient. If there is a question on the diagnosis, you could always do a skin biopsy. I would also agree with Jeff's recommendation on documentation.