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Compression Therapy

SUMMARY

Background: Compression therapy is considered the mainstay of venous leg ulcer (VLU) treatment [1] and along with standard care has the potential to heal 50%-75% of VLUs [1] [2]. Despite existing guidance, many patients with VLU who are treated at primary care settings do not receive adequate compression therapy due to several factors, some related to patients (e.g., adherence) and to clinicians (e.g, application skills, etc) [3] .

Indications:

  • Treatment and prevention of VLU
  • Varicose veins and edema
  • Lymphedema
  • Post-thrombotic syndrome
  • Prevention of deep venous thrombosis (DVT)

Contraindications:

  • Severe peripheral artery disease (PAD)
  • Acute DVT
  • Cellulitis
  • Unstable cardiac failure

Product Types:

  • Static:
    • Compression bandages:
      • Elastic
      • Inelastic
      • Combination/ Multicomponent
    • Tubular dressings (bandages):
      • Elastic
      • Inelastic
    • Gradient compression stockings
      • Elastic
    • Gradient compression wrap
      • Inelastic
  • Dynamic:
    • Intermittent pneumatic compression

Evidence and Recommendations

  • 1B
    For VLU patients with no contraindications, we recommend compression over no compression therapy to promote wound healing (Grade 1B).
  • 2B
    As for initial choice of compression therapy, we suggest multi-component compression bandages over single-component compression bandages (Grade 2B), and multi-component bandages with an elastic layer (e.g, 4LB) over those composed mainly of inelastic layers (e.g, SSB) (Grade 2B).
  • 2B
    Two-layer gradient compression stockings (HH) that deliver 40 mmHg pressure at the ankle can be considered an effective alternative to multi-component compression systems (4LB) (Grade 2B).
  • 2C
    Intermittent pneumatic compression (IPC) therapy can be used associated with compression bandages when all other compression therapy methods have failed or on patients that do not tolerate multi-component compression systems or high compression gradient stockings (Grade 2C).
  • 2C
    To decrease risk of ulcer recurrence in patients with a healed VLU, we suggest compression therapy with gradient compression stockings at the highest pressure patients can tolerate (Grade 2C).

Practice Tips

  • When considering compression devices, both multicomponent systems with an elastic layer (e.g. 4LB)  and non-elastic systems (e.g, SSB) can be effective choices, depending on several factors such as availability of resources, clinicians’ experience and familiarity with the compression method, characteristics of the ulcer, patient preference and support from caregivers
  • For VLU patients with stable and controlled congestive heart failure (CHF) or for VLU patients with peripheral arterial disease (PAD) and ankle brachial index (ABI) between 0.5 and 0.8, modified compression can be applied under close supervision

Coding and Coverage

  • Compression bandages, wraps and certain gradient compression stockings are covered by Medicare part B as long as used on patients with active VLU.
  • IPC for treatment of VLU also may be covered at least partially, if applied or supervised by a home visiting nurse, or if utilized in a hospital or nursing home setting.

Clinical

Overview

Venous leg ulcer (VLU) is discussed in detail elsewhere (See “Venous Ulcer”). This topic provides a high-level overview on the use of compression therapy in the treatment of VLU. For more details on compression subtypes please see “Compression Bandages”, “Tubular Dressings (Bandages)”, “Gradient Compression Stockings” and “Dynamic or Intermittent Compression”

Background

  • VLU is the most common type of leg ulcer (~ 80% of  leg ulcers) [4]. VLU are extremely common in the U.S. and affect between 500,000 to 2 million people per year [5]. It is typically a chronic condition with episodes that can last weeks to more than 10 years [1].
  • Compression therapy is considered the mainstay of VLU treatment [1] and along with standard care has the potential to heal 50%-75% of VLUs [1] [2].
  • Despite existing guidance, many patients with VLU who are treated at primary care settings do not receive compression therapy. In Europe, records indicate that only 10-53% of patients with VLU receive adequate compression therapy [3]. In contrast, at specialist centers, up to 88% of patients with VLU receive compression therapy [6].
  • Reasons why compression therapy is underutilized are: lack of knowledge or confidence by clinicians, unclear referral pathways because of the variety of specialties that may be involved, local unavailability of compression bandages or hosiery, and unwillingness of patients to wear compression therapy [3].

How the intervention might work

  • Most VLU are associated with chronic venous insufficiency, however the etiology of VLU is not yet fully understood[1] [7] . Chronic venous insufficiency has been shown to be associated with venous hypertension [8], which most often results from thrombosis and/or valve disease affecting the superficial, perforator or deep veins [2]. In individuals with healthy venous valves, use of muscle pump reduces the intravenous pressure at the ankle during ambulation, however in venous dysfunction pressure remains high, resulting in ambulatory venous hypertension (Video 1, Figure 1[9] [10].  Venous hypertension results in inflammatory alterations with microcirculatory changes that can culminate in edema, venous stasis and VLU [11].
  • External compression has been used in an attempt to reverse venous hypertension and aid venous return [8]. Venous stasis and edema can be reduced by effectively applying external local compression, which facilitates reabsorption of fluid from the interstitium into the lymphatics (Figure 2[9].  This phenomenon has been described by the Starling equation (Figure 3[9] [12]

 

Video 1. Video on how the muscle pump works in healthy individuals

Figure 1 – Changes in pressure (measured at the ankle) in venous system of individuals with healthy and dysfunctional venous valves during lying, rising, standing and exercise

Figure 2. The mechanism of action on compression

Figure 3. Starling equation

 

  • Two physical laws apply to compression therapy [9]:
    • Pascal’s Law: external static pressure exerted on a confined fluid is distributed evenly (Figure 4)

Figure 4. Pascal’s Law

    • Laplace’s Law. Pressure applied by compression is proportional to the tension at the interface with skin and inversely proportional with limb radius (Figure 5)

 

Figure 5. Laplace’s Law

  • These laws explain the following facts observed in compression therapy:
    • Each additional bandage layer adds more pressure. The same tension applied at the ankle will generate more pressure than if applied at the calf, due to the smaller radius at the ankle [13].
    • More layers of elastic compression bandaging incrementally increase compression and result in a less elastic bandage. This is in part due to friction between the layers [14].
    • Less elastic bandages exert greater compressive pressure when the wearer stands from a supine position, likely due to muscle expansion [14].
    • The calculated value for sub-bandage pressure is the average pressure that will be exerted by a bandage on a limb of known circumference. Padding can be applied beneath compression bandages to reduce local variations in sub-bandage pressure [13].
    • Bandage width matters. A 10cm wide bandage applied with a total force of 'F' Newtons, will produce only half the pressure developed beneath a 5cm wide bandage applied with the same force as the force is distributed over twice the area [13].
  • Clinician or patient-related factors also affect sub-bandage pressure
    • Patient-related: calf muscle and foot pump function, shape of the limb, ability to tolerate compression [3].
    • Clinician-related:  many clinicians are not familiar with compression therapy in general [15] . Compression application skills and available resources can affect sub-bandage pressure [2]. Even clinicians who are confident in their ability to apply compression can apply compression in a suboptimal way [16] [17]. Some bandages offer visual guides that indicate proper application of the device. See application techniques in section ‘How to use’ in “Compression Bandages”, “Tubular Dressings (Bandages)”, “Gradient Compression Stockings” and “Dynamic or Intermittent Compression”

Grades of Compression

  • Sub-bandage pressure is measured in mmHg at the ankle level. Classification of pressure exerted by compression devices varies across countries. The following standard (Table 1) has been suggested recently by an International Consensus [18]:

Table 1.Grades of Compression, International Consensus

Classification

Pressure (mmHg)

Mild

<20

Moderate

≥20-40

Strong

>40-60

Very strong

>60

General Indications and Contraindications

Indications

  • Different pressure levels are indicated according to the severity of the diseased being treated [9]. The CEAP (Clinical- Etiology-Anatomy-Pathophysiology) classification system has been used to standardize documentation and description of the several manifestations of chronic venous disease. The C (Clinical) category is divided as follows:
  • C0: No visible or palpable signs of venous disease.
  • C1: Telangiectasies or reticular veins
  • C2: Varicose veins.
  • C3: Edema.
  • C4: Changes in skin and subcutaneous tissue divided into two subclasses:
    • C4a Pigmentation or eczema
    • C4b Lipodermatosclerosis or atrophie blanche.
  • C5: Healed venous ulcer.
  • C6: Active venous ulcer.
  • Table 2 summarizes indications and pressure levels commonly used in compression therapy for chronic venous disease. Compression is also utilized to treat other conditions not addressed here (e.g., lymphedema, post-thrombotic syndrome, prevention of deep venous thrombosis  [9].

Table 2. Chronic venous insufficiency and compression pressure levels

Condition

Indicated pressure level

Active VLU (C6)

Strong and very strong pressure compression (>40mmHg) is better than lower pressure levels for venous ulcer healing [19]

Healed VLU, to reduce recurrence post-healing (C5)

Highest pressure patient can tolerate [1]

Varicose veins and edema (C2, C3)

Moderate level - 30-40 mmHg [20]

Simple varicose veins (C2)

Moderate level - 20-30 mmHg [21]

Contraindications

  • Severe peripheral arterial disease: all patients should be screened for arterial disease using Doppler measurement of the ankle-brachial pressure index (ABPI) by trained staff before receiving compression therapy [1]. Compression on a limb compromised by arterial disease can lead to ischemic sequelae and tissue necrosis [22]. ABI below 0.8 is often considered clinically significant.
    • Patients with ABI between 0.5 and 0.7 may be eligible to receive modified (reduced) compression (23-30 mmHg at the ankle), pending consultation and indication by a vascular specialist [1] [23].
    • Patients with ABI at or below 0.5, ankle pressure <70 mmHg or toe pressure <50 mmHg  or ABI at or above 1.3 should not receive compression and should be referred to vascular specialist [3] [22] [23] 
  • Acute deep venous thrombosis: if present, acute deep venous thrombosis needs to be treated with anticoagulants first for 7 days before compression therapy is started [24]
  • Cellulitis: if present, cellulitis needs to be treated first with systemic antibiotics for 24 hours and need to be afebrile before compression therapy is applied [3]. Patients can receive reduced compression if standard compression is difficult to tolerate, and dressing change frequency can be increased to monitor infection.
  • Unstable congestive cardiac failure (CHF): cardiac failure and hemodynamic condition need to be under control prior to commencing compression, as heart can be overloaded once edema starts to subside [3]. Signs and symptoms of unstable CHF include: significant peripheral edema, dyspnea, altered mental status, decreased diuresis, tachycardia, hypoperfusion, markedly elevated neck veins  [25]

Subtypes of compression therapy devices

  • Compression can be achieved by several methods, including by using a single component or layer (such as a compression stocking or one type of bandage) or by using multiple components or layers (different types of bandages or stockings and bandages used together) [1] [26]. Overall, evidence shows that multi-component systems are more effective than single-component systems. High compression is more effective than low compression but there are no clear differences in the effectiveness of different types of high compression [1].
  • All patients who are candidates to compression therapy should have their ABPI measured and recorded [3]. ABPI is a major determinant of the grade of compression to be applied. Other factors that influence choice of compression are clinician’s preference and experience, wound status, exudate level, patient mobility, ability of the patient to self-apply compression, patient’s preferences, pain level, access to care, level of compression required, and availability of compression systems [3].
  • In general, compression devices for treatment of VLU can be classified in static or dynamic:
    • Static: Compression bandages and gradient compression stockings are forms of static compression, and apply constant pressure gradient from distal to proximal in the extremity [3] [27]. This gradient of a 20–30% reduction in pressure from ankle to below knee is thought to aid venous return to the heart and occurs naturally when compression is applied to a limb of normal proportions due to the principles of Laplace’s Law [27]. Patients with altered limb shape such as inverted champagne bottle shape may require reshaping of the limb with padding prior to the application of compression in order to benefit from graduated compression. However, it is not clear how important this gradient is, especially for mobile patients [27].
    • Dynamic: Intermittent pneumatic compression (IPC) is an example of dynamic compression. The sequential inflation and deflation of the chambers creates intermittent pressure peaks, mimicking the effect of the calf muscle pump and offering a number of benefits. It might be useful for patients with reduced mobility or wasting of the calf muscle [27].
  • Static or dynamic compression devices can be elastic, inelastic or a combination of both:
    • Elastic: elastic systems (also known as “long stretch”) contain elastomeric fibers and are capable of stretching and returning to almost their original size. They can sustain pressure for up to a week due to their ability to accommodate changes in limb shape and movement [10] [27]. Elastic compression provides compression when patients are either walking or resting, which might not be desirable in patients with PAD [2].
    • Inelastic: inelastic systems contain no or few elastomeric fibers. They include “non-stretch” materials, such as zinc paste bandages, and “short-stretch” materials, which have a minimal extensibility (SSB) [27]. Inelastic systems can maintain levels of 30-60 mmHg in the first 24 hours after application, but this level decreases with movement of edema reduction. Most multi-component systems (two and four-components) function as an inelastic system even if they contain mainly elastic components [10]. Inelastic systems will produce higher pressures during standing and lower pressures when lying down than elastic systems [2] [10] making it more desirable in patients with mild arterial insufficiency [2].
    • Combination: compression system composed of both elastic and inelastic materials.  

Table 3 below summarizes characteristics of the different types of compression devices:

Types of compression devices

Beneficial to

Comments

Static

Bandages

Elastic

Elastic bandages are beneficial to individuals who ambulate or who have reduced mobility [24] [28]

Elastic bandages are not desirable for patients with PAD

Inelastic

Inelastic bandages (e.g., Unna Boots,SSB) can be useful in the initial phases of edema reduction; when frequent dressing changes are needed due to weeping or when there is pressure damage from elastic bandages [24]; for patients with mild PAD  [2], or pressure damage [27]. Not indicated for patients with reduced mobility as it requires functional muscle pump to be effective [28]

Inelastic bandages may be more adequate for patients with PAD [2]. Inelastic systems can maintain 30-60 mmHg in the first 24hs, but decreases with movement and edema reduction [10] [27]

Multi-

component

Guidelines and evidence suggest multicomponent compression systems with an elastic component (4LB) as the first choice of initial therapy for most patients with VLU with no contraindications [1] [29]. Elastic multicomponent system is recommended for immobile patients   [28]

4LB are more cost-effective than multicomponent compression systems without an elastic component   [30] [31]. Most multicomponent compression systems are designed to deliver 40mmHg at the ankle, decreasing to around 17 mmHg at the calf

Tubular Dressing

Elastic or
Inelastic

Patients with VLU who cannot tolerate multi-component compression bandages with an elastic component, such as patients with PAD and ABPI between 0.5 and 0.8

Patients with VLU who require frequent daily dressing changes   [32]

Tubular dressings can provide either uniform or graduated compression [1]

Gradient Compression Stockings

Elastic

Patients with CEAP C0-6 (different levels of compression needed)


Prevention of new VLU and recurrence, healing of VLU


Can be used as a first-line treatment for patients with small, uncomplicated ulcers who wish to self-care, who find bandages too hot or bulky [27] , and with no morbid obesity, lipodermatoesclerosis or severe edema [33].

Custom fitted stockings may provide the best compression to patients, however they are difficult to don and may lead to low adherence [34].


Two-layer compression stockings (HH) that deliver 40 mmHg are as effective in healing VLU as 4LB, and they seem to have the additional benefit of reducing recurrence rates and being more cost-effective [33] .

Gradient Compression

Wrap

Inelastic

Patients who are unable to wear 35 to 45 mmHg gradient compression stockings because of weakness or arthritis or those who are unable to tolerate Unna boot [35]

Inelastic compression provided by Velcro bands, can be adjusted as limb swelling decreases. Provides higher working and lower resting compression levels with low-stretch materials. A lower resting compression level can make it more tolerable

Dynamic

Intermittent Pneumatic Compression

n/a

Patients with VLU who cannot wear or tolerate any of the other compression methods due to severe PAD, excessive pain, pressure damage [24], severe difficulty in donning compression stockings  or have failed to respond to prolonged compression therapy alone [22]


Patients with VLU with reduced mobility or wasting of the calf muscle [27].

Whereas it is advantageous to use IPC compared with no compression therapy, currently there is limited evidence to suggest that the addition of IPC to compression therapy offers benefit [22]  [36].

Pressure levels are generally set to 50 mmHg but are never greater than diastolic pressure [28]

Table 3. Types of compression devices

Insert Figures of different types of compression

Compression bandages

Setopress, Surepress, Lowpress bandages with visual guide for ideal compression pressure

Tubular

Stocking

Wrap

Dynamic

Evidence and Recommendations

Please see “Venous ulcers”, section on ‘Compression’ for rationales and summary of evidence supporting the recommendations below.

  • 1B
    For VLU patients with no contraindications, we recommend compression over no compression therapy to promote wound healing (Grade 1B).
  • 2B
    As for initial choice of compression therapy, we suggest multi-component compression bandages over single-component compression bandages (Grade 2B).
  • 2B
    Two-layer gradient compression stockings (HH) that deliver 40 mmHg pressure at the ankle can be considered an effective alternative to multi-component compression systems (4LB) (Grade 2B).
  • 2C
    Intermittent pneumatic compression (IPC) therapy can be used when all other compression therapy methods have failed or on patients that do not tolerate multi-component compression systems or high compression gradient stockings (Grade 2C).
  • 2C
    To decrease risk of ulcer recurrence in patients with a healed VLU, we suggest compression therapy with gradient compression stockings at the highest pressure patients can tolerate (Grade 2C).

Practice Tips

Choosing an ideal compression device
  • With the goal of achieving optimal sub-bandage pressure and gradient compression, clinicians should choose the type of compression device according to availability of resources, clinicians’ experience and familiarity with the compression method, characteristics of the ulcer, patient preference and support from caregivers. Multicomponent systems with an elastic layer (e.g. 4LB) and without elastic layer – non-elastic systems (e.g, SSB) can both be effective choices depending on the factors above.
Compression for VLU patients with CHF and PAD
  • For patients with CHF or history of CHF - if patient is not unstable, compression should be applied as long as patient is being treated and under control. If needed, diuretics can be increased upon application of compression for the first time and patient should be reassessed within 24-48 hours.
  • For patients with PAD and ABPI between 0.5 and 0.8, use reduced level of compression (23-30 mmHg at the ankle) and closely monitor for complications. If resources are available and if uncertain about whether compression can be applied, clinicians can measure toe pressure with the patient lying in dorsal decubitus before and immediately after application of modified compression with inelastic multicomponent bandages (e.g, SSB like Coban™ 2 layer compression system). If toe pressure before compression is >50 mmHg, compression can be applied and toe pressure measured again to confirm and document that perfusion was not altered. Clinicians have reported increased toe pressure after SSB application.
Get a head start on reducing edema
  • If a patient with VLU has significant edema and no CHF, and resources are available, a quick course of high pressure compression (e.g., with Ace wrap) can be applied to the patient’s leg for 10-20 minutes in the clinic before applying the dressings and compression bandages/stockings/wrap that the patient will go home with. Practitioners have seen patients lose 1-2 cm in leg diameter with the addition of this step.


Risks and Complications

Most complications due to compression therapy are avoidable if appropriate measures to mitigate risks are taken. If complications arise, it is important that they be addressed promptly. Below are some of the complications and a few practical suggestions to manage them [27]:

  • Pain: compression, when applied appropriately should reduce pain. However, effective compression may cause initial discomfort and anxiety. Suggestions based on expert opinion include:
    • Rule out any other causes of pain, such as PAD-related pain. Teach patient to recognize signs of PAD (e.g., changes in limb color/perfusion). If ABPI <=0.5, avoid static compression and refer to vascular specialist, who may prescribe IPC
    • Ensure local wound care is done properly (see “Venous Ulcer”, section on ‘Local Wound Care’)
    • If pain is related to compression: offer analgesics during the initial phase (1-2 weeks) until discomfort subside, stage compression (start with a lower pressure level)
    • If pain remains uncontrolled, perform full reassessment (see “Venous Ulcer”, section on ‘Plan Reassessment’)
  • Pressure Damage: signs of pressure damage resulting from compression therapy are erythema, blistering, altered limb shape. Among risk factors are: patients with impaired peripheral perfusion, thin or altered limb shape, foot deformities, reduced sensation/pain sensation, long-term systemic steroid use and presence of a chronic disease (eg rheumatoid arthritis) associated with reduced mobility, loss of calf muscle and foot/ankle deformity. Suggestions based on expert opinion include:
    • Avoid strong, sustained compression. Consider using inelastic compression and IPC associated with hosiery
    • Apply extra padding over bony prominences
    • Ensure overlap is even mainly at the dorsum of the foot, ankle and calf
  • Loss of calf muscle: may be seen in patients receiving long-term compression, most likely due to reduced patient activity and underlying comorbidities (as opposed to compression itself). Suggestions based on expert opinion include:
    • Ensure compression allows patient to flex knee and ankle at or near 90 degrees
    • Ensure shoes do not restrict patient’s ankle range of motion. Flat, comfortable shoes are preferred
    • Encourage calf muscle exercise
  • Skin problems: can arise due to excessive exudate or allergic reactions. Suggestions based on expert opinion include:
    • Fungal infection: excessive exudate can lead to fungal infection. Fungal infection needs to be treated to resolution before reapplication of occlusive dressings and compression. Prevent fungal infections by adequately managing exudate (see local wound care) and increasing frequency of dressing and compression system change until exudate is controlled.
    • Contact dermatitis: susceptible patients may develop contact dermatitis from one of the components of the compression system (e.g., latex, zinc, wool). Remove irritant or use a cotton stockinette liner or paste bandage against the skin to avoid irritation from wool padding.

Patient Adherence

  • Many patients cannot tolerate, or do not adhere to, compression bandaging therapy [37]. It is estimated that 60 to 70% of patients do not appropriately adhere to compression therapy  [38] [39]. Patients might find it difficult to tolerate compression due to several reasons, such as bandage bulk, lifestyle, climate or cultural factors [27]. Patients with obesity, frailty or arthritis will struggle to apply elastic compression stockings. Also, patients’ beliefs that compression is unnecessary and uncomfortable, or conversely that is worthwhile and prevent recurrence affect adherence or non-adherence [40]. Thus, adherence can be improved by educating patients on the importance of compression therapy [41], and also by properly selecting the best compression alternative for each patient.
  • Below are some practical suggestions based on expert opinion to aid in patient adherence  [3]:
    • Determine reasons for non-concordance and address any modifiable reason
    • Consider implementing lower level of compression and gradually increasing to a level that is tolerable for the patient
    • Consider the use of compression hosiery, tubular compression or IPC associated with hosiery
    • Limit bulk around the ankle/foot
    • Bandage protector to enable bathing/showering

Patient Education - for Clinicians

  • VLU are a chronic, long-term problem, with recurrence rates are as high as 70%. Therefore, long-term maintenance must be addressed even for healed ulcers [42]. See “Venous Ulcers”, section on ‘Patient Education’ for details on patient education for VLU healing, prevention of new VLU and prevention of recurrence.
  • We recommend sharing our patient education materials with VLU patients (for all materials, see Patient Education Materials)

Compression therapy patient education materials:

Related Patient Education materials:

  • Basic principles of wound care (handout)
  • Chronic ulcers (handout)
  • Debridement (handout)
  • Nutrition (handout)
  • Showering instructions (handout)
  • Smoking cessation (handout)
  • Ulcer infection (handout)

Coding and Coverage

This section provides an overview how the different compression modalities are coded and covered by Medicare in the United States. For more detailed coding and coverage information for each compression subtype, please see section on “Coding, Coverage, Reimbursement” in the topics “Compression Bandages”, “Tubular Dressings (Bandages)”, “Gradient Compression Stockings” and “Dynamic or Intermittent Compression”

  • Overall, compression bandages, wraps and certain gradient compression stockings are covered by Medicare part B as long as used on patients with active VLU. Multicomponent compression systems with elastic components have been shown to be more cost-effective than usual care [43] [44]. IPC also may be covered at least partially, if applied or supervised by a home visiting nurse, or if utilized in a hospital or nursing home setting.
  • Medicare coverage of compression devices is managed by Medicare Administrative Contractors (MAC). Policies are explained by:
  • LCD and Policy Article guidance is summarized in table 4 below:

Table 4. Medicare Coverage Guidelines

Type of compression device

HCPCS code

Frequency of replacement

Coverage requirements

Not covered for

Bandages

Padding bandages, non-elastic

A6441

up to 1/week*

be part of multicomponent system to treat VLU **

strains, sprains, edema, or situations other than as a dressing for a wound.

Conforming bandages, non-elastic

A6442-A6447

same as underlying dressing

hold dressings covering any wound or be part of multicomponent system to treat VLU **

Light compression bandages, elastic (i.e., ACE type)

A6448-A6450

up to 1/week*

hold dressings covering any wound

Moderate compression bandages, elastic

A6451

up to 1/week*

be part of multicomponent system to treat VLU**

High compression bandages, elastic

A6452

up to 1/week*

be part of multicomponent system to treat VLU**

Self-adherent bandages, elastic

A6453-A6455

up to 1/week*

hold dressings covering any wound or be part of multicomponent system to treat VLU**

Gradient compression wrap

Gradient Compression stockings


Gradient compression wrap, non-elastic

A6545

1 per 6 months/leg

be used to treat VLU

venous insufficiency without VLU,prevention of new VLU, prevention of recurrence of VLU that have healed, treatment of lymphedema in the absence of VLU

Gradient compression stockings 30-40, 40-50 mmHg

A6531, A6532

1 per 6 months/leg

be used to treat VLU

Gradient compression stockings other than above

A6530, A6533-A6544

A6549

n/a

not covered for any indication

Other

Surgical stockings

A4490-A4510

n/a

not covered for any indication

Non-elastic binder

A4465

n/a

* unless part of a multicomponent system

** When multi-layer compression bandage systems are used for the treatment of a VLU, each component is billed using a specific code for the component

CMS Quality Measures

Below are measures that are directly related to compression therapy for VLU. For other measures related to VLU see “Venous Ulcers”, section ‘CMS Quality Measures’. For a comprehensive list of wound care related measures, see “Wound Care Quality Measures”.

MIPS currently does not have VLU-specific measures. Listed below are VLU/compression therapy-specific measures issued by the US Wound Registry.

 

QCDR

Title

Description

ID

Measure Type

US Wound Registry (USWR)

Adequate Compression at each visit for Patients with VLUs

Percentage of venous leg ulcer visits of patients aged 18 years and older that received adequate compression within the 12-month reporting period.

5

Process

additional resources


Official reprint from WoundReference® woundreference.com ©2018 Wound Reference, Inc. All Rights Reserved

REFERENCES

  1. O'Meara, Susan; Cullum, Nicky; Nelson, E Andrea; Dumville, Jo C et al. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. Date of publication 2017 Oct 7;volume 11():CD000265.
  2. Kirsner, Robert S et al. Compression of venous ulcers: standardizing standard care. JAMA dermatology. Date of publication 2014 Jul 1;volume 150(7):736-737.
  3. Harding, Keith; Dowsett, Caroline; Fias, Lore; et, al et al. Simplifying venous leg ulcer management. Consensus recommendations. . Date of publication 2017 Oct 7;volume ():.
  4. Collins, L; Seraj, S et al. Diagnosis and Treatment of Venous Ulcers Am Fam Physician. Date of publication 2017 Oct 7;volume 81(8):989-996.
  5. AHRQ, et al. Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities Comparative Effectiveness Review. Date of publication 2017 Oct 7;volume (127):.
  6. Begarin, L; Beaujour, A; Fainsilber, P; Hermil, J-L; Lévesque, H; Benhamou, Y et al. [Compression and venous leg ulcer: observational study in general medicine]. Journal des maladies vasculaires. Date of publication 2014 Dec 1;volume 39(6):382-388.
  7. Comerota, Anthony; Lurie, Fedor et al. Pathogenesis of venous ulcer. Seminars in vascular surgery. Date of publication 2015 Mar 1;volume 28(1):6-14.
  8. Moffat, C et al. Compression therapy in practice . Date of publication 2017 Oct 7;volume ():.
  9. Attaran, Robert R; Ochoa Chaar, Cassius I et al. Compression therapy for venous disease. Phlebology. Date of publication 2017 Mar 1;volume 32(2):81-88.
  10. Wounds International, et al. Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. . Date of publication 2017 Oct 7;volume ():.
  11. Chi, Yung-Wei; Raffetto, Joseph D et al. Venous leg ulceration pathophysiology and evidence based treatment. Vascular Medicine. Date of publication 2015 Apr 1;volume 20(2):168-181.
  12. Lim, Chung Sim; Davies, Alun H et al. Graduated compression stockings. Canadian Medical Association Journal. Date of publication 2017 Oct 7;volume 186(10):E391-8.
  13. Thomas, S. et al. The use of the Laplace equation in the calculation of sub-bandage pressure Eur Wound Manage Assoc. Date of publication 2017 Oct 7;volume 3(1):21-23.
  14. Chassagne, Fanette; Martin, Frédéric; Badel, Pierre; Convert, Reynald; Giraux, Pascal; Molimard, Jérôme et al. Experimental investigation of pressure applied on the lower leg by elastic compression bandage. Annals of Biomedical Engineering. Date of publication 2015 Dec 1;volume 43(12):2967-2977.
  15. Protz, Kerstin; Heyer, Kristina; Dörler, Martin; Stücker, Markus; Hampel-Kalthoff, Carsten; Augustin, Matthias et al. Compression therapy: scientific background and practical applications. Journal der Deutschen Dermatologischen Gesell.... Date of publication 2014 Sep 1;volume 12(9):794-801.
  16. Kirsner, Robert S; Margolis, David J et al. Stockings before bandages: an option for venous ulcers. The Lancet. Date of publication 2017 Oct 7;volume 383(9920):850-851.
  17. Zarchi, Kian; Jemec, Gregor B E et al. Delivery of compression therapy for venous leg ulcers. JAMA dermatology. Date of publication 2014 Jul 1;volume 150(7):730-736.
  18. Partsch, Hugo; Clark, Michael; Mosti, Giovanni; Steinlechner, Erik; Schuren, Jan; Abel, Martin; Benigni, Jean-Patrick; Coleridge-Smith, Philip; Cornu-Thénard, Andre; Flour, Mieke; Hutchinson... et al. Classification of compression bandages: practical aspects. Dermatologic Surgery. Date of publication 2008 May 1;volume 34(5):600-609.
  19. Callam, M. J.; Harper, D. R.; Dale, J. J.; Brown, D.; Gibson, B.; Prescott, R. J.; Ruckley, C. V. et al. Lothian and Forth Valley Leg Ulcer Healing Trial, Part 1: Elastic versus Non-Elastic Bandaging in the Treatment of Chronic Leg Ulceration Phlebology. Date of publication 2017 Oct 7;volume 7(4):136-141.
  20. Motykie, G D; Caprini, J A; Arcelus, J I; Reyna, J J; Overom, E; Mokhtee, D et al. Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatologic Surgery. Date of publication 1999 Feb 1;volume 25(2):116-120.
  21. Gloviczki, Peter; Comerota, Anthony J; Dalsing, Michael C; Eklof, Bo G; Gillespie, David L; Gloviczki, Monika L; Lohr, Joann M; McLafferty, Robert B; Meissner, Mark H; Murad, M Hassan; Padbe... et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. Journal of Vascular Surgery. Date of publication 2011 May 1;volume 53(5 Suppl):2S-48S.
  22. O'Donnell, Thomas F; Passman, Marc A; Marston, William A; Ennis, William J; Dalsing, Michael; Kistner, Robert L; Lurie, Fedor; Henke, Peter K; Gloviczki, Monika L; Eklöf, Bo G; Stoughton, Ju... et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. Journal of Vascular Surgery. Date of publication 2014 Aug 1;volume 60(2 Suppl):3S-59S.
  23. Bonham, Phyllis A; Flemister, Bonny G; Droste, Linda R; Johnson, Jan J; Kelechi, Teresa; Ratliff, Catherine R; Varnado, Myra F et al. 2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary. Journal of Wound, Ostomy, and Continence Nurs.... Date of publication 2016 Feb 1;volume 43(1):23-31.
  24. Livingston, M; Wolvos, T et al. Scottsdale Wound Management Guide . Date of publication 2017 Oct 7;volume ():37.
  25. Joseph, Susan M; Cedars, Ari M; Ewald, Gregory A; Geltman, Edward M; Mann, Douglas L et al. Acute decompensated heart failure: contemporary medical management. Texas Heart Institute Journal. Date of publication 2009 Jan 1;volume 36(6):510-520.
  26. Mauck, Karen F; Asi, Noor; Elraiyah, Tarig A; Undavalli, Chaitanya; Nabhan, Mohammed; Altayar, Osama; Sonbol, Mohamad Bassam; Prokop, Larry J; Murad, Mohammad Hassan et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. Journal of Vascular Surgery. Date of publication 2014 Aug 1;volume 60(2 Suppl):71S-90S.e1.
  27. World Union of Wound Healing Societies (WUWHS), et al. Principles of best practice: Compression in venous leg ulcers. A consensus document. . Date of publication 2017 Oct 7;volume ():.
  28. Joseph McCulloch PhD PT CWS FACCWS FAPTA, ; Luther C. Kloth MS PT CWS FACCWS FAPTA, et al. Wound Healing: Evidence-Based Management (Contemporary Perspectives in Rehabilitation) . Date of publication 2017 Oct 7;volume ():.
  29. O'Donnell, Thomas F; Balk, Ethan M et al. The need for an Intersociety Consensus Guideline for venous ulcer. Journal of Vascular Surgery. Date of publication 2011 Dec 1;volume 54(6 Suppl):83S-90S.
  30. Iglesias, C P; Nelson, E A; Cullum, N; Torgerson, D J; VenUS I collaborators et al. Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers. The British Journal of Surgery. Date of publication 2004 Oct 1;volume 91(10):1300-1306.
  31. Ukat, A; Konig, M; Vanscheidt, W; Münter, K C et al. Short-stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. Journal of Wound Care. Date of publication 2003 Apr 1;volume 12(4):139-143.
  32. Dabiri, Ganary; Hammerman, Scott; Carson, Polly; Falanga, Vincent et al. Low-grade elastic compression regimen for venous leg ulcers--an effective compromise for patients requiring daily dressing changes. International wound journal. Date of publication 2015 Dec 1;volume 12(6):655-661.
  33. Ashby, Rebecca L; Gabe, Rhian; Ali, Shehzad; Adderley, Una; Bland, J Martin; Cullum, Nicky A; Dumville, Jo C; Iglesias, Cynthia P; Kang'ombe, Arthur R; Soares, Marta O; Stubbs, Nikki C; Torg... et al. Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised controlled trial. The Lancet. Date of publication 2017 Oct 7;volume 383(9920):871-879.
  34. Sippel, K; Seifert, B; Hafner, J et al. Donning devices (foot slips and frames) enable elderly people with severe chronic venous insufficiency to put on compression stockings. European Journal of Vascular and Endovascular.... Date of publication 2015 Feb 1;volume 49(2):221-229.
  35. Blecken, Sonja R; Villavicencio, Juan Leonel; Kao, Tzu C et al. Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial. Journal of Vascular Surgery. Date of publication 2005 Dec 1;volume 42(6):1150-1155.
  36. Nelson, E Andrea; Hillman, Alex; Thomas, Kate et al. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database of Systematic Reviews. Date of publication 2017 Oct 7;volume (5):CD001899.
  37. Bale, Sue; Harding, Keith G et al. Managing patients unable to tolerate therapeutic compression. British Journal of Nursing. Date of publication 2003 Oct 1;volume 12(19 Suppl):S4-13.
  38. Raju, Seshadri; Hollis, Kathryn; Neglen, Peter et al. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Annals of Vascular Surgery. Date of publication 2007 Nov 1;volume 21(6):790-795.
  39. Raju, Seshadri; Lurie, Fedor; O'Donnell, Thomas F et al. Compression use in the era of endovenous interventions and wound care centers. Journal of vascular surgery. Venous and lymph.... Date of publication 2016 Jul 1;volume 4(3):346-354.
  40. Van Hecke, Ann; Grypdonck, Maria; Defloor, Tom et al. A review of why patients with leg ulcers do not adhere to treatment. Journal of Clinical Nursing. Date of publication 2009 Feb 1;volume 18(3):337-349.
  41. Jull, A B; Mitchell, N; Arroll, J; Jones, M; Waters, J; Latta, A; Walker, N; Arroll, B et al. Factors influencing concordance with compression stockings after venous leg ulcer healing. Journal of Wound Care. Date of publication 2004 Mar 1;volume 13(3):90-92.
  42. Marston, William; Tang, Jennifer; Kirsner, Robert S; Ennis, William et al. Wound Healing Society 2015 update on guidelines for venous ulcers. Wound Repair and Regeneration. Date of publication 2016 Feb 1;volume 24(1):136-144.
  43. O'Brien, J F; Grace, P A; Perry, I J; Hannigan, A; Clarke Moloney, M; Burke, P E et al. Randomized clinical trial and economic analysis of four-layer compression bandaging for venous ulcers. The British Journal of Surgery. Date of publication 2003 Jul 1;volume 90(7):794-798.
  44. Taylor, A. D.; Taylor, R. J.; Marcuson, R. W. et al. Prospective Comparison of Healing Rates and Therapy Costs for Conventional and Four-Layer High-Compression Bandaging Treatments of Venous Leg Ulcers Phlebology. Date of publication 2017 Oct 7;volume 13(1):20-24.
  45. Center for Medicare and Medicaid Services (CMS), et al. Local Coverage Determination for Surgical Dressings (L33831) . Date of publication 2017 Oct 7;volume ():.
  46. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . Date of publication 2015 Oct 1;volume ():.

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