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How to Apply Unna Boot

How to Apply Unna Boot

How to Apply Unna Boot

ABSTRACT

Unna Boot, also known as Unna's Boot or paste boot, is an inelastic bandage that is frequently used in compression therapy to treat venous leg ulcers. Application of UB is one of the most common clinic procedures billed to Medicare. A 2019 study showed that it was among the top ten most performed procedures by a large multi-regional health care system in the U.S.[1] 

This topic focuses on application of UB. For a review on compression therapy and other types of compression devices, see topic "Compression Therapy". For guidance on selecting compression pressure level, see "How to Select Adequate Compression Therapy Pressure Levels and Products". For examples of different brands, see "Compression Brands Quick Reference". 

Resources provided by this topic include:

  • Definition, composition, types of Unna Boot
  • General indications and contraindications
  • Frequency of change
  • Step-by-step protocol for application of Unna Boot: Pre-procedure, During the Procedure and Post-procedure
  • Documentation checklist
  • How to assess effectiveness
  • Coding and reimbursement

CLINICAL

Overview

Unna Boot, also known as Unna's Boot (UB) or paste boot, is an inelastic bandage that is frequently used in compression therapy to treat venous leg ulcers (VLU). This topic focuses on application of UB. For a review on compression therapy and other types of compression devices, see topic "Compression Therapy". For guidance on selecting compression pressure level, see "How to Select Adequate Compression Therapy Pressure Levels and Products". For examples of different brands, see "Compression Brands Quick Reference".

Background

  • Compression therapy is considered the mainstay of VLU treatment. Along with standard care it has the potential to heal 50%-75% of VLUs.[2][3]
  • Adequate compression can be achieved by several methods, for instance by using a single component/layer (such as a compression stocking or one type of bandage) or by using multiple components/layers (different types of bandages or stockings and bandages used together).[2][4] Overall, evidence shows that multi-component systems are more effective than single-component systems. High compression is more effective than low compression, but among different types of high compression no clear differences have been observed.[2] See different types of compression therapy devices in section 'Types of Compression Therapy Devices' in topic "Compression Therapy". 
  • Prior to compression therapy, all patients who are candidates for compression therapy should be assessed for concomitant peripheral artery disease (PAD) with a noninvasive arterial assessment, such as ankle brachial index (ABI), doppler waveform or toe brachial index (TBI).[5] Assessment of arterial blood supply with these tests is a major determinant of the pressure level of compression to be applied.[5] See topic "How to Interpret Audible Handheld Doppler Ultrasound and Waveforms to Rule out PAD"
    • If PAD is suspected and noninvasive arterial assessment (e.g. ABI, doppler waveform, TBI) cannot be performed right away, compression with low modified pressure (e.g. tubular dressings) may be applied until arterial assessment is completed. See 'Algorithms' in topic "How to Select Adequate Compression Therapy Pressure Levels and Products".
Definition
  • Unna Boot (UB): classified as a non-stretch, inelastic compression bandage, an UB is an impregnated bandage that was originally developed by the German dermatologist Paul Gerson Unna in 1896. Commercially available UB is typically applied as a 2 to 4-layer bandage system by trained personnel.[6] The paste bandage coupled with a self-adherent elastic wrap can deliver 20-30 mmHg on the leg gaiter area.[7] Examples include Viscopaste, Gelocast, Primer Unna Boot, CoFlex UBZ/UBC.
    • How it works: the bandage stiffens after drying and forms an inelastic, semi-rigid mold around the leg (i.e., low resting pressure). When the patient walks, the mold offers resistance and counteracts calf muscle movement, increasing venous return (i.e., increased working pressure).[6]   
    • Typical UB components are
      • Inner layer: rolled gauze bandage impregnated with zinc oxide, calamine, glycerin, sorbitol gelatin or magnesium aluminum silicate, applied with graded compression from the forefoot to just below the knee.
      • Intermediate layer(s): continuous gauze dressing. Cast padding may be applied on top of inner layer for padding of bony prominences or to absorb wound exudate
      • Outer layer: self-adherent elastic wrap applied with graded compression or tubular dressing (i.e. stockinette)
Relevance
  • Application of UB is one of the most common clinic procedures billed to Medicare. A 2019 study showed that it was among the top ten most performed procedures by a large multi-regional health care system in the U.S.[1]

Skills and Education

  • A physician/Qualified Healthcare Professional (QHP) order is needed to apply an UB in the U.S. and other countries.
  • Clinicians applying an UB should be trained and competent in application of compression therapy bandages including UB.

General Indications and Contraindications

Indications

UB is indicated:

  • For ambulatory patients with venous insufficiency and/or VLUs who presents with one of the following [3][8][9]:
    • Conditions requiring modified compression (20-30 mmHg), such as mild/moderate PAD. To determine compression level indicated for a patient, see topic "How to Select Adequate Compression Therapy Pressure Levels and Products".
    • Leg eczema/dermatitis [8][9]
    • Need for frequent dressing changes due to weeping
    • Cutaneous pressure damage from previous use of elastic bandages

    UB should be used with caution and in collaboration with a vascular specialist in the following situations:

    • Signs or symptoms of mild/moderate PAD (e.g, claudication, atypical leg pain) despite ABI in normal range (0.8-1.3)
    • ABI or audible handheld doppler indicating PAD. See values in 'Algorithms' in topic "How to Select Adequate Compression Therapy Pressure Levels and Products".

    Contraindications 

    Contraindications to UB include:

    • Contraindications to compression therapy in general (e.g. severe PAD, unstable congestive heart failure with pulmonary edema, untreated lower limb skin or ulcer infection, untreated acute deep venous thrombosis). See 'Contraindications' in topic "Compression Therapy"
    • Patient allergy to any of the ingredients in the UB paste (i.e., zinc oxide, calamine, glycerin, sorbitol gelatin or magnesium aluminum silicate)
    • Patients who do not ambulate, as UB requires functional muscle pump to be effective.[10]

    Frequency of Change

    • If ulcer present, change UB after every dressing change. For non-infected wound with small to moderate drainage and adequate dressing, may change weekly. 
      • Medicare allowed frequency of change under the Surgical Dressing Benefit is once every week. See section 'Coding, Coverage and Reimbursement' below.
    • If ulcer not present, may change weekly. 
      • If VLU not present, UB is not covered under the Surgical Dressing Benefit. See section 'Coding, Coverage and Reimbursement'  below.

    Risks

    • Paste-impregnated bandage may cause contact dermatitis requiring discontinuation of UB.[6] 
    • May contribute to non-adherence to care plan, as some patients find UB bulky and uncomfortable.[6][11]
    • Application is largely operator-dependent. Incorrect application may lead to inefficient compression, pressure damage or other complications.[6][12]

    HOW TO APPLY AN UNNA BOOT

    Assessment and Plan

    Application of an UB is part of a comprehensive care plan. Prior to applying, it is important that a comprehensive assessment be performed so that the following questions can be answered:

    • Does the patient have a VLU? If so, is it healable?
      • For compression therapy recommendations for VLUs based on their potential for functional healing (i.e. healability), see section 'Compression Therapy' in topic "Venous Ulcers - Treatment and Prevention"
    • Are there any contraindications to compression therapy/UB? 
      • See 'General Indications and Contraindications' above
    • If using compression therapy, what pressure level is indicated? 
      • See topic "How to Select Adequate Compression Therapy Pressure Levels and Products".
    • What are the risks and benefits for the patient? 

    For details on VLU assessment, see topic "Venous ulcers - Introduction and Assessment". For guidance on treatment plan for VLU, see topic "Venous Ulcers - Treatment and Prevention"

    Procedure

    Tables 1 to 3 below illustrate steps and rationale to appropriately apply an UB.[6][13]

    Table 1. Pre-Application

    StepsRationale/ Tips

    1. Apply/re-apply UB early morning, as soon as patient wakes up if possible

    • If patient sleeps on a bed, legs are probably least swollen in the morning 

    2. Ensure adequate supplies and assistance if needed:

    • Appropriate lighting
    • Clean gloves
    • Soap and water
    • Bandage scissors (with blunt tips)
    • Wound dressings for ulcer if present
    • Commercially prepared rolled gauze bandage impregnated with paste (e.g., Viscopaste, McKesson Unna Boot)
    • Cast padding
    • Elastic bandage, self-adhesive elastic roll or gauze wrap and tubular dressing (e.g. stockinette) to apply over inner bandage 
    • Commercially prepared bandages may come plain (with zinc oxide only, white color) or with calamine and/or other substances. 
      • Zinc with calamine: usually a non-hardening pink paste. Calamine may help reduce itching, pain and skin irritation (e.g., Gelocast Unna Boot, McKesson Unna Boot with Calamine)
    • Cast padding may be used over impregnated bandage to protect bony prominences or absorb exudate


    3. Remove previous bandage/wound dressing if present. Wash, cleanse or shower leg with water and soap. Dry leg 
    • To remove previous bandage, may cut bandage off with bandage scissors with blunt tips by lifting bandage away from the skin to avoid skin damage (and away from the ulcer location, if applicable).

    4. Measure the ankle circumference 10 cm from the bottom of the heel; measure the calf circumference 30 cm from the bottom of the heel

    • To obtain a baseline edema measurement prior to first time application of an UB, and compare prior to subsequent applications and monitor improvement

    5. If ulcer present, don clean gloves and perform local wound care and apply wound dressing as needed 

    • If wound dressing contains silver (e.g., Acticoat Flex3 or Acticoat Flex7), use an interface (e.g.,gauze dressing) between the silver containing dressing and the paste-impregnated bandage, to prevent the paste’s emulsifier from coming in contact with the silver dressing

    Table 2. Application

    StepsRationale/ Tips

    1. Don clean gloves


    • To keep new bandage clean during application
    2. Position patient: if seated, support foot off the floor. If supine, elevate affected leg. Position the patient's leg and foot at a 90- degree angle (Figure 1).
    Fig. 1. Position the patient's leg and foot at 90 degree angle

    • Dorsiflexion helps with comfort and functionality when patient walks



    3. Apply first/inner layer: Bandage can be applied in a spiral or fanfold fashion. It is important that bandage be applied without tension.

    Spiral fashion: 

    • Begin at the base of the toes. Wrap bandage loosely around the foot, heel and around the leg in a spiral fashion and with an overlap of 50% up until just below the knee. Once applied, the bandage should then be smoothed and molded around the leg (Figure 2)

    Fig. 2. Application of paste bandage on right leg, spiral fashion

    Fanfold fashion:

    • Begin at the base of the toes. Wrap bandage loosely around the foot and heel and then, whilst wrapping from the ankle, apply a pleat, at the front of the leg, with an overlap of 50%. Repeat the movement up the leg until just below the knee (Figure 3).

    Fig. 3. Application of paste bandage on right leg, fanfold fashion

    • The paste-impregnated bandage has no elasticity so the fan-folded pleats allow the wrap to expand slightly in the presence of increasing edema
    • A variation of the spiral technique for the ankle and heel regions includes (Figure 4):
      • Wrapping with 50% overlap from the base of the toes
      • Then wrapping around the ankle with 1-3 figure eights, and
      • Continue spiral wrapping with 50% overlap up until just below the knee 

    Fig. 4. Figure of eight around the ankle, spiral fashion

    4. Apply intermediate layer: Apply continuous gauze wrap and secure with tape. 

    • Cast padding may be applied on top of inner layer for padding of bony prominences or to absorb wound exudate.

    5. Apply outer layer: Apply elastic wrap or self-adhesive elastic roll (e.g. Coban) with graded compression and 50% overlap, or a tubular dressing (i.e. stockinette) 

    • This layer prevents soiling of clothes and bedcover

    Table 3. Post-Application

    StepsRationale/ Tips
    1. If possible have patient in supine position or with legs elevated until UB dries 
    • So that UB molds to leg with minimal edema. Pressure level may be highest after application but will likely decrease with usage. 
    2. Monitor patient for leg pain, or other signs of circulatory impairment (cyanosis, coolness, numbness). If present, UB is too tight and must be removed immediately. Consult with patient's physician before reapplying the boot
    • To reassess for PAD or other condition impairing leg blood supply
    3. Complete required documentation as listed in section ‘Documentation’ below.
    • Documentation should be thorough and consistent for quality of care and reimbursement
    4. Educate patient to look for signs/symptoms of circulatory impairment, keep UB dry during shower/bathing, avoid damaging the boot when walking
    • See topic "Patient Education - Shower Instructions for People with Wounds"
    5. Schedule follow up within one week or as ordered
    • See “How to Assess Effectiveness” below

    Documentation

    Following the procedure, document the following:

    • Patient consent   
    • Medical diagnosis
    • Location of the VLU
    • Previous ulcer debridement (required for Medicare reimbursement of dressing supplies and UB)
    • Appearance of the wound:
      • Pre-debridement dimensions: diameter, depth, area in centimeters
      • Undermining or tunneling, wound bed tissue composition by percentage, color, presence of exudates or necrotic tissue, signs of infection, purulent drainage or abscess, visible structures such as bone, tendon, vessels or nerves
      • Vascular status, or evidence of reduced circulation
      • Photograph of the wound  
    • Type of dressing applied to the wound 
    • Type of UB applied to the wound
    • Presence/absence of signs/symptoms of circulatory impairment after application   
    • Date for follow-up assessment     
    • Other post procedure notes or patient teaching, including follow up instructions

    The medical record must include a plan of care containing treatment goals and physician or other qualified provider follow-up. 

    HOW TO ASSESS EFFECTIVENESS

    Signs of effectiveness include:

    • Increasing proportion of granulation tissue on wound bed and no signs or symptoms of infection
    • Decrease in wound area, depth, exudate, necrotic tissue
    • Resolved eczema or dermatitis within 2 weeks;
    • Measurable improvement in the ankle and calf measurements within 1 week

    CODING AND REIMBURSEMENT

    Overall, compression bandages (including UB), wraps and certain gradient compression stockings are covered by Medicare under the conditions below. 

    Coverage under the Medicare Part B Surgical Dressing Benefit

    If UB is used at a Medicare beneficiary's residence and not applied by a physician who bills Medicare for UB application, UB is covered under the Medicare Part B Surgical Dressing Benefit.[14] Medicare coverage for compression devices, including UB, is managed by Medicare Administrative Contractors (MAC). Coverage is explained by the following articles:

    • Local Coverage Determination (LCD) Surgical Dressings (L33831) [14], and
    • Local Coverage Article: Surgical Dressings - Policy Article (A54563) [15]

    Zinc Paste Impregnated Bandage (Unna boots)

    • HCPCS: (A6456)
    • Coverage requirements: VLU that meet the statutory requirements for a qualifying wound (surgically created/modified, or debrided).
    • Frequency of replacement allowed by Medicare: 1 time/week
    • Non-covered conditionsNon-qualifying wounds (see coverage requirements above)
    BILLING REMINDERS:
    • When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer, each component is billed using a specific code for the component - e.g., moderate or high compression bandages (A6451, A6452), conforming bandages (A6443, A6444), self-adherent bandages (A6454), padding bandages (A6441), zinc paste impregnated bandage (A6456)
    • Medicare billable unit for bandages used in multilayer systems are "per yard".
    • When billing Medicare, check number of yards per bandage as described by manufacturer and indicate number of units (i.e., yards) to be used during the period for which supplies are being requested. As per Medicare Policy: "For all dressings, if a single dressing is divided into multiple portion/pieces, the code and quantity billed must represent the originally manufactured size and quantity".

    Coverage as part of a physician/QHP professional service  

    If a physician applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable. Claims for these dressings must not be submitted. Claims for the professional service, which includes the dressings, must be submitted to the local carrier or intermediary. If dressing changes are sent home with the beneficiary, claims for these dressings may be submitted (see above). In this situation, use the place of service corresponding to the beneficiary's residence; Place of Service "Office" (POS=11) must not be used. [15]  

    Strapping: Unna Boot (CPT code 29580)

    • CPT: 29580 Strapping: Unna Boot
    • Coverage requirements: check with your specific MAC. In general, UB application is covered for VLUs, and may be covered for treatment of ligamentous injuries (sprains and strains) of the ankle.[16] See topic "Medicare Coverage Determinations for Wound Care"
    • Modifier: Bilateral UBs should be billed with a modifier -50 (bilateral procedure).[16]
    Billing reminders: 
    • Debridement and UB: All supply items related to the Unna boot are inclusive in the reimbursement for CPT code 29580. When both a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) should not be reported with codes 29580, 29581 for the same anatomic area.[17][18] For information on coding/coverage for debridement, see section 'Coding and Reimbursement' in topic "How to Perform Conservative Sharp Wound Debridement".

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    NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

    REFERENCES

    1. Poulin EA, Swartz AW, O'Grady JS, Kersten MPM, Angstman KB et al. Essential Office Procedures for Medicare Patients in Primary Care: Comparison With Family Medicine Residency Training. Family medicine. 2019;volume 51(7):574-577.
    2. O'Meara, Susan; Cullum, Nicky; Nelson, E Andrea; Dumville, Jo C et al. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. 2012;volume 11():CD000265.
    3. Kirsner, Robert S et al. Compression of venous ulcers: standardizing standard care. JAMA dermatology. 2014;volume 150(7):736-737.
    4. 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. 2014;volume 60(2 Suppl):71S-90S.e1.
    5. Harding, Keith; Dowsett, Caroline; Fias, Lore; et, al et al. Simplifying venous leg ulcer management. Consensus recommendations. . 2017;.
    6. Gloviczki, P., American Venous Forum et al. Handbook of Venous and Lymphatic Disorders: Guidelines of the American Venous Forum CRC Press Taylor & Francis Group. 2017;.
    7. Sullivan V, Weir D et al. Compression Therapy: Inside the Wrap Today's Wound Clinic. 2009;volume 2(1):.
    8. Livingston, M; Wolvos, T et al. Scottsdale Wound Management Guide . 2015;.
    9. World Union of Wound Healing Societies (WUWHS), et al. Principles of best practice: Compression in venous leg ulcers. A consensus document. . 2017;.
    10. 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) . 2010;.
    11. Silva MH, Jesus MC, Oliveira DM, Merighi MA et al. Unna's boot: experience of care of people with venous ulcers. Revista brasileira de enfermagem. 2017;volume 70(2):349-356.
    12. Cardoso LV, Godoy JMP, Godoy MFG, Czorny RCN et al. Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature. Revista da Escola de Enfermagem da U S P. 2018;volume 52():e03394.
    13. British Columbia Provincial Nursing Skin and Wound Committee . Procedure: Unna Boot Compression Therapy (without self-adherent wrap) . 2016;.
    14. Center for Medicare and Medicaid Services (CMS), et al. Local Coverage Determination for Surgical Dressings (L33831) . 2015;.
    15. Centers for Medicare and Medicaid Services, et al. Local Coverage Article for Surgical Dressings - Policy Article (A54563) . 2015;.
    16. National Government Services. Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) . 2015;.
    17. Novitas Solutions Inc. Local Coverage Article: Billing and Coding: Wound Care (A53001) . 2015;.
    18. First Coast Service Options, Inc. et al. Local Coverage Article: WOUND Care Coding Guidelines (A55818) . 2017;.
    Topic 1439 Version 1.0