CLINICAL

Overview

According to guidelines adopted by the Centers for Medicare and Medicaid Services (CMS), the different methods of wound debridement include selective (e.g., sharp debridement), non-selective (mechanical, enzymatic, autolytic or larval), or surgical.[1][2][3][4][5][6] This document focuses specifically on conservative sharp wound debridement (CSWD), which is considered a selective method of debridement. For a review on different types of wound debridement, see topic “Debridement”. 

Background

• CSWD is a quick and efficient debridement method that may be associated with significant risk to the patient if performed inappropriately.[7]
• CSWD should be part of a comprehensive care plan that addresses patient concerns, treats causes that led to the wound, and provides adequate local wound care. 

Definition

• Wound debridement: is the process of removing necrotic or nonviable tissue and biofilm from pressure ulcers, burns, and other acute and chronic wounds to for the purpose of exposing healthy tissue.[8][9]  Debridement may be categorized as selective, non-selective or surgical (excisional).[1][2][3][4][5][6] The context in which CSWD fits into the spectrum of debridement options is described below. For definitions of non-selective and surgical debridement, see topic “Debridement”.
• • Selective Debridement (CPTs 97597 and 97598) is the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue by high-pressure waterjet with/without suction, sharp dissection/debridement utilizing scissors, scalpel, curettes, and/or tweezers/forceps. This procedure typically requires no or limited topical or local anesthesia and generally has minimal associated bleeding. 
  • • Selective conservative sharp wound debridement (CSWD): is the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along/above the margin of viable tissue, utilizing sharp instruments such as scissors, scalpel, curettes, and/or tweezers/forceps.[1][2][3][4][5][6][8][9] Minimal pain and bleeding are expected with CSWD and repeated debridement is often needed.[8][9][10]
• Differences between CSWD and surgical debridement: CSWD is not as aggressive as surgical (also known as excisional) wound debridement performed by physicians and other qualified healthcare professionals (QHPs), who remove devitalized tissue down to a viable, bleeding wound bed; this typically requires local, regional or general anesthesia.[9][11][12][13] Of note, the routine application of a topical or local anesthetic does not elevate the procedure from active wound care management or selective CSWD to surgical debridement.[2] For details on differences among types of debridement see section 'Types of debridement' in "Debridement".

Care Settings

CSWD may be performed in a multitude of care settings, including inpatient hospital, outpatient hospital, home health, skilled nursing facilities, etc. For details on coding, coverage, and reimbursement, see section below 'Coding and Reimbursement'.

Regardless of the care setting, when performing CSWD, clinicians should ensure that the: 

• Facility has policies in place to allow nurses and other clinicians to perform CSWD.[14]
• Clinician performing the procedure has been appropriately trained, and competency has been updated as per facility requirements.
• Clinician has facility privileges and is allowed to perform CSWD as per facility policies.
• Care setting has sufficient resources to address potential complications.
• Patient provides written or verbal informed consent as required by facility policies.

Scope of Practice in the U.S.

• Scope of practice concerning CSWD differs from that of surgical sharp debridement in that [13]:
• • Surgical sharp debridement privileges are limited to physicians and other QHPs, depending on state board regulations.
  • CSWD may be performed by physicians and other clinicians, as determined by state boards’ regulations and facility policies.[3]
  • • A physician’s or advanced practice registered nurses’ (depending on each state) order is required to perform CSWD.
• Regulations on what type of healthcare professionals can perform CSWD vary from state to state. Regulations may change, thus healthcare professionals should consult the individual state practice act prior to performing CSWD.[13]
• • For instance, with regard to nursing, each state’s Nurse Practice Act or Board of Nursing dictates specific regulations for this procedure.[13] 
  • For a summary of regulations and links to board of nursing organizations by state see topic "State-by-State Regulations on Conservative Sharp Debridement by Nurses in the United States"

Skills and Education

• Requirements for performing CSWD include specific education, training and demonstration of competency in CSWD according to licensure, and facility policy and procedures.[9][14][10]
• Some State Boards of Nursing require completion of a course on debridement (courses can be found by searching online for “courses on conservative sharp debridement’). Continued competency requirements shall include but are not limited to [9][14][14][10][15]:
• • infection control procedures;
  • types of debridement;
  • wound etiology and disease process;
  • complications;
  • terminology;
  • pharmacology pertaining to medications utilized in debridement;
  • skin and tissue anatomy and physiology; see section 'Understanding Relevant Tissue Anatomy' below
  • skill competency validation. 

Understanding Relevant Tissue Anatomy 

Knowledge of the skin and relevant tissue anatomy is a requirement prior to performing CSWD. Timely recognition of underlying anatomical structures such as bone, tendon, fascia, muscle, ligaments, vessels and nerves can help prevent unintentional damage during CSWD. Those structures should not be disturbed during CSWD. If any of these structures is cut or injured during CSWD, immediate physician involvement is warranted.[7] Figures 1 to 6 below illustrate examples of anatomical structures that may be encountered during CSWD. 

General Indications and Contraindications

When assessing for indications and contraindications for CSWD, it is important to first determine the potential for functional healing of the wound. See topic "How to Determine Healability of a Chronic Wound".   

• For wounds whose underlying causes cannot be immediately corrected or if there is inadequate blood supply to heal (i.e., maintenance or non-healable wounds), CSWD of slough may be performed if no contraindications exist.  
• For healable wounds, surgical debridement is an appropriate method of initial debridement, if available as an option.[16] CSWD may be performed subsequently, or if surgical debridement is not an option or contraindicated.[7]

Indications

In general, indications for CSWD include [9]:

• Presence of necrotic tissue as well as cellular or proteinaceous debris [2][17]
• Various types of acute and chronic wounds: pressure, neuropathic/diabetic, and venous leg ulcers requiring removal of any nonviable tissue
• Callus on the foot or at the margins of a non-ischemic diabetic foot ulcer [7]
• Presence of bioburden, biofilm and/or local wound infection [7] 

CSWD should be performed with caution and in collaboration with a physician or advanced practice registered nurse in a controlled setting in the following situations [7]: 

• Patient is at risk for increased bleeding (e.g., use of anticoagulants)
• Moderate or severe peripheral arterial disease is present
• Patient has significant wound pain or pain associated with CSWD
• Wound has exposed bones, ligaments or tendons
• Devitalized tissue is over a major blood vessel, organ or structure

Contraindications 

Contraindications to CSWD include [9][12]:

• Inability to determine interface between viable and nonviable tissue 
• Extensive undermining or tunneling
• Abscess (if present, incision and drainage is initially indicated; may be followed by CSWD as needed)
• Dry, stable heel ulcers 
• Stable, ischemic wounds 
• Dry, stable (densely adherent) eschar 
• Advancing cellulitis or sepsis, in which case surgical debridement is preferred 
• Malignant cutaneous wounds such as fungating tumors 
• Pyoderma gangrenosum or vasculitic ulcers, in which case debridement may exacerbate the condition. See topic "Pyoderma Gangrenosum - Introduction and Assessment"
• Wounds on face, hands, and feet near nerves, vascular structures, grafts, prostheses, dialysis fistulae, or joints  
• Patient does not consent to CSWD

Ideal Frequency

The appropriate interval and frequency of debridement depends on the individual clinical characteristics of the patient and the extent of the wound. The extent and number of services provided should be medically necessary and reasonable based on the documented medical evaluation of the patient's condition, diagnosis, and plan.[2]

In the U.S., some Local Coverage Determinations state that for DFUs, debridement more frequently than once every seven (7) days, for a period longer than three months may not be reasonable and necessary, and therefore may not be eligible for reimbursement.[4] 

• For chronic wounds with biofilm, consensus guidelines suggest clinicians perform repeated maintenance debridement at every dressing change [18]
• • Rationale: Experts strongly agree that surgical or CSWD are both effective methods in removing biofilm.[18] However, it is difficult to remove all biofilm, and mature biofilms can regrow as soon as within 24 hours post-debridement. Thus, in order to suppress biofilm reformation the consensus suggests that debridement be performed repeatedly and be followed by application of topical antiseptic within the initial 24 hours post-debridement.[18] Initially, CSWD may be performed weekly, then at longer intervals as wound shows signs of improvement.

• For large wounds, if quantity of non-viable tissue is extensive or more difficult to remove, clinicians may consider consecutive serial debridements in order to partially remove the necrotic tissue at each time.[7][12]
• • Rationale: Keeping length of the procedure between 15 to 30 minutes helps prevent nurse and patient fatigue.[7][12]

HOW TO PERFORM CONSERVATIVE SHARP WOUND DEBRIDEMENT

Assessment

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

• Is the wound healable?
• Is debridement indicated?
• Are there any contraindications? 
• What are the risks and benefits for the patient? 

The comprehensive assessment includes [7]:

• Patient’s and caregiver’s concerns 
• • Impact of CSWD on daily routine, quality of life, environment of care
• Pain assessment
• Wound healability (see topic "How to Determine Healability of a Chronic Wound")
  
• • Comorbidities: conditions that increase the risk for bleeding (e.g. bleeding disorders), or delay wound healing (e.g. immunosuppression)
  • Medications: use of medications that increase risk for bleeding (e.g, aspirin, anticoagulants) or delay healing (e.g. corticosteroids, etc)
• Lower limb assessment if the wound is on the leg or foot
• • If signs or symptoms of peripheral artery disease, venous insufficiency, decreased sensation (i.e. neuropathy) are present, conduct a more in-depth lower limb assessment, beginning with non-invasive bedside arterial testing (e.g. ankle-brachial index - ABI)
• Detailed wound assessment
• • History of current and previous wounds 
  • Etiology (e.g. CSWD on malignant or pathergic wounds is contraindicated)
  • Location: 
  • • Local anatomy: proximity to arteries, veins, nerves, tendons
    • Proximity to vascular grafts, prostheses or dialysis fistulae
  • Wound dimensions: length, width, area, depth
  • Tunneling and undermining
  • Wound bed: percentage of tissue type (eschar, fibrin/slough, granulation, epithelization), presence of a foreign body and/or exposed underlying structures, e.g. tendon, muscle or bone. 
  • Periwound: callus, maceration
  • Visibility of interface between viable and nonviable tissue
  • Type of material requiring debridement: fibrin/slough, eschar, callus, debris, biofilm
• Assessment for wound infection
• • Bioburden, localized infection
  • Spreading or systemic infection (if present, sharp surgical debridement is indicated) 

Procedure

After determining that debridement is indicated via a thorough patient and focused wound assessment as described above, clinicians may utilize the following steps as a guide for performing CSWD.

Tables 1 to 3 below illustrate steps and rationale to appropriately perform CSWD before, during and after the procedure. [12][10][19][20]

Table 1. Pre-Procedure

Table 2. During the Procedure

Documentation

Following the procedure, document the following [21][17] (see Conservative Sharp Wound Debridement Documentation Checklist and Template):     

• Patient consent   
• Medical diagnosis
• Location of the debridement: 
• • Anatomical site of wound
  • Specificity is necessary when documenting debridement of multiple wounds
• Indication(s) and medical necessity for the debridement
• Debridement will be considered not reasonable and necessary for a wound that is clean and free of necrotic tissue/slough.[17]
• Debridement of extensive eczematous or infected skin is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furuncles, and localized skin infections.[17]
• Surgical debridement will be considered not reasonable and necessary when documentation indicates the wound is without devitalized, fibrotic, nonviable tissue, infection, necrosis, foreign matter, or if the wound has pink to red granulated tissue. When utilized, it is expected that the frequency of debridement will decrease over time.[17]
• The following services are considered to be not reasonable and necessary wound debridement services [17]:
• Removal of necrotic tissue by cleansing or dry-to-dry or wet-to-dry dressing.
  
• Washing bacterial or fungal debris from lesions.
  
• Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
• Dressing of small or superficial lesions.
• Paring or cutting of corns or non-plantar calluses.
• Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts.
• Removal of non-tissue integrated fibrin exudates, crusts, or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.
• Type of anesthesia (if used), including route, length of application, and person administering (e.g., none, topical 1% lidocaine, 5% lidocaine, or other)
• Appearance of the wound prior to debridement such as:
• • 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
• Narrative of the CSWD procedure to include:
• • Method used for debridement (CSWD)
  • Instruments used (e.g., scalpel, scissors, curette, etc)
  • Wound debridement utilizing a method which is unproven by valid scientific literature would be considered investigational and not reasonable and necessary.[17]
    
  • Statement that non-viable tissue was removed, and debridement was performed along/above the margins of viable tissue
  • Level/depth of tissue debrided:
  • • Partial thickness,
    • Full thickness,
    • Subcutaneous tissue debridement,
    • Subcutaneous tissue and muscle debridement,
    • Subcutaneous tissue, muscle and bone debridement.
  •  Description of the types(s) of tissue involved and the tissue(s) removed.
  • • Epidermis
    • Dermis
    • Subcutaneous tissue
    • Muscle
    • Bone 
• Presence of untoward events and treatment used:    
• • Pain during or following the procedure     
  • Bleeding if present especially if difficult to control. Hemostasis achieved?   
  • Any damage to underlying tissue   
• Appearance of the wound following debridement including:
• • Post-debridement dimensions, 
  • Description of any remaining non-viable material present, degree of epithelialization
• Other types of debridement performed on the wound.   
• Type of dressing applied to the wound   
• Photograph  before and after debridement    
• Date for follow-up assessment     
• Date for follow-up debridement session, based on agency policy  
• Other post procedure notes or patient teaching, including follow up instructions

Plan of Care

The medical record must include a plan of care containing treatment goals and physician or other qualified provider follow-up. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan.[17] A wound that shows no improvement after 30 days may require a new approach, which may include a physician reassessment of underlying infection, off-loading, biofilm, metabolic, nutritional, or vascular problems which may inhibit wound healing. It is expected the wound care treatment plan is modified in the event that appropriate healing is not achieved after serial debridement over 30 days.[17] 

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

Signs that CSWD is not being effective include:

• No increase in granulation tissue or improvement in wound dimensions upon serial examination/assessment

If the wound shows no signs of improvement within 30 days, clinicians should reassess the treatment approach. Documentation may include a physician/QHP reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, and a new treatment approach.[17]

TROUBLESHOOTING

Pain

• For patients with significant wound pain prior to the procedure, CSWD may not be indicated. Other methods may be preferred.
• For patients with wound pain prior to the procedure, for large wounds or if pain is anticipated, the following options are indicated:
• • Oral analgesics: coordinate care so that medication is administered prior to CSWD, with sufficient time to obtain analgesia. 
  • Topical anesthetics:
  • EMLA: EMLA has been shown to reduce pain and decrease the length of time needed to achieve a clear wound bed. [12]  Apply 30-60 minutes ahead of CSWD on area to be debrided. Apply 1-2 grams per 10 cm² (2 inches), up to 10 grams in total. Cover the wound with an occlusive dressing for 30-60 minutes, and debride immediately after removal of EMLA cream. [22]
  • Lidocaine 4% gel: may be applied topically on the area to be debrided and covered with occlusive dressing (e.g. transparent film) for 5 minutes (onset 3-5 minutes) 
  • Local infiltrative anesthesia. For details, see topic "How to Administer Local Anesthesia for Wound Care Procedures".

Bleeding

• If bleeding occurs, isolate the source, using irrigation to clear the field and gauze to blot the area.
• If bleeding is generalized oozing:
• • Apply pressure for 5 minutes. If bleeding slows but does not stop, apply cellulose foam or powder or alginate, cover with moist gauze, and apply pressure again for 5 minutes. Do NOT remove cellulose material after application; apply moist pressure dressing, monitor patient, and reassess to ensure hemostasis.
  • • Cellulose agents are physical barriers to bleeding, and therefore removal of these agents by wiping with gauze will negate their role in hemostasis; pressure over cellulose dressings should be carried out with a moist dressing as to not dislodge the material inadvertently. 
  • Silver nitrate may also be applied to the location of bleeding, rolling the tip of the applicator over the area for 15-30 seconds; this may be repeated 2-3 times.
  • • If silver nitrate is used, consider cleansing wound with sterile water as to not inactivate the agent (if desired).
• If bleeding is pulsatile:
• • Alert supervising provider immediately, or take appropriate action per facility policy, licensure, and individual competency (e.g. topical application of epinephrine, electrocautery, suture ligation).
• Any bleeding not completely controlled within 15 minutes requires additional evaluation.

CODING AND REIMBURSEMENT

Medicare Administrative Contractors and Local Coverage Determinations

• See section "Medicare Administrative Contractors and Local Coverage Determinations" in topic "Debridement"

CPT Codes

• 97597 Deb (e.g, high pressure waterjet with / without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debridement, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area, first 20 SQ CM or Less. 
• 97598 Deb (e.g, high pressure waterjet with / without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debridement, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area, each additional 20 SQ CM, or part thereof (list separately in addition to code for primary procedure) 

Billing Tips

• CSWD versus surgical sharp debridement (CPT 11042-11047) [2][3]:
• Do not bill CPT 97597 and 97598 with CPT 11042-11047.
• When deciding which code to use, the deepest layer of viable tissue removed (e.g., skin, subcutaneous tissue, muscle, etc) determines the appropriate code. For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. If viable muscle substance was debrided, the 11043-11046 series would be appropriate, depending on the surface area.[2][3]
• For detailed guidance, see section 'Types of Debridement' in topic "Debridement".
• Debridement and Unna boot
• 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. [2]
• Place of service:
• • Skilled nursing facility (SNF): do not bill Medicare for debridement services performed on Medicare beneficiaries receiving Medicare Part A-covered care in a SNF. CPT 97597 and 97598 codes in a skilled nursing facility setting are part of the Medicare Part A skilled nursing facility consolidated billing protocols. Therefore, you should discuss this with nursing facilities for direct payment from them for these services.[23]
  • Home health (HH): CSWD services performed by physical therapists on Medicare beneficiaries under a HH benefit who have CSWD listed in their Plan of Care are included in the consolidated home health billing and are not reimbursed separately. When CSWD services are delivered by physicians or QHPs, services may be separately reimbursed by Medicare Part B, even if the beneficiary is under an active HH plan of care. See CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.10 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states. [24][25]