Compression therapy + billing & reimbursement

What are the types of compression you can provide?

• short stretch & long stretch bandages

• Unna boot or paste bandages

• 4-layer wrap

• pneumatic compression or compression pumps

• compression garments

What are the indications for compression therapy?

• UE/LE lymphedema

• venous edema

• post-surgical or post-traumatic edema

• shape residual limb post-amputation

What are the precautions for compression therapy? Contraindications?

Precautions:

• cardiac edema

• arterial disease/wounds

• diabetes (sensory deficits)

• paralysis

• altered mental status

• sensitivity to compression

• inability to perform home management

Contraindications:

• acute untreated infections

• acute untreated DVT

• untreated cardiac edema

• renal edema

• undiagnosed edema

What are the effects of compression?

• reduces arterial filtration

• reduces venous reflux

• improves valve competence

• prevents re-accumulation of fluid

• increases calf mm pump

• assists in breakdown of fibrosis

• supports tissues that lost elasticity

What is the Law of Laplace?

pressure that is exerted on the tissues from the bandaging system

• Pressure = tension/radius (P=t/r), where:

  • tension = delivered from the bandage; each bandage is applied w/ even tension (same degree of stretch)

  • radius = the smaller the radius of the limb, the greater the pressure exerted on the tissues

What is the function of padding?

Where should the padding be applied?

provides more even distribution of compression around the limb

• areas of concavity

• to increase the radius of the limb

• areas of concern for the soft tissues

What are the differences b/w resting pressure & working pressure?

Resting pressure:

• constant pressure applied by bandage

• may hinder refill of superficial vessels

• achieved w/ strong, elastic bandages (ACE wraps, 4-layer wraps)

Working pressure:

• pressure from mm contraction

• improves mm pump

• achieved w/ rigid dressings (short stretch, Unna boot)

What are the differences b/w short stretch & long stretch bandages?

Short stretch:

• can be elongated 10-100% of resting length

• low resting pressure, high working pressure

• rigid

• prevent circulatory compromise & tourniquet effect

• minimize fluid re-accumulation

• loosen over time

Long stretch:

• can be elongated >100% of resting length

• high resting pressure, low working pressure

• very elastic

• may compromise circulation at rest

• poor support w/ mm work

• maintain pressure over time

• not indicated for lymphedema treatment

What are the determinants of compression?

• elasticity

• tension (should be 50% of the ability of the bandage to stretch)

• # of bandages applied

• condition of bandages or garments

What should you consider when applying short stretch bandages?

• apply stockinette over moisturized skin

• pad skin & bony prominences

• apply multiple bandages of varying widths (6, 8, 10, 12cm)

• overlap bandages by 50%

• 50% tension

Pressure should steadily decrease from..?

distal to proximal

What is intermittent pneumatic compression (IPC)?

repetitive, graded, sequential compression to assist in edema control

• inflates from distal to proximal

• limbs should be elevated, covered w/ stockinette

• trunk should be compressed too

• used adjunctly w/ CDT

What are the precautions & contraindications for IPC?

Precautions:

• swelling in abs or genitalia

• primary lymphedema or >1 area of the body involved

• BIL mastectomy

Contraindications:

• untreated acute infections

• untreated acute DVT

• untreated cardiac edema

• renal failure

• undiagnosed edema

What is the difference b/w the role compression bandages vs. compression garments?

• bandages: achieve a stable volume reduction

• garments: maintain the volume reduction

What are circular knit garments?

• knitted on a cylinder

• lack a seam

• made in finer/thinner fabrics

• cosmetically more attractive

• highest degree of compression distally

• typically non-custom fit

  • standard sizing

  • less expensive, variable insurance reimbursement

  • for limbs w/ “normal” contours

  • for less severe edema

What are flat knit garments?

• knit row by row

• produced in unlimited shapes & sizes to fit limb presentation

• typically custom fit → precise level of compression

  • stronger than circular knit

  • expensive, variable insurance reimbursement

  • exact fit to limb presentation; for limbs w/ “abnormal” shape

  • for moderate/severe edema

What are the 4 different compression classes?

• 12-20 mmHg (TED Hose): for achiness, fatigue, mild edema in foot/ankle, mild varicose ties, DVT prevention, post-op

• 20-30 mmHg (Compression Class 1): for family hx of varicose veins, mild lymphedema, venous ulcer prevention, DVT prevention, mild venous insufficiency

• 30-40 mmHg (Compression Class 2): for chronic venous insufficiency, moderate lymphedema, active venous ulcers, moderate & post-traumatic edema, varicosities during pregnancy, DVT/post-thrombotic syndrome prevention

• 40-50 mmHg (Compression Class 3): for severe lymphedema, active venous ulcers, severe chronic venous insufficiency, severe tendency towards edema

What are some adverse effects of using compression garments?

• often d/t poor choice of therapeutic material, knit type, compression level

• UE garments:

  • use of arm sleeve w/o hand compression → hand edema

  • rubbing of seams → blisters/ulcers

• LE garments:

  • open toe garments → exacerbate toe edema

  • closed toe garments may not resolve this issue

What conditions have to be met for Medicare coverage to be allowed?

• physician documented Dx of lymphedema

• pt documented signs & Sx’s of lymphedema

• pt or caregiver able to understand & comply w/ continuation of treatment at home