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 Skin Failure: A New Diagnosis

Skin is the largest organ of the human body; yet, while people talk about “kidney failure” or “heart failure,” practitioners or others seldom refer to “skin failure.”

According to Jeffrey Levine, MD, AGSF, CMD, CWSP, a New York-based physician and frequent speaker and author on wound care, “skin failure should be considered as a diagnosis in advanced chronic illness as well as in situations when patients are approaching death.” This is consistent with the recognition that many chronic illnesses worsen over time and increase the likelihood of comorbidities and decreased functional status.

“Recognizing skin failure across the continuum will unify clinical observations and will help adjust quality measurement, which is essential in the world of Accountable Care Organizations and bundled payments,” says Levine in the July issue of JAMDA, the Journal of Post-Acute and Long-Term Care Medicine.
There currently aren’t any blood tests or biomarkers for skin failure, so the clinical diagnosis is based on signs and symptoms documented during a physical exam, and there is no applicable code for skin failure in the ICD billing guide, Levine says. However, this may change, as the Centers for Medicare & Medicaid Services is working on rendering quality measures uniform across systems, he says.
In preparation, Levine suggests that facilities improve documentation standards, implement flow sheets that may include photographs, and train wound care personnel to regularly write notes that describe the wound as well as the patient’s underlying conditions.
“Wound documentation has to include notification of the family about what is happening with the wound and collaboration with various disciplines, including dietary, physical therapy, and nursing,” Levine says.
While technology and clinical evidence regarding wound care have advanced, terminology hasn’t kept up, he says. “Terminology needs to advance and go beyond the use of ‘terminal’ designations and apply this terminology across care settings.” He further suggests applying the term “skin failure” as a diagnosis related to organ system disease beyond the wound.
Levine defines “skin failure” as “the state in which tissue tolerance is so compromised that cells can no longer survive in zones of extreme stress and physiological impairment that includes hypoxia, local mechanical stresses, impaired delivery of nutrients, and buildup of toxic metabolic byproducts.”
Defining and recognizing skin failure is controversial, Levine says. “There are barriers. For one, most physicians weren’t taught about wound care or skin failure in medical school. Wound care is a fractured field due to the variety of practitioners and needs to be unified.”
Once skin failure is clearly defined and its signs and symptoms are recognized as an organ system disease, physicians can acknowledge and use this as a valid medical diagnosis. This is likely to lead to more accurate coding and reimbursement across care settings, Levine says.
Additionally, he says, “when skin failure is an accepted disease state and diagnosis, some pressure injuries will lose their validity as a quality measure as long as appropriate pressure redistribution methods are used. This is important as we move into a care system that focuses on balancing quality and costs.”
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