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4.4: Age Related Changes to the Integumentary System - Biology


Aging and the Integumentary System

All systems in the body accumulate subtle and some not-so-subtle changes as a person ages. The hypodermis, with its fat stores, loses structure due to the reduction and redistribution of fat, which in turn contributes to the thinning and sagging of skin.

Figure 4.17. Aging
Generally, skin, especially on the face and hands, starts to display the first noticeable signs of aging, as it loses its elasticity over time. (credit: Janet Ramsden)

The accessory structures also have lowered activity, generating thinner hair and nails, and reduced amounts of sebum and sweat. A reduced sweating ability can cause some elderly to be intolerant to extreme heat. Other cells in the skin, such as melanocytes and dendritic cells, also become less active, leading to a paler skin tone and lowered immunity. Wrinkling of the skin occurs due to breakdown of its structure, which results from decreased collagen and elastin production in the dermis, weakening of muscles lying under the skin, and the inability of the skin to retain adequate moisture.

Many anti-aging products can be found in stores today. In general, these products try to rehydrate the skin and thereby fill out the wrinkles, and some stimulate skin growth using hormones and growth factors. Additionally, invasive techniques include collagen injections to plump the tissue and injections of BOTOX® (the name brand of the botulinum neurotoxin) that paralyze the muscles that crease the skin and cause wrinkling.


Effects of Hormones

Virtually all of the effects of pregnancy can be attributed in some way to the influence of hormones&mdashparticularly estrogens, progesterone, and hCG. During weeks 7&ndash12 from the LMP, the pregnancy hormones are primarily generated by the corpus luteum. Progesterone secreted by the corpus luteum stimulates the production of decidual cells of the endometrium that nourish the blastocyst before placentation. As the placenta develops and the corpus luteum degenerates during weeks 12&ndash17, the placenta gradually takes over as the endocrine organ of pregnancy.

The placenta converts weak androgens secreted by the maternal and fetal adrenal glands to estrogens, which are necessary for pregnancy to progress. Estrogen levels climb throughout the pregnancy, increasing 30-fold by childbirth. Estrogens have the following actions:

  • They suppress FSH and LH production, effectively preventing ovulation. (This function is the biological basis of hormonal birth control pills.)
  • They induce the growth of fetal tissues and are necessary for the maturation of the fetal lungs and liver.
  • They promote fetal viability by regulating progesterone production and triggering fetal synthesis of cortisol, which helps with the maturation of the lungs, liver, and endocrine organs such as the thyroid gland and adrenal gland.
  • They stimulate maternal tissue growth, leading to uterine enlargement and mammary duct expansion and branching.

Relaxin, another hormone secreted by the corpus luteum and then by the placenta, helps prepare the mother&rsquos body for childbirth. It increases the elasticity of the symphysis pubis joint and pelvic ligaments, making room for the growing fetus and allowing expansion of the pelvic outlet for childbirth. Relaxin also helps dilate the cervix during labor.

The placenta takes over the synthesis and secretion of progesterone throughout pregnancy as the corpus luteum degenerates. Like estrogen, progesterone suppresses FSH and LH. It also inhibits uterine contractions, protecting the fetus from preterm birth. This hormone decreases in late gestation, allowing uterine contractions to intensify and eventually progress to true labor. The placenta also produces hCG. In addition to promoting survival of the corpus luteum, hCG stimulates the male fetal gonads to secrete testosterone, which is essential for the development of the male reproductive system.

The anterior pituitary enlarges and ramps up its hormone production during pregnancy, raising the levels of thyrotropin, prolactin, and adrenocorticotropic hormone (ACTH). Thyrotropin, in conjunction with placental hormones, increases the production of thyroid hormone, which raises the maternal metabolic rate. This can markedly augment a pregnant woman&rsquos appetite and cause hot flashes. Prolactin stimulates enlargement of the mammary glands in preparation for milk production. ACTH stimulates maternal cortisol secretion, which contributes to fetal protein synthesis. In addition to the pituitary hormones, increased parathyroid levels mobilize calcium from maternal bones for fetal use.


The Aging Body Systems: Explaining Physiological Aging

Ever wonder what happens to the body systems as the person ages? Moreover, what changes would one qualify as part of normal or physiological aging? These are just some of the most commonly encountered questions by nurses.

While the scientific community actively seeks for the answers as to why people age, it is also helpful to determine the normal physical changes associated with aging. It holds particular relevance to nursing assessment and plan of care. Moreover, it is a vital health education topic that should be taught so the greying population and their families can institute protective measures for the points of strains in their body.

Here are the body systems and the changes they undergo while aging:

Integument

This is the system with the most obvious changes because this involves the skin, hair, and nails. The skin loses its moisture and elasticity which makes older people more susceptible to skin tears and shearing injuries. The hair loses color and the nails become thickened and brittle.

Progressive loss of subcutaneous fat and muscle tissue accompany the previously mentioned integumentary changes. As a result, muscle atrophy, “double” chin, wrinkling of skin, and sagging of eyelids and earlobes are frequently observed in older people. In older women, breasts become less firm and may sag. Tolerance to cold also decreases because of loss of subcutaneous fats.

Health promotion teaching can include maintaining healthy skin through optimal nutrition and hydration, avoiding sun damage through sunscreens and protective clothing, and preventing skin injury by avoiding strong detergents and rough textures.

Neuromusculoskeletal

Speed and power of muscle contractions are gradually reduced with age. While exercise can strengthen muscles, there would be steady decrease in muscle fibers by age 50. This condition is called sarcopenia. Also, loss in overall stature occurs with age. Kyphosis, osteoporosis, and pathologic fractures are consequently common. On the other hand, reaction time also slows with age. Decreased muscle tone further reduces reaction time. This is because diminished physical activity can decrease muscle tone.

There age-related changes are a threat to elders’ safety. The nurse must assess for factors that may increase the elders’ risk for falls and decrease their ability to perform their activities of daily living (ADLs). Importance of calcium supplements and Vitamin D should be emphasized.

Sensory/Perceptual

All five senses become less efficient as the person ages.

As for vision, acuity becomes poor and elders have presbyopia, or the inability to focus or accommodate due to inflexible lens which can start as early as age 40. Loss of peripheral vision, atrophy of lacrimal glands, and difficulty in discriminating similar colors like blues, greens, and purples are common.

Elders over age 65 start having gradual loss of hearing, a condition called presbycusis. It is more common in men. Hearing loss is greater in the higher frequencies than the lower. Hard consonants (e.g. k,d,t) and long vowel sounds (e.g. ay) are more easily recognized while the sibilant sounds (e.g. s,th,f) are the most difficult to hear.

Older people have poorer sense of taste and smell and are less stimulated by food than the young. Sense of smell commonly declines more than sense of taste. This is the reason why changes in appetite are common in elders.

Lastly, older people become less sensitive to sensations of pain, touch, and temperature because they lose skin receptors gradually.

Pulmonary

Respiratory efficiency is reduced with age. They are unable to compensate for increased oxygen need and are significantly increasing the amount of air inspired. Therefore, difficulty in breathing is usually common especially during activities. Expiratory muscles become weaker so their cough efficiency is reduced and the amount of air left in the lungs is increased.

Health promotion teaching can include smoking cessation, preventing respiratory infections through handwashing, and ensuring up to date influenza and pneumonia vaccinations.

Cardiovascular

Of course, the capacity of the heart for work decreases with age. Elders’ heart rate is slower to respond to stress and slower to return to normal after periods of physical activity. Changes in arteries occur frequently which can negatively affect blood supply.

Health promotion teaching can include risk detection and reduction for cardiovascular diseases, blood pressure and cholesterol level monitoring, ideal weight maintenance, and low-sodium diet.

Gastrointestinal

Age-related changes in the gastrointestinal system include reduced saliva, decreased esophageal and stomach motility, decreased stomach emptying time, decreased production of intrinsic factor, and decreased intestinal absorption, motility, and blood flow. In addition, tooth enamel becomes harder and more brittle, making teeth more susceptible to fractures.

Health promotion teaching for elders include preventive dental care and effective oral hygiene, appropriate diet and sufficient fluid intake, regular bowel maintenance, and importance of colorectal cancer screening.

Urinary

The function of the kidney decreases with age but is still able to carry out excretory functions unless a disease process intervenes. Waste products may be filtered and excreted more slowly. Therefore, nurses must include in their responsibility the effect of drugs that elders take to their kidneys.

Aside from the kidneys, the bladder makes more noticeable changes. Complaints of urinary urgency and frequency are common because the capacity of the bladder and its ability to completely empty diminish with age. It is important to note that urinary incontinence (UI) is never normal so the nurse must promptly investigate it, particularly when of new onset.

Good urinary function in elders can be promoted by sufficient fluid intake, reducing bladder-irritant foods in the diet (e.g. sugar, caffeine, spicy and acidic foods), and practicing pelvic muscle exercises.

Genitals

There is gradual degenerative change in the gonads of men. However, testosterone production continues albeit decrease in number of sperms produced.

Changes in the gonads of older women result from diminished secretion of ovarian hormones. However, shrinking of uterus and ovaries go unnoticed. Other changes are obvious, like breast atrophy and reduced lubricating vaginal secretions.

Sexual response and performance also change. Both men and women take longer to become sexually aroused, longer to complete intercourse, and longer before sexual arousal can occur again. Generally, the elder man’s libido may decrease, but not disappear. Erection is less firm but can still penetrate. Ejaculation also takes longer.

People are aging every single day. Aging is human nature taking its normal course. While this is gradual in the early phase, small changes can be seen and felt. These changes may interfere with people’s acceptance of slowing and dulling capacities. Meanwhile, negative attitudes and stereotypes towards aging still remain as challenges needing to be addressed and put to rest.

Therefore, it is important for nurses to work closely with the older people in identifying risks that might inhibit them from experiencing normal and healthy aging. It is also important for nurses to assist older people in adapting to the new roles and milestones that come with aging. Moreover, nurses are instruments in making elder people feel cared for, accepted, guided, and understood.

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The integumentary system

Hyperpigmentation is the most frequent integumentary alteration during pregnancy. Changes in pigmentation are seen in up to 91% of pregnant women, tend to be more frequent in women with dark hair or complexions, and are progressive throughout pregnancy. 62 Most women experience a mild, generalized increase in pigmentation that is especially prominent in areas of the body that tend to be naturally more intensely pigmented. These areas include the areolae, genital skin, axillae, inner aspects of the thighs, and linea alba. 23 , 28 , 61 , 77 , 93

Freckles, nevi, and recent scars may darken during pregnancy, perhaps due to an up-regulation of receptors for estrogens and progesterone on the nevus cell surface. 27 Existing melanocytic nevi may increase in size or new nevi may develop during pregnancy, although some have reported that existing melanocytic nevi do not change significantly during pregnancy. 57 Increased malignant degeneration of nevi is not seen during pregnancy. 57 , 85 Prophylactic removal of nevi following pregnancy may be considered. Any nevi showing signs suggestive of malignancy should be excised. 28 , 61 , 93 , 96

Melasma.

Melasma (also known as chloasma or the “mask of pregnancy”) is a common occurrence in pregnant women. 5 , 15 , 77 , 93 , 96 Melasma is characterized by irregular, blotchy areas of pigmentation on the face, usually bilateral and symmetrical and seen most commonly on the cheeks, chin, and nose. 77 The areas of altered pigmentation are not elevated and can range in color from light to dark brown. Three distribution patterns have been described: centrofacial (63%), involving the cheeks, forehead, upper lip, nose, and chin malar (21%), over the cheeks and nose and mandibular (16%), over the ramus of the mandible. 5 Three histological patterns have also been identified: epidermal (increased deposition of melanin in the melanocytes of the basal and suprabasal layers), which is seen in 70% of women dermal (macrophages with large amounts of melanin can be found in both the papillary and reticular layers of the dermis), which is seen in 10% to 15% and a mixed form, which is seen in 2%. 5 , 61 Although these pigmentary changes tend to fade completely within 1 year following pregnancy, they may persist (especially in dark-haired individuals). 63 , 93 , 96

Melasma is associated with increased expression of α-melanocyte stimulating hormone in the involved skin area. 93 There is a genetic predisposition toward development of melasma. 5 , 100 Melasma is seen most frequently in women with dark hair and complexions, is exacerbated by the sun, and tends to recur (often with increased intensity) in subsequent pregnancies or with use of oral contraceptives. 10 Melasma has also been reported occasionally in nonpregnant individuals who are not on oral contraceptives or other hormonal medications. 54 , 93 , 96 , 118

Avoidance of sun tanning during pregnancy, use of hats to avoid facial exposure to sun, and use of sunscreens with sun protective ratings greater than 15 may reduce the severity of melasma (Table 14-1). Because melasma often fades spontaneously following pregnancy, treatment is generally limited to the less than 10% of individuals with persistent pigmentation postpartum. 77 Various depigmenting formulas have been developed to treat persistent melasma, with varying success. These formulas tend to be relatively effective on epidermal-type melasma but have little effect on the dermal type. Treatment may need to be continued for 5 to 7 weeks before satisfactory results are achieved. Topical 2% to 5% hydroquinone with or without retinoic acid and corticosteroids has also been used postpartum, again with varying success. This treatment can result in complications such as hypopigmentation, hyperpigmentation, and contact dermatitis. 5 , 10 , 93 , 96 , 118


Respiratory Failure in the Neonate—Preferred Practice Pattern 6G

Systems Review

The systems review is a brief and gross examination, a “quick check,” to identify additional information and the existence of other health problems to be considered in the diagnosis, prognosis, and plan of care. In addition, there may be findings that necessitate referral to another health provider.

Cardiovascular/pulmonary

Although these systems will be examined in detail, the brief review should include blood pressure determination, pulse and respiratory rate, and any gross indications of edema. The neonate with respiratory failure will likely be monitored extensively, and most of the vitals signs noted earlier will be available to the therapist from the monitors.

Integumentary

The physical therapist should answer the following questions during the review of the integumentary system : Is the skin color and integrity normal? Are there any old scars or new scars and are new scars healing appropriately? Is there any evidence of infection at the site? Which indwelling lines and tubes must be considered during the interventions?

Musculoskeletal

A record of the infant's length and weight should be available. Any obvious physical asymmetries should be identified—this is particularly important in the intubated infant who is being mechanically ventilated. The physical therapist should determine gross muscle tone and range of motion (ROM). Active handling of the infant with respiratory failure is often limited, and some of the review might be postponed.

Neuromuscular

Determination of neuromuscular status as a quick check or review is difficult in the neonate and may require more formalized testing.

Systems Review

Cardiovascular and pulmonary status showed a respiratory rate of 52 breaths/min during spontaneous respiratory efforts. His heart rate was 160 beats/min and blood pressure was 85/42 mm Hg. Integument was characterized by pale, fragile skin with some evidence of bruising. B.L. had a left lateral thoracotomy scar. There was a transpyloric tube in place for continuous feeding and an umbilical catheter inserted for monitoring. Musculoskeletal review was limited because of the presence of multiple monitors, lines, and tubes in this tiny newborn. Gross ROM of the extremities appeared adequate. There was limited spontaneous movement and symmetry was disturbed by the thoracotomy incision. Neuromuscular review showed obvious hypotonia, but when stimulated, B.L. could suck a small nipple, albeit very weakly. Noxious stimuli resulted in a rapid irritable response.

Systems Review

Cardiovascular and pulmonary status for A.C. showed a respiratory rate of 60 breaths/min with obvious distress. Her heart rate was 152 beats/min and blood pressure was 98/56 mm Hg. Notable items in the integumentary system review were pale skin and a chest tube, which was attached to an underwater seal system, sutured in place in her right anterior thorax. As with B.L., musculoskeletal review of A.C. was limited because of various lines but showed a large infant with spontaneous movement of all extremities. Gross ROM was tested and seemed appropriate for age. Neuromuscular review showed a spontaneously moving infant who attempted to cough upon endotracheal suctioning by the nursing staff.


4.4: Age Related Changes to the Integumentary System - Biology

This is the skin, and skin derivatives (hair, nails, glands and receptors). The Integumentary system has many functions:

  • Protects the body's internal living tissues and organs
  • Protects against invasion by infectious organisms
  • Protects the body from dehydration
  • Protects the body against abrupt changes in temperature
  • Helps dispose of waste materials
  • Acts as a receptor for touch, pressure, pain, heat and cold
  • Stores water, fat, and vitamin D.

The skin has two main layers, the epidermis and the dermis :

The Epidermis (thin outer layer of skin)

The Epidermis itself is made up of many layers. The basale stratum is the only layer capable of cell division 'pushing up' cells to replenish the outer layer which is constantly shedding dead cells. The Epidermis does not contain blood vessels (non-vascular). It contains the pigment melanin which gives skin colour and allows the skin to tan, uneven distribution of melanin causes 'freckles'.

The protein keratin stiffens epidermal tissue to form finger nails. Nails grow from a thin area called the 'NAIL MATRIX' , growth of nails is about 1 mm per week on average. The lUNULA is the crescent shaped area at the base of the nail, this is a lighter colour as it mixes with the matrix cells.

The epidermis.contains different types of cells, the most common are squamous cells which are flat, scaly cells on the surface of the skin, basal cells which are round cells, and melanocytes which give the skin its colour. The epidermis also contains Langerhan's cells , these are formed in the bone marrow and then migrate to the epidermis. They work in conjunction with other cells to fight foreign bodies as part of the body's immune defense system. Granstein cells play a similar role.

The Dermis (thick inner layer of skin)

The dermis consists of blood vessels, connective tissue, nerves, lymph vessels, glands, receptors, hair shafts. The dermis has two layers, the upper papillary and lower reticular layers. The Papillary is the upper layer of the dermis, it has ridges and valleys causing finger prints. It contains receptors which communicate with the Central Nervous System, these include touch, pressure, hot, cold and pain receptors. These are not evenly distributed over the body, for example there are more on the lips and finger tips making them more sensitive. The reticular layer is made of dense elastic fibers (connective tissue), this houses hair follicles, nerves, and certain glands.

The dermis contains several important glands. The sebaceous glands located near the hair follicles secrete oil to keep skin and hair soft and moist. The sudorferous glands secrete sweat to regulate temperature and are located under the dermis with ducts to the surface. The ceruminous glands secrete wax to stop dust entering the ear.

HAIR There is hair on every part of body (except palms and soles), this helps maintain body temperature. Eye lashes filter out harmful particles. Hair grows from follicles that contain the lower shaft and root of the hair. The hair shaft projects through the dermis and epidermis and is kept soft by the sebaceous glands. Hair colour is determined by the concentration of melanin. There are tiny muscles attached to the follicles (arrector pili), when cold or frightened these tighten forming 'goose pimples'.

Anatomy of a skin. Short animation narrated by Dannishi. Source: http://youtu.be/c_IGuPYLsFI

Connective tissue and Membranes

These are not necessarily part of the Integumentary System, and are general to many of the other systems of the body.

Connective tissues support and protect the body's organs, and bind organs together. They usually are highly vascular (rich blood supply) and contain fibres. There are many types of connective tissue, for example loose connective tissue occurs around organs and attaches the skin to the underlying tissues. Dense connective tissues are tougher, for example tendons attach muscles to bones.

Membranes Mucous membranes line a body cavity that opens directly to the exterior, preventing the cavity from drying out e.g. in the mouth. Serous membranes line a body cavity that does not directly open to the outside, and provide lubrication so that organs can move more easily e.g. the pleura is a membrane that lines the thoracic cavity and protects the lungs.

Roots, suffixes, and prefixes

Most medical terms are comprised of a root word plus a suffix (word ending) and/or a prefix (beginning of the word). Here are some examples related to the Integumentary System. For more details see Chapter 4: Understanding the Components of Medical Terminology

component meaning example
CUT- skin subcutaneous layer = layer below the skin
DERMA- skin dermatology = study of the skin and its diseases
EPI- upon epidermis = layer above the dermis
LIPO- fat lipoatrophy = atrophy of fat below the skin
MELAN- black melanin = the black pigment in the skin
ONYCH- nail onychectomy = excision of a nail
PACHY- thick pachyderma = abnormal thickening of skin
SCLERO- hand / tough scleroderma = chronic hardening of the skin
SUDOR- sweat sudorific = an agent that promotes sweat
-ITIS inflammation dermatitis = inflammation of the skin
-OMA tumour melanoma = black coloured skin tumour
-OSIS condition / disease dermatophytosis = a fungal infection of the skin

Cancer Focus

Overview of Skin Cancer Skin cancer is the most common type of cancer and accounts for half of all new cancers in Western populations. It occurs more often in people with light coloured skin who have had a high exposure to sunlight. The two most frequent types of skin cancer are Basal Cell Carcinomas and Squamous Cell Carcinoma (often grouped under "non-melanoma skin cancer"). The third most frequent skin cancer is Melanoma, this is a malignancy of the cells which give the skin it's colour (melanocytes). In addition there are a number of other, less common cancers starting in the skin including Merkel cell tumours, cutaneous lymphomas, and sarcomas (see the pages on sarcoma and lymphoma in this guide).

Internet Resources for Skin Cancer Melanoma Melanoma is a malignancy of the skin in which melanocytes (the cells which give the skin it's colour) become cancerous. Melanoma occurs most frequently in white people, and is rare in people with dark skin it is usually found in adults, though occasionally melanoma may develop in children and adolescents. Over exposure to sunlight can cause skin changes which can lead to melanoma. Half of all melanomas are thought to arise in a benign (non-cancerous) pigmented nevus (a mole). Moles are very common and normally change only slightly over time however in melanoma there may be a more rapid increase in size - symptoms include a darker or variable discoloration, itching, and possibly ulceration and bleeding.

Internet Resources for Melanoma Basal Cell Carcinoma (BCC) This is where the basal cells become cancerous basal cells are found in the epidermis (the outermost layer of skin). This is the most common type of skin cancer which is usually highly curable when detected early.

Internet Resources for Basal Cell Carcinoma Squamous Cell Carcinoma (SCC) A type of skin cancer arising in squamous cells (the flat, scaly cells on the surface of the skin). Cure rates are very hight when detected and treated early.

Internet Resources for Squamous Cell Carcinoma (skin) Merkel cell cancer Merkel cell cancer (also known as trabecular cancer, or neuroendocrine cancer of the skin) is a rare type of malignancy developing on or just beneath the skin. These tumours can develop at any age, but the peak incidence is between ages 60 - 80. They are more frequent in white people, the most common sites of diseases are the face or scalp and other areas of high sun exposure.

Related Abbreviations and Acronyms

BCC Basal Cell Carcinoma
LMM Lentigo Maligna Melanoma
MM Malignant Melanoma
NBCCS Nevoid basal cell carcinoma syndrome
NM Nodular Melanoma
NMSC Non Melanoma Skin Cancer
SC Subcutaneous
SCC Squamous Cell Carcinoma
SSM Superficial Spreading Melanoma
UVR Ultra Violet Radiation

Further Resources (4 links)

Integumentary System Overview

YouTube
Lecture by 'bullharrier'

WebAnatomy, University of Minnesota
Test your anatomy knowledge with these interactive questions. Includes different question types and answers.

University of Pennsylvania Health System
Detailed guide with diagrams, from the ADAM Body Guide.


Subjective Assessment

Begin the assessment by asking focused interview questions regarding the integumentary system. Itching is the most frequent complaint related to the integumentary system. See Table 14.4a for sample interview questions.

Table 14.4a Focused Interview Questions for the Integumentary System

Questions Follow-up
Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole, lump, bump, or nodule? [3] Use the PQRSTU method to gain additional information about current symptoms. Read more about the PQRSTU method in the “Health History” chapter.
Have you ever been diagnosed with a condition such as acne, eczema, skin cancer, pressure injuries, jaundice, edema, or lymphedema? Please describe.
Are you currently using any prescription or over-the-counter medications, creams, vitamins, or supplements to treat a skin, hair, or nail condition? Please describe.

2011 CPT Changes to the Integumentary System

Rosalind Richmond, chief coding and compliance officer of GENASCIS, which provides revenue cycle services and supporting technologies for surgery centers, outlines the 2011 CPT changes made to codes in the integumentary system.

Debridement

Below are key changes, additions and revisions to the Inegumentary System, specific to Debridement:

  • Subheading revised, removing reference to excision.
  • 11010, 11011, 11012 revised, replacing "associated with open fracture" with "at the site of an open fracture".
  • 11040, 11041 deleted, to report use 97597, 97598 for debridement of skin, i.e., epidermis and/or dermis.
  • 11042, 11043, 11044 revised by surface area and depth.
  • +11045, +11046, +11047 added.
  • 97597: Debridement (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, debris, biofilm), including topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area first 20 sq cm or less.
  • 97598: each additional 20 sq cm, or part thereof. Note: Do not report 11042-11047 in conjunction with 97597-97602.
  • Single wound reported to the depth of deepest level.
  • Multiple wounds reported by sum of the surface area of wounds of same depth.
  • Do not sum wounds of different depths, report codes for appropriate depths with modifier -59 with codes 11042, 11045 and 11044.

Repair (Closure)

Complex repair includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs (e.g., excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.

Skin Replacement Surgery and Skin Substitutes

Surgical preparation guidelines have been revised:

  1. 15002-15005 related to graft placement, flap, skin replacement, skin substitute, or negative pressure wound therapy.
  2. In some cases closure may be possible using adjacent tissue transfer (14000-14061) or complex repair (13100-13153).
  3. Appreciable nonviable tissue is removed to treat a burn, traumatic wound or necrotizing infection.
  4. Intent is to heal wound by primary intention or negative pressure wound therapy. When intent is to heal by secondary intention use debridement codes.
  5. The closure, application of graft, flap, skin replacement or skin substitute may be delayed, but the intent is to include these treatments.
  6. Do not report 15340, 15341 in conjunction with 11042, 15002-15005 and 15430, 15431 in conjunction with 11042, 15002-15005.

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.


Watch the video: Why the integumentary system is important? Skin,nails, and hair (January 2022).