Wagner Classification, downgrading

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Im hoping someone can provide some insight to some questions our podiatrist has regarding grading DFUs. We currently use the Wagner Classification system for grading diabetic foot ulcers in our clinics. We have always been taught to never downgrade the DFU Wagner grade over the course of the care plan, yet its plausible that we might have to increase the DFU Wagner grade if the ulcer worsens. Our podiatrist believes and informs us they are taught to downgrade DFUs. After reviewing the article, The Dysvascular Foot: A System for Diagnosis and Treatment, by F. William Wagner, Jr., MD, Wagner states, "that any grade except Five may be converted back to a Grade Zero foot which has no open lesions." First question, should we be downgrading DFUs throughout the care plan?

My concern is for the Wag 3 DFU patient in HBOT. The only thing that separates a Wag 2 from a Wag 3 is the presence of infection. The NCD for HBOT requires the patient have a Wag 3 DFU or higher to meet criteria and that we performed "necessary treatment to resolve any infection that might be present." Second question, does a Wag 3 DFU have to be actively infected for HBOT to be used? If we resolve the infection prior to starting HBOT but are still failing other standard wound care measures or if the infection resolves during the HBOT treatment plan, should we downgrade the ulcer to a Wag 2? Wouldn't this eliminate the medical necessity for HBOT?

Any guidance with something I can reference for our podiatrist would be appreciated.

Thanks,

Sean

Nov 7, 2023 by Sean Finley, EMT-B, CHT

5 replies

Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, CRNFA

Hi Sean, thanks for the question! That is a tough topic and is definitely subject to a great deal of rumination among clinical as well as coding and billing personnel.

In short, there is no true unanimous consensus. It is important to understand that the Wagner system does not factor in severity of infection, if present. There are other classification systems that can be utilized, though the Wagner unfortunately is married to reimbursement.

The link below outlines some information that may help you make the best decision for your practice in order to maintain consistency in clinical assessment, documentation, as well as treatment and ensuring synergy with reimbursement guidelines. The Introduction as well as Treatment Protocol Guidelines discuss the confounding issues you present.

https://woundreference.com/app/topic?id=diabetic-foot-ulcers-classification-systems_x

Nov 7, 2023

Elaine Horibe Song
MD, PhD, MBA

In addition to the resources and insights that Sam presented above, this section has further information that might be helpful in the context of the use of Wagner classification and HBOT

https://woundreference.com/app/topic?id=diabetic-foot-ulcer-hyperbaric-oxygen-thera#-wagner-classification-

Nov 7, 2023

Sean Finley
EMT-B, CHT

Thanks for the information, I did review the links provided and the information is helpful. In your opinion do we risk denials for CTPs if a chart reflects a Wag 3 DFU?

Nov 8, 2023

Elaine Horibe Song
MD, PhD, MBA

Tiffany and I talked about your question: since a Wagner 3 is by definition a DFU "with deep abscess, osteitis or osteomyelitis, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths", application of CTP would risk a denial upon post payment review. See excerpt of CMS LCD L36690 below:

"Presence of neuropathic ulcers and diabetic foot ulcer(s) having failed to respond to documented conservative wound-care measures of greater than four weeks, during which the patient is compliant with recommendations, and without evidence of underlying osteomyelitis or nidus of infection."

Nov 12, 2023

Sean Finley
EMT-B, CHT

Dr Song, thanks for your reply. I agree. I really don't want to instruct providers to downgrade Wagner classification. Even if a DFU Wag 3 is improving through the use of HBOT and standard wound care for medical necessity purposes I think we need to keep the DFU listed as a Wag 3 and not downgrade. Per the NCD the provider must document improvement every 30 days for the continued use of HBOT. If after the infection in the Wag 3 ulcer is resolved, and our provider wants to use a CTP as long as our provider documents to the status of the infection I think we should be able to fight any denial.

Nov 13, 2023

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult 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.

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