wound care nurse visit cpt code

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Billing and Coding: Wound Care

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Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37166, Wound Care. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.

Active Wound Care Management – CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608

Currently, code 97602 is a status B (bundled) code for physician’s services; therefore, separate payment is not allowed for this service.

A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifier to the CPT code billed. In addition the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. Please see MM10176 for more information.

For debridement codes 97597, 97598, or 97602:

Debridement should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed. 

Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately. 

It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service. 

Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047. The wound depth debrided 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 muscle substance was debrided, the 11043-11046 series would be appropriate, depending on the area. 

Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.

Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier 59 or a more specific modifier as appropriate (e.g., LT, RT, XS, etc). 

Surgical Debridements – CPT codes 11000-11012 and 11042-11047

Dressings applied to the wound are part of the service for CPT codes 11000-11012 and 11042-11047 and may not be billed separately.

Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. It is only appropriate to provide an Advance Beneficiary Notice of Non-coverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.

Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.

The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.

For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.

CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.

Use appropriate modifiers when more than one wound is debrided on the same day.

The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.

The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.

For example, CPT code 11042 defined as “debridement, subcutaneous tissue” should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.

Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.

For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.

The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.

For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.

Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical Debridements

E/M codes are not usually billed in conjunction with a debridement procedure. When providing and billing surgical debridement, the surgical debridement service is to include: the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. When a "reasonable and necessary" E/M service is provided and documented on the same day as a debridement service, it is payable by Medicare when the documentation clearly establishes the service as a "separately identifiable service" that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.

Low frequency, non-contact, non-thermal ultrasound (MIST Therapy) – CPT code 97610

One 97610 service per day is allowable for a qualifying wound. CPT Code 97610 is not separately reportable for treatment of the same wound on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).

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.

Debridement including removal of foreign material at the site of an open fracture or open dislocation may be reported with CPT codes 11010-11012. Since these codes would be reported with a CPT code for treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.

Response To Comments

Coding information, bill type codes, revenue codes, cpt/hcpcs codes.

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

CPT/HCPCS Modifiers

Icd-10-cm codes that support medical necessity.

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

No procedure code to diagnosis code limitations are being established at this time.

ICD-10-CM Codes that DO NOT Support Medical Necessity

Icd-10-pcs codes, additional icd-10 information.

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual , for further guidance.

Other Coding Information

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Page Help for Article - Billing and Coding: Wound Care (A55818)

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Find-A-Code Articles, Published 2021, September 28

When is it proper to bill nurse visits using 99211.

by   Christine Woolstenhulme, QMC QCC CMCS CPC CMRS Sep 28th, 2021 - Reviewed/Updated Aug 29th

When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using  99211  and an E/M office visit reporting  99202  ‑  99215  and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit where vaccines are administered is not always understood. The answer depends on whether the provider performs a medically necessary and significant, separately identifiable E/M visit, in addition to the immunization administration.

CMS states, when a separately identifiable E/M service (which meets a higher complexity level than CPT code  99211 ) is performed, in addition to drug administration services, you should report the appropriate E/M CPT code reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

It is incorrect to bill a  99211  when the provider provides an E/M service that meets a higher complexity level than CPT code  99211 , you must bill the higher complexity, and you cannot bill for two services in one day. 

Charging for Nurse Visits

There are times when it is appropriate to report for a nurse visit using CPT code  99211 . The  Incident-to rule  applies when reporting this code, and services provided must be documented as medically necessary services, including the clinical history, clinical exam, making a clinical decision, and physician supervision. 

• NOTE: A nurse visit is not paid if billed with a drug administration service such as chemotherapy or non-chemotherapy drug infusion code, including therapeutic or diagnostic injection codes. The reasoning is because diagnostic IV infusion or injection services typically require direct physician supervision, and using  99211 is reported by qualified healthcare professionals other than physicians.

08/29/2023 NOTE: (These CPT codes,90782, 90783, 90784, or 90788  were deleted in 2006, but still showing in CMS - Claims processing manual) When reporting CPT codes 90782, 90783, 90784, or 90788 , CPT code 99211  cannot be reported. In addition, it is improper billing to report a visit solely for an injection that meets the definition of the injection codes. 

When the only reason for the visit is for the patient to receive an injection, payment may be made only for the injection (if it is covered). An office visit using  99211 would not be warranted where the services rendered did not constitute a regular office visit and a part of the plan of care and not at the patient's request.

Unlike other E/M codes  99202 - 99205 , and 99212 - 99215 , time alone cannot be used when reporting  99211  when selecting the appropriate code level for E/M services. Effective January 1, 2021, time was removed as an available code-selection criterion. The typical time spent on this code is five minutes.  

Other visits billed with  99211

Several other visits may be reported using  99211 , and nurses are not the only staff that can report this code; medical Assistants and technicians are also included under non-physician.  

Covid-19 Testing

According to  CMS ; Physician offices can use CPT code  99211  when office clinical staff furnish assessment of symptoms and specimen collection for Covid-19 incident to the billing professionals services for both new and established patients. When the specimen collection is performed as part of another service or procedure, such as a higher-level visit furnished by the billing practitioner, that higher-level visit code should be billed. The specimen collection would not be separately payable.

Examples from CMS

The following are examples of when  CPT  99211  might be used:

• Office visit for an established patient for blood pressure check and medication monitoring and advice. History, blood pressure recording, medications, and advice are documented, and the record establishes the necessity for the patient's visit.
• Office visit for an established patient for return to work certificate and advice (if allowed to be by other than the physician). Exam and recommendation are noted, and the Return to Work Certificate is completed, copied, and placed in the record.
• Office visit for an established patient on regular immunotherapy who developed wheezing, rash, and swollen arm after the last injection. Possible dose adjustments are discussed with the physician, and an injection is given. History, exam, dosage, and follow-up instructions are recorded.
• Office visit for an established patient's periodic methotrexate injection. Monitoring Lab tests, query signs and symptoms, obtain vital signs, repeat testing, and injection advised. All this information is recorded and reviewed by the physician. (Note that in this circumstance, if  99211  is billed, the injection code is not separately billable). An office visit for an established patient with a new or concerning bruise is checked by the nurse (whether or not the patient is taking anticoagulants), and the patient is advised on how to care for the bruise and what to be concerned about, and, if on anticoagulants, continuing or changing current dosage is advised. History, exam, dosage, and instructions are recorded and reviewed by the physician.
• Office visit for an established patient with atrial fibrillation who is taking anticoagulants and has no complaints . The patient is queried by the nurse, vital signs are obtained, the patient is observed for bruises and other problems, the prothrombin time is obtained, the physician is advised of prothrombin time and medication dose, and medication is continued at present dose with follow up prothrombin time in one month recommended. History, vital signs, exam, prothrombin time, INR, dosage, physician's decision, and follow-up instructions are recorded.

References/Resources

About christine woolstenhulme, qmc qcc cmcs cpc cmrs.

Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code.  Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.

When is it Proper to Bill Nurse Visits using 99211. (2021, September 28). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/nurse-visits-and-injections-36866.html

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Procedural Coding for Wound Care Management – Medicare and PMR Billing Guidelines

by Outsource Strategies International. | Published on Nov 9, 2017 | Medical Coding News (A) , Resources | 0 comments

Approximately 6.5 million Americans suffer the effects of chronic wounds every day, according to a recent report from Hutch News. A study published in the Journal of Hospital Administration in 2013 reported that wound care services represent a large percentage of reimbursement income for hospital facilities and physicians. Most people with chronic wounds are also under treatment for chronic diseases such as diabetes and obesity, which greatly increase the risk of damage to the skin. From the perspective of a medical coding service provider, the definition of wound care covers wound treatment as well as evaluation and management (E/M).

Wound care involves treatment for various types of damage to the skin and includes:

• Assessment, management, and cleansing of the wound
• Simple debridement; and
• Removal and reapplication of the wound dressings

In-depth understanding of skin anatomy, the codes for wound care services, and documentation requirements are necessary to ensure accurate reporting of wound care services.

Active wound care procedures involve removing devitalized and/or necrotic tissue to promote healing. Medicare’s definition of debridement is: “The removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.” Codes must be assigned based on the deepest level of tissue debrided or removed first, and the total surface area second.

CPT Codes for Active Wound Care Management

• Wounds not involving subcutaneous tissue 97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, 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   each additional 20 sq cm, or part thereof (these should be list separately in addition to code for primary procedure)

Debridement

• Wounds involving subcutaneous tissue 11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less +11045    each additional 20 sq cm, or part there of (List separately in addition to code for primary procedure)
• Wounds involving muscle and/or fascia 11043 Debridement, muscle and/or fascia (includes epidermis and dermis and subcutaneous tissue, if performed); first 20 sq cm or less +11046  each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
• Wounds involving bone 11044 Debridement, bone, (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less +11047  each additional 20 sq cm, or part there of (List separately in addition to code for primary procedure)

Point to Note: Multiple wounds debrided to the same depth

• If multiple wounds are all debrided to the same depth, the combined measurements of the debrided surface should be used to determine the appropriate code(s)
• The total surface area of each debrided wound must be documented separately
• Each debridement may not be reported separately, unless performed on different tissue types.

Medicare Billing Guidelines for CPT Codes 97597, 97598 and 11042-11047

• Active wound care procedures and debridement services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.
• A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).
• CPT codes 97597 and/or 97598 are typically used to bill recurrent wound debridements when medically reasonable and necessary.
• These two CPT codes are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.
• CPT codes 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). The mere removal of secretions (cleansing of a wound) does not represent a debridement service.
• CPT codes 11042-11047 are not appropriate to report the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. These procedures should be reported when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

Physical Medicine and Rehabilitation (PM&R) Codes – 97597, 97598, 97602)

• CPT Codes 97597, 97598 and 97602 are considered “sometimes” therapy codes.
• A physician, NPP or therapist acting within their scope of practice and licensure may provide debridement services and use the PM&R codes including CPT 97597, 97598 and 97602.
• These treatment codes may be provided without a therapy plan of care by physician/NPPs or as incident-to services. When these “sometimes therapy” services are provided under physicians/NPPs treatment plan they should be billed without a therapy modifier.
• When wound care services are delivered by therapists, there must be a physician certified therapy plan of care based on a thorough evaluation signed by the treating physician or NPP.
• CPT 97597, 97598 and 97602 must only be billed for services that include medically necessary skilled debridement services.
• CPT code 97602 Removal of devitalized tissue from wound(s), non-selective debridement without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion) including topical application(s), wound assessment, and instruction(s) for ongoing care, per sessionis not separately payable.
• Documentation must support the HCPCS being billed.
• Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598).
• Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

Evaluation/Re-assessment is Included in Wound Care Service

• It is generally inappropriate to report an evaluation and management (E/M) service in addition to a wound care service (e.g., debridement, application of an Unna’s boot, etc.).
• E/M can be reported in conjunction with would care if, during the wound care encounter, the provider performs (and documents) a significant, separately identifiable service. The E/M service must be unrelated to the scheduled visit for wound care and require medical evaluation and treatment over and above that for the wound care.
• If E/M service is reported in addition to wound care, append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Documentation Essentials

An AAPC report lists the essentials of wound care documentation as follows:

• Description of the wound, including size (length x width); depth; total sq cm; appearance; drainage; undermining; peri-wound character; presence of edema, infection, and disease causing underlying problems or complication(s) for the wound healing process.
• Description of the method of debridement (scalpel, nippers, scissors, curette), and which deepest layer of tissue was removed or debrided (fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm; subcutaneous tissue; muscle and/or bone).
• Clear description of the tissue being cut away in the chart notes.
• Specification of which dressings were applied, post-op care instructions provided, progress of the wound, and on follow-up visit notes, future plans.
• Description of wound improvement or measurable changes (e.g., decrease in drainage, inflammation, necrotic tissue or slough, pain, swelling, wound dimension changes, or declining improvement). Steps done to address the new condition might include oral antibiotics, further testing, biopsy of the wound, consultations requested for vascular intervention, or podiatric consultation for bracing or off-loading.

Coding Errors to Watch Out For

According to a Medscape article, the common issues that can lead to claim denial for wound care services include:

• Inappropriate use of modifier 25, that is, whether there is a separately billable service
• Not taking add-on codes into consideration, especially with wound dimensions for the debrided area
• Use of hyperbaric oxygen when all other wound management modalities have failed not accompanied by physician orders for the procedure
• Lack of or poorly documented wound dimensions
• Confusing selective and nonselective debridement
• Coding multiple layers of debridement per site instead of coding the deepest layer for debridement (for e.g., bone and muscle debridement cannot be coded together for the same site)
• Coding dressing of wounds separate from an E/M service.

With the complexities involved in coding and billing wound care services, the support of an expert can be invaluable to ensure proper reimbursement. Skilled coders in medical coding companies are knowledgeable about services provided as well as how they are provided and the management modalities and services that are bundled by payers or packaged for payment.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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Wound Care Billing & Coding Guidelines

Find the billing and coding guidelines you need, including access to ICD-10 information, documentation tools, evaluation and management, CMS HBO National Coverage Determination (NCD), modifiers and more.

Evaluation and Management (E&M)

Cms’ evaluation and management (e&m) services guide.

Review CMS’ E&M guidelines when selecting an E&M code for billing purposes that accurately represents the services provided.

DOWNLOAD THE GUIDE

CMS’ 1995 Evaluation and Management Documentation Guidelines

Healogics Specialty Physicians (HSP) uses CMS’ 1995 guidelines to determine the appropriate patient E&M level. Reference these guidelines for accurate E&M coding.

Evaluation and Management (E&M) Tools by CPT Code

Required components for initial and subsequent hospital care e&m services (cpt codes 99221-99223 and 99231-99233).

This tool summarizes the required components to properly document and select the patient’s correct E&M level CPT code 99221-99223 and 99231-99233.

DOWNLOAD THE REQUIREMENTS

Required Components for New and Established Patient E&M Services (CPT code 99201-99205 and 99211-99215)

This guide summarizes the requires components to properly document and select the patient’s correct E&M level CPT code 99201-99205 and 99211-99215.

Coverage Policies & Other Tools

Cms’ national coverage determination (ncd) for hyperbaric oxygen therapy section 20.29.

CMS’ HBO NCD provides the list of the 15 covered HBO indications. The NCD also includes additional coverage guidance for the Diabetic Wounds of the Lower Extremity (DWLE) indication.

Modifier Reference Sheet

The Modifier Reference Sheet will allow providers to accurately append modifier(s) when necessary to provide the required information to the payer regarding the services or procedures rendered to a patient during their encounter to ensure proper billing and payment.

DOWNLOAD THE REFERENCE SHEET

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Billing Guidelines for Wound Care in 2022

Basics of wound care.

Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.

These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

Common procedure codes (CPT) used while billing for wound care include wound care codes i.e., 97597, 97598, and debridement codes i.e., 11042 up to 11047. We referred to local coverage determination (LCD) for wound care as a reference to discuss billing guidelines for wound care in the year 2022.

For Wound Care Billing Services, please read more here.

Billing Guidelines for Wound Care

• Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing. The provider is required to have direct (one-on-one) patient contact. These procedures have a 0 global period. These codes include the use of topical applications, suction, whirlpool wound assessment, and instructions for ongoing care.
• Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary. CPT codes 97597 and 97598 are used for wet-to-dry dressings, application of medications with enzymes to dissolve dead tissue, whirlpool baths, minor removal of loose fragments with scissors, scraping away tissue with sharp instruments, debridement with pulse lavage, high-pressure irrigation, incision, and drainage. These codes involve the dermis and epidermis only.
• CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.
• CPT codes 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.
• Debridement of a wound, performed before the application of topical or local anesthesia is billed with CPT codes 11042 – 11047. Wound debridements (11042-11047) are reported by the depth of tissue that is removed and by the surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.
• Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound. CPT codes 11043, 11046, and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital, or ambulatory surgical center (ASC). CPT codes 11043, 11046, and 11044, 11047 are codes that describe deep debridement of the muscle and bone.
• The use of CPT codes 11042-11047 is not appropriate for the services like washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision, and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.
• When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation. Separate billing of the whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.
• Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing services. We referred CMS LCD document to discuss billing guidelines for wound care in the year 2022.

By outsourcing your wound care billing, you don’t have to hire wound care billers and coders for your practice. For more assistance in billing for wound care, email us at: [email protected] or call us: 888-357-3226 .

Reference: Billing and Coding Guidelines for Wound Care

CPT © Copyright 2022 American Medical Association.

Read more Articles on Wound Care Billing:

Efficient Coding: The Backbone of Wound Care Billing

Understanding Financial Markers for Successful Wound Care Billing

Benchmarking Wound Care Billing Success

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Coding for E/M home visits changed this year. Here’s what you need to know

CPT has revised codes for at-home evaluation and management (E/M) services as of Jan. 1, 2023. Services to patients in a private residence (e.g., house or apartment) or temporary lodgings (e.g., hotel or shelter) are now combined with services in facilities where only minimal health care is provided (e.g., independent or assisted living) in these code families:

Home or residence E/M services, new patient

• 99341, straightforward medical decision making (MDM) or at least 15 minutes total time,

• 99342, low level MDM or at least 30 minutes total time,

• 99344 (code 99343 has been deleted), moderate level MDM or at least 60 minutes total time, 

• 99345, high level MDM or at least 75 minutes total time.

Home or residence services, established patient   

• 99347, straightforward MDM or at least 20 minutes total time,

• 99348, low level MDM or at least 30 minutes total time,

• 99349, moderate level MDM or at least 40 minutes total time,

• 99350, high level MDM or at least 60 minutes total time. 

Select these codes based on either your level of medical decision making or total time on the date of the encounter , similar to selecting codes for office visits . The E/M codes specific to domiciliary, rest home (e.g., boarding home), or custodial care (99324-99238, 99334-99337, 99339, and 99340) have been deleted, and the above codes should also be used in those settings.

When total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, you can add code 99417 to report prolonged services. The exception to this is for patients with Medicare. For those patients, report prolonged home or residence services to Medicare with code G0318 in addition to 99345 (requires total time ≥140 minutes) or 99350 (requires total time ≥110 minutes). Code G0318 is not limited to time on the date of the encounter, but includes any work within three days prior to the service or within seven days after.

Services provided in facilities where significant medical or psychiatric care is available (e.g., nursing facility, intermediate care facility for persons with intellectual disabilities, or psychiatric residential treatment facility) are reported with codes 99304-99310 .

— Cindy Hughes, CPC, CFPC

Posted on Jan. 19, 2023

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