wound care office visit cpt code

Coding clarification: coding for wound care

KENT MOORE AND EMILY HILL, PA-C

Many family physicians provide wound care for their nursing facility patients. Coding and billing correctly for such wound care is important to assure appropriate payment and avoid potential allegations of fraud or abuse. One of the challenges in this regard is understanding when to report chemical cauterization of granulation tissue versus debridement, especially as it pertains to Medicare patients.

Coding for chemical cauterization of granulation tissue

According to Medicare claims data, Current Procedural Terminology (CPT) code 17250 for chemical cauterization of granulation tissue (i.e., proud flesh) is a service increasingly reported by family physicians in the nursing facility setting. CPT code 17250 is specific to the application of chemicals such as silver nitrate to excessive healing tissue known as proud flesh or granulation tissue and may include the removal of loose granulation tissue and subsequent hemostasis. The service typically begins with the physician explaining the procedure to the patient and/or family, reviewing risks and complications, and obtaining informed consent. The physician also verifies all required instruments and supplies are available and assists with appropriate positioning to expose and stabilize the procedure site. Lastly, the physician helps drape and prepare the site and scrubs up.

During the procedure itself, the physician gently curettes loose granulation tissue and irrigates the wound with sterile saline. The physician also applies a chemical cauterization agent (e.g., silver nitrate) to granulation tissue and achieves controlled hemostasis. Following the procedure, the physician applies sterile dressing, writes orders for antibiotic and pain medication, as appropriate, and discusses after-care treatment, including home restrictions (e.g., bathing). Finally, the physician dictates the procedure note and completes medical record documentation.

Clinical examples:

A clinical example of code 17250 is a 78-year-old female presenting four months after placement of a gastrostomy tube with excessive granulation tissue. The physician treats the exposed tissue with chemical cauterization. Another example is a patient who presents two weeks after incision and drainage of a paronychia with excessive granulation tissue on the nail bed. The physician treats the exposed tissue with chemical cauterization.

When not to use code 17250:

As noted in the parentheticals below the code in CPT, code 17250 is not intended to be reported in the following situations:

• With removal or excision codes for the same lesion,
• When chemical cauterization is used to achieve wound hemostasis,
• In conjunction with active wound care management 97597, 97598, or 97602 for the same lesion.

Coding for debridement 

Codes 97597, 97598, and 97602 describe a more extensive service than described by code 17250, as follows:

97597 Debridement (e.g., high-pressure waterjet with or 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 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 (list separately in addition to code for primary procedure),

97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing. For instance, code 97597 involves cleansing the wound thoroughly with copious irrigation, then removing proteinaceous slough, fibrin, and debris covering the wound bed with curette, scalpel, and forceps or scissors until healthy tissue is visualized. Code 97598 involves the same service done over an additional surface area. Chemical cauterization (code 17250) to achieve wound hemostasis is included in these procedures and should not be reported separately for the same lesion.

Clinical example:

A clinical example of 97598 involves a 60-year-old male who presents with a neuropathic diabetic ulcer on the left plantar forefoot. The wound edges and the wound bed are viable with granulations but covered with an adherent proteinaceous slough, fibrin, and debris. He undergoes debridement to the depth of dermis.

Medicare payment for wound care services

Correctly coding wound care services in the nursing facility setting is important, given the different ways Medicare pays for such services. Medicare beneficiaries can either be in a Part A covered skilled nursing facility (SNF) stay, which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which Part A benefits are exhausted but certain medical services are still covered, although room and board are not. Under the Balanced Budget Act of 1997, Congress mandated that payment for most services provided to beneficiaries in a Medicare covered Part A SNF stay be included in a bundled prospective payment to the SNF. The SNF is required to bill these bundled services in a consolidated bill to the Part A Medicare administrative contractor. The bundled services cannot be billed separately.

There are a limited number of services specifically excluded from consolidated billing and, therefore, separately payable. Currently, CPT code 17250 is among those excluded from the consolidated billing rule and, therefore, separately reportable. In contrast, CPT codes 97597 and 97598 are subject to the SNF consolidation billing. Reporting 17250 rather than 97597/97598 to avoid consolidated billing would be inappropriate.  

When reporting services, clinicians should use the code that accurately identifies the service performed, per CPT guidelines. It is not appropriate to select a code that approximates the service or to report a code solely for reimbursement purposes. Further, CPT code selection should always be supported by the clinical documentation in the medical record. Selecting the proper code for wound care services requires an understanding of wound care techniques and the code descriptors and guidelines found in CPT.

— Kent Moore, senior strategist for physician payment, American Academy of Family  Physicians, and Emily Hill, PA-C, president of Hill & Associates, a Wilmington, N.C., consulting firm specializing in coding and compliance

Posted on May 11, 2022, by Kent Moore

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CPT Coding for E/M Visits With Wound Care

Analysis  |  By Revenue Cycle Advisor    |    April 16, 2021

The service must be performed for a condition unrelated to the scheduled visit and must be a new condition that requires further evaluation.

Q: Is it appropriate to report an E/M code for visit services provided in conjunction with a wound care procedure?

A: E/M visit codes are not usually billed in conjunction with wound or ulcer procedures.

Keep in mind that outpatient encounters for wound care procedures involve examinations and assessments, cleansing and debridement, and removal and reapplication of wound dressings.

If the provider performs distinct and separately identifiable work, it may be documented using an E/M code and modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

For example, an E/M code with modifier -25 may be billed if the provider diagnoses a new ulcer or orders laboratory tests for an unrelated condition.

Editor’s note : This question was answered by  Gloria Miller, CPC, CPMA, CPPM , former vice president of reimbursement services at Comprehensive Healthcare Solutions Inc. in Seattle, during the HCPro webinar, “ Clean Up CPT/ICD-10-CM Coding and Billing for Wound Care .”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Revenue Cycle Advisor combines all of HCPro's Medicare regulatory and reimbursement resources into one handy and easy-to-access portal. News is not just repeated from other sources. It is analyzed by our Medicare experts so professionals can comprehend any new rule and regulatory updates thoroughly. Learn more .

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Wound Care Coding: A Comprehensive Look at CPT Code Categorization

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Accurate and effective coding is essential in wound care to ensure proper documentation, appropriate reimbursement, and improved patient care. Understanding the different CPT code categories specific to wound care is crucial for healthcare providers and coding professionals. In this article, we have explored the key CPT code categories in wound care coding, including Evaluation and Management (E/M) codes, wound preparation codes, wound closure codes, surgical excision and repair codes, and skin substitute codes.

1. Evaluation and Management (E/M) Codes

Introduction: Evaluation and Management (E/M) codes play a crucial role in wound care by capturing the work performed during patient visits for assessment, diagnosis, and treatment planning. These codes provide a standardized method for reporting medical services, ensuring accurate documentation and appropriate reimbursement. Evaluation and Management (E/M) codes include 99202, 99203, 99204, and 99205.

Clinical example: A patient with a chronic leg ulcer presents to the wound care clinic for evaluation. The provider conducts a comprehensive examination of the wound, measures its dimensions, assesses the surrounding tissue, reviews the patient's medical history, and develops a treatment plan. Based on the complexity of the case, the provider determines that CPT code 99203, an office visit involving a moderate level of medical decision-making and a comprehensive examination, is the appropriate E/M code to report.

Common mistakes:

• Insufficient documentation: Ensure that the medical record includes a detailed description of the patient's history, physical examination, medical decision-making, and any procedures performed. Incomplete documentation may lead to downcoding or denial of claims.
• Inaccurate code selection: Understand the level of medical decision-making and examination required for each E/M code and select the code that best reflects the complexity of the visit. Choosing an incorrect code can result in inaccurate reimbursement.
• Lack of supporting documentation: Include relevant information such as the chief complaint, history of present illness, review of systems, and assessment of risk factors. This documentation strengthens the medical necessity of the visit and justifies the chosen E/M code.

2. Wound Preparation Codes

Introduction: Wound preparation is a critical component of wound care, involving the cleansing, debridement, and application of appropriate dressings to promote healing. Wound preparation codes are used to accurately report the work performed during these procedures, ensuring proper documentation and reimbursement. Wound preparation codes include 15002, 15003, 15004, and 15005.

Clinical example: A patient with a chronic diabetic foot ulcer requires surgical debridement and preparation of the wound bed. The provider performs extensive excision of necrotic tissue, debrides the wound edges, and thoroughly irrigates the wound to remove any debris or bacteria. Based on the size and location of the wound, the provider selects CPT code 15002, which represents the surgical preparation of the recipient site for open wounds, burn eschar, or scars on the trunk, arms, and legs.

• Improper code selection: Carefully review the documentation and accurately measure the wound size and location to choose the appropriate code. Selecting an incorrect code can lead to under- or over-coding, impacting reimbursement.
• Lack of specificity: Ensure that the documentation clearly describes the extent of the wound preparation, including the excision or debridement performed, the type of tissue involved, and the location of the wound. Specificity in documentation helps to support accurate code selection.
• Inadequate documentation of wound characteristics: Document important wound characteristics such as depth, size, presence of necrotic tissue, and surrounding tissue condition. This information is crucial for determining the appropriate code and supporting medical necessity.

3. Wound Closure Codes

Introduction: Wound closure is a crucial step in wound care that involves bringing the edges of a wound together and securing them to promote healing and minimize the risk of infection. Wound closure codes are used to report the procedures performed to close wounds, such as suturing, stapling, or adhesive application. Wound preparation codes include 12001, 12002, 12004, 12031, and 12032.

Clinical example: A patient sustains a laceration on their forearm while cooking and visits the emergency department. The physician cleans the wound thoroughly, assesses its length, depth, and tissue involvement, and decides to close it using sutures. After measuring the wound, the physician determines that it falls within the range of 2.6 cm to 7.5 cm. Consequently, CPT code 12002, which represents the simple repair of superficial wounds in this size range, is selected to report the closure procedure.

• Incorrect code selection: Ensure accurate measurement and classification of wound sizes to select the appropriate code. Choosing a code that does not align with the wound's characteristics can lead to incorrect reimbursement.
• Lack of documentation: Thoroughly document the wound closure procedure, including wound assessment, closure technique used (e.g., sutures, staples), and the number of closures applied. Inadequate documentation can lead to claim denials or coding inaccuracies.
• Omission of additional procedures: If ancillary procedures, such as debridement or irrigation, are performed during the wound closure, they should be appropriately documented and reported separately using the relevant CPT codes.

 4. Surgical Excision and Repair Codes

Introduction: Surgical excision and repair codes are essential in wound care to accurately capture procedures involving the removal of tissue and subsequent closure or reconstruction. These codes provide a standardized method for reporting surgical interventions, ensuring proper documentation and appropriate reimbursement. Surgical excision and repair codes include 11000, 11042, 12001, 12031, 13100, and 14040. 

Clinical example: A patient presents with a large laceration on the forearm caused by a sharp object. The wound extends through the subcutaneous tissue, requiring debridement and repair. The surgeon performs a thorough debridement of the subcutaneous tissue to remove any damaged or contaminated material. Following debridement, the wound is carefully closed using sutures. Based on the complexity of the procedure and the anatomic location, CPT Code 11042 for subcutaneous tissue debridement and CPT Code 12001 for simple repair of a superficial wound on the extremity are appropriate codes to report.

• Inaccurate coding of debridement: Ensure the appropriate level of debridement is accurately documented and coded. Different codes exist for debridement of skin, subcutaneous tissue, and deeper structures. Select the code that best reflects the depth and extent of tissue removal.
• Failure to document wound closure complexity: Document the complexity of wound closure (simple, intermediate, complex) based on factors such as wound size, location, and involvement of deeper structures. Accurately identifying the appropriate repair code is crucial for proper reimbursement.
• Lack of supporting documentation: Include detailed descriptions of the wound, including its dimensions, location, and any associated complications or comorbidities. Clear documentation ensures accurate code selection and supports medical necessity.

5. Skin Substitute Codes

Introduction: Skin substitutes play a vital role in wound care, providing temporary or permanent coverage for wounds that are difficult to heal. These substitutes promote wound healing, reduce pain, and prevent infection. In medical coding, skin substitute codes allow healthcare providers to accurately report and bill for the use of these specialized products. Skin substitute codes include 15271, 15272, 15275, 15276, 15277, and 15278.

Clinical example: A patient with a large full-thickness burn wound on their leg requires the application of a skin substitute graft for wound coverage. The provider applies a skin substitute graft measuring 80 square centimeters. In this case, CPT Code 15275, which represents the application of a skin substitute graft to the trunk, arms, or legs for a total wound surface area up to 100 sq cm, is the appropriate code to report.

• Incorrect code selection: Understand the specific anatomical areas and surface area limitations associated with each skin substitute code. Ensure accurate code selection based on the location and size of the wound.
• Lack of documentation: Provide detailed documentation that supports the use of skin substitute grafts, including the size of the wound, the type of graft applied, and the medical necessity for utilizing the skin substitute. Comprehensive documentation is essential for proper reimbursement.
• Failure to document the product used: Clearly indicate the specific type of skin substitute graft used in the medical record. This information helps validate the code choice and ensures accurate billing.

To Conclude,

To ensure success in wound care coding, healthcare providers and coding professionals must be aware of the specific requirements and guidelines associated with each code category. Avoiding common mistakes, such as insufficient documentation, inaccurate code selection, and lack of supporting documentation, is crucial for appropriate reimbursement and compliance. By understanding and implementing these guidelines, healthcare providers can accurately report the services provided, enhance documentation quality, and ultimately improve patient care in the field of wound care.

About Medical Billers and Coders (MBC)

Medical Billers and Coders (MBC) is a trusted billing company specializing in wound care services. With our expertise in medical coding and billing, MBC ensures accurate and timely reimbursement for wound care providers. We have a team of experienced coders who are well-versed in the intricacies of wound care coding, including Evaluation and Management (E/M) codes, wound preparation codes, wound closure codes, surgical excision and repair codes, and skin substitute codes.

Our dedication to staying updated with the latest coding regulations and industry trends makes us a reliable partner for wound care providers, ensuring efficient and compliant billing practices. To know more about our wound care billing services, email us at: [email protected]  or call us at: 888-357-3226

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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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Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services

Document note, note history, contractor information, article information, general information.

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023 , the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Article guidance.

This article clarifies wound care and debridement services provided by a therapist, physician, non-physician practitioner (NPP) or as incident-to services. Medical Necessity All Providers (including therapists) must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating practitioner/clinician. Coding Proper wound care coding requires careful reading of all Current Procedural Terminology (CPT) code descriptors and related CPT Manual instructions. Providers should note that some codes are per session or per wound surface area, not per wound or site. Evaluation and Management (E/M) Coding Requirements • Only physicians and NPPs (Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) can provide and bill E/M and CPT 11000 series codes when the services are appropriate and state licensure allows. These services may not be provided as incident-to services by hospital staff. • Services provided by qualified incident-to hospital staff, must meet both the incident-to service delivery requirements and the CPT descriptor requirements for the specific procedure. *Note: For claims with dates of service prior to January 1, 2014: Hospitals may bill any E/M level within the "established patient" category that corresponds to the resources used in the provision of the covered 99211 service in the specific clinic. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled "Incident To" Clarification for OPPS and CAH Outpatient attached below for additional information. For claims with dates of service on or after January 1, 2014: Hospitals may only bill HCPCS G0463. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled "Incident to" Clarification for OPPS and CAH Outpatient attached below for additional information. Physical Medicine and Rehabilitation (PM&R) Codes (i.e. 97597, 97598, 97602) • 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 codes must only be billed for services that include medically necessary skilled debridement services. • Hospital staff acting within their scope of practice and/or licensure may provide wound care, including debridement services, incident-to the services of a physician/NPP. • Staff providing therapy services incident-to the physician treatment plan must meet the qualification guidelines established for auxiliary personnel as described in the IOM Medicare Benefit Policy Manual , Publication 100-02, Chapter 15, Sections 220(A), 230.5. •CPT 97597, 97598, 97602 are considered “sometimes therapy” codes according to the IOM Medicare Claims Processing Manual , Publication 100-04, Chapter 5, Section 20. As such, 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 a physician's/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. The services must be billed using the appropriate therapy modifier and deliver within the CMS therapy guidelines found in the IOM Medicare Benefit Policy Manual , Publication 100-02, Chapter 15, Sections 100 and 220-230. Dressing Change 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). • Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable E/M or procedure code that, commonly but not necessarily, occurs on the same date of service as the dressing change. If not included in another service, the costs associated with dressing changes may be reported as not separately payable. • All topical applications (e.g. medications, ointments, and dressings) are included in the payment for the procedure codes. • It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. An ABN for a dressing change is NOT appropriate since the costs of the dressing change are packaged into other procedures billed. Evaluation/Re-assessment In general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable. • Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable Evaluation and Management (E/M) service or i.e., physical therapy initial evaluation CPT codes 97161-97163. Note that CPT codes 97160-97163 are "always" therapy codes and the therapy modifier must be applied. • Re-assessment/re-evaluation of a wound (which may be completed with a dressing change) is generally considered to be a non-covered routine service. An exception would require documentation clearly supporting that there had been a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care and required further evaluation. • The evaluation must be provided by a physician, NPP or therapist or other qualified incident-to hospital staff. • Patients may be evaluated by the physician/NPP and the follow-up care may then be provided by qualified hospital incident-to staff working under the physician’s plan of care. When a physical therapist provides these incident-to follow-up services and provides an initial therapy evaluation (CPT 97161-97163), the documentation must clearly indicate the medical necessity for these additional evaluative services (as compared to the previously completed physician evaluation of the patient’s condition) in order to be separately reimbursable. • An ABN may be given when medical necessity is not supported for the initial therapy evaluation. However, an ABN may not be given when medical necessity is not supported for a follow-up visit since there is no billable therapy code for a routine re-assessment (i.e. routine wound assessment with/without a dressing change). • While a physician/NPP may not bill a new patient E/M with modifier 25 for any global service, the hospital may bill the E/M. See the IOM Medicare Claims Processing Manual , Publication 100-04, Chapter 12, Section 40.3. Debridement Selective Debridement (CPTs 97597 and 97598) - Documentation to support selective debridement should include the following: • Clear description of instruments used for debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps). • Thorough objective assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridement Non-Selective Debridement (CPT 97602) - Documentation to support non-selective debridement should include: • Type of technique utilized i.e., wet-to-moist, enzymatic, abrasion. • Thorough objective assessment of the wound as described in Selective Debridement above. Whirlpool • If the patient uses whirlpool for treatment of a wound prior to receiving selective debridement services for the wound during the same visit , then the whirlpool is not separately reimbursable and should not be billed with modifier 59 unless two separate wounds are treated with the different modalities. • If the patient uses whirlpool for treatment of a wound prior to receiving non-selective debridement services for the wound during the same visit , then the whirlpool is separately reimbursable and may be billed with modifier 59. • Whirlpool can also be completed during the same visit for non-wound care related purposes. It is appropriate to separately bill CPT 97022 when the whirlpool is used for other purposes not involving wound care i.e., facilitation of range of motion activities Unna Boot Application All supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580. High Compression Multi-Layered Bandage Systems The application of the high compression bandage systems (i.e., Profore, Dyna-Flex, Surepress, Setopress, and other similar product systems) are used to primarily treat lymphedema and venous or stasis ulcers. Providers should note that the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare. However, a brief period of patient and/or caregiver education may be medically necessary and reimbursable. Noridian will cover and separately reimburse for the application training when Medicare coverage requirements are met. Further information may be found in the Noridian article titled Billing and Coding: High Compression Bandage System Clarification. Sources:

• Current Procedural Terminology Assistant - May 2002 “Active Wound Care Management;”
• Current Procedural Terminology Manual ;
• IOM Medicare Benefit Policy Manual Publication 100-02, Chapter 15, Sections 100 and 220-230;
• IOM Medicare Claims Processing Manual Publication 100-04, Chapter 5, Sections 20 and 100.7 and Chapter 12 , Sections 30.6 and 40.3;
• National Corrective Coding Initiatives (NCCI) ;
• Change Request 9782 .

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• Debridement
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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.

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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.

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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.

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