Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound debridement services coded as 97598 and 97597 
provided February 18, 2022. 
 
You asked the Plan to pay for the wound care services. You say that the medical records provided support the 
necessity of the services in dispute. The Plan denied your request. The Plan says LCD Part B missing or invalid 
diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97597 is debridement (eg, 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 and for 97598 is debridement (eg, 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; each 
additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the wound care services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our reviewer 
found the review indicates that the enrollee presented on February 18, 2022 for further evaluation and 
management of frostbite with hemorrhagic bullae of right hand. Superficial frostbite of right hand, initial 
encounter. Superficial frostbite of left hand, initial encounter procedures: wound #1 pre-procedure diagnosis of 
wound #1 is an atypical located on the right hand- palm. There was a selective/open wound non-viable tissue 
debridement with a total area of 132 sq cm. With the following instrument(s): curette, forceps, and scissors to 
remove non-viable tissue/material. Material removed includes callus and other: de-roofed blisters. No 
specimens were taken. A time out prior to the start of the procedure. A minimum amount of bleeding was 
controlled with pressure. The procedure was tolerated well. Post debridement measurements:11cm length x 
12cm width x 0.1cm depth; 10.367cm^3 volume. Character of wound/ulcer post debridement is improved. 
Wound #2 pre-procedure diagnosis of wound #2 is an atypical located on the left hand -palm. There was a 
selective/open wound non-viable tissue debridement with a total area of 20 sq cm. With the following 
instrument(s): curette, forceps, and scissors to remove non-viable tissue/material. Material removed includes 
callus and other: de-roofed blisters. No specimens were taken. A time out was conducted at 14:00, prior to the start of the procedure. A minimum amount of bleeding was controlled with pressure. The procedure was 
tolerated well. Post debridement measurements: 8cm length x 11cm width x 0.1cm depth; 6.912cm^3 volume. 
Character of wound/ulcer post debridement is improved. The review has determined that the Plan paid for 
99213. The records did not support that the enrollee met the medically necessary criteria for Medicare coverage 
for codes 97598 and 97597. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the wound care services have not been met. Therefore, we decided that the Plan 
does not have to pay for wound debridement services coded as 97598 and 97597 provided February 18, 2022.