Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes G2212, 97597, 29580, and 29581 for date of service 
April 3, 2023. 
 
You asked the Plan to pay for codes G2212, 97597, 29580, and 29581. You say that you disagree with the 
Plan's denial. The Plan denied your request. The Plan says the services billed are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also state that providers may bill 
services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 
 
In this case, the CPT Code Manual definition of code G2212 is Prolonged office or other outpatient evaluation 
and management service(s) beyond the maximum required time of the primary procedure which has been 
selected using total time on the date of the primary service; each additional 15 minutes by the physician or 
qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 
99205, 99215, 99483 for office or other outpatient evaluation and management services) (do not report g2212 
on the same date of service as 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 
minutes). 
 
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. 
 
We find that CPT codes G2212 and 97597 are not supported in the medical record. Specifically, the submitted 
medical records do not indicate prolonged office or other outpatient evaluation and management service(s) 
beyond the maximum required time of the primary procedure which has been selected using total time on 
the date of the primary service; each additional 15 minutes by the physician or qualified healthcare 
professional, with or without direct patient contact was performed. An additional time of each additional 15 
minutes should be documented in the medical records. The medical records submitted do not indicate that 
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 was performed; therefore, code 97597 is not 
supported. 
 
In this case, we have confirmed that code 29580 is a column II code to column I code 97597. We have also 
confirmed that code 29581 is a column II code to column I code 97597. While code 29581 was billed with 
modifier -59, the medical records provided do not show that the service billed with the -59 modifier is a distinct 
procedural service. Based on this information, we decided that Medicare rules for coverage of codes G2212, 
97597, 29580, and 29581 have not been met. Therefore, we decided that the Plan does not have to pay for 
codes G2212, 97597, 29580, and 29581 for date of service April 3, 2023.