Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 97597. We decided that the Plan does not have to pay for 99213 and 
97598.  
 
You asked the Plan to pay for procedure codes 97597, 97598, and 99213 rendered on February 20, 2023.. You 
say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 97597.  
 
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 definition of CPT 97597 is "CPT 97597: 
 
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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 97597. Our reviewer says that the 
documentation supports that this procedure was performed on the date of service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
97597.  
 
We also decided that the Plan does not have to pay for 99213 and 97598. 
 
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 definition of the remaining reported codes 
is: 
 
CPT 97598: 
 
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) 
 
CPT 99213: 
 
Office or other outpatient visit for the evaluation and management of an established patient, which requires a 
medically appropriate history and/or examination and low level of medical decision making. When using time 
for code selection, 20-29 minutes of total time is spent on the date of the encounter 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 97597 and CPT 99213. Our reviewer says that 
CPT 97597 covers the first 20 sq cm of debridement. Per the documented measurements, CPT 97598 was not 
needed to be reported. 
 
 Additionally, the enrollee has been receiving treatment for this condition for five weeks prior to this date of 
service. The office visit reported CPT 99213 was not separately identifiable to these debridement services, as 
the plan of care was already established, and was not changed in the office visit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99213 and 97598 have not been met. Therefore, we decided that the Plan does 
not have to pay for 99213 and 97598. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.