Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the wound care management services described by 1 unit of code 
97597 and 3 units of code 97598 performed on date of service May 17, 2023. 
 
You asked the Plan to pay for 97597 and 97598. You say that 97597 and 97598 should be paid as billed 
because they are supported in the documentation. The Plan denied your request. The Plan says that 97597 and 
97598 are denied because they are not supported in the documentation. 
 
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 (for example, high pressure waterjet with/without suction, sharp selective 
debridement with scissors, scalpel and forceps), open wound, (for example, 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 square 
centimeters or less. 
 
The CPT Code Manual definition of code 97598 is debridement (for example, high pressure waterjet 
with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (for 
example, 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 square centimeters, or part thereof (List separately in addition to 
code for primary procedure). 
 
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 to pay for 97597 and 97598. Our reviewer says that 1 
unit of 97597 and 3 units of 97598 are supported in the documentation. Our reviewer found CPT code 97597 
describes debridement which can be performed by multiple different methods (waterjet or various sharp 
techniques). The CPT description does not state that all the listed debridement methods must be used. The 
provided records in this case document a sharp debridement of biofilm with a scalpel was performed along with 
a wound assessment and instructions for ongoing care for the first 20 square centimeters, as required by the 
CPT description. Records also include documentation of additional debridement up to a total of 79.80 square 
centimeters to meet criteria for the 3 units of 97598. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 97597 and 97598 have been met. Therefore, we decided that the Plan has to pay 
for the wound care management services described by 1 unit of code 97597 and 3 units of code 97598 
performed on date of service May 17, 2023.   

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.