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

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](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c15.pdf)_ , 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](https://www.cms.gov/Regulations-
and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf)_ , 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](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c15.pdf)_ , 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](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c12.pdf)_ , 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](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf)_ Publication 100-02, Chapter 15, Sections 100 and 220-230;



    * IOM _[Medicare Claims Processing Manual](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf)_ Publication 100-04, Chapter 5, Sections 20 and 100.7 and [Chapter 12](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf), Sections 30.6 and 40.3;



    * National Corrective Coding Initiatives [(NCCI)](https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/);



  * Change Request [9782](https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3654CP.pdf).