Billing and Coding: Wound Care

**Coding Guidelines**

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to Correct Coding Initiative (CCI)
edits. This information does not take precedence over CCI edits.  Per CMS
Medicare Learning Network (MLN) Medicare Matters number MM8863, the use of
NCCI-associated modifiers should NOT be used to bypass a procedure-to-
procedure (PTP) edit unless the proper criteria for use of the modifier are
met. Documentation in the medical record must satisfy the criteria required by
any NCCI-associated modifier that is used. Please refer to CCI for correct
coding guidelines and specific applicable code combinations prior to billing
Medicare.

Claims must be submitted with an ICD-10-CM code that represents the reason the
procedure was done. The ICD-10-CM code must be billed to the highest level of
specificity for that code set. The ICD-10-CM code must be linked to the
appropriate procedure code.

Active Wound Care Management - CPT codes 97597, 97598, 97602, 97605, 97606,
97607, and 97608

  * Currently, code 97602 is a status B (bundled) code on the Medicare Fee Schedule for physician's services (MFSDB); therefore, separate payment is not allowed for this service.

  * A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifier (GN, GO, GP) to the CPT code billed. In addition the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. Please see MM10176 for more information.

  * For debridement codes 97597, 97598, or 97602:

    * Debridements should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed. 

    * Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately. 

    * It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service. 

    * Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047. The wound depth debrided determines the appropriate code.

      * For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. But if muscle substance were debrided, the 11043-11046 series would be appropriate, depending on the area. 
  * Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.

  * Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier 59 or a more specific modifier as appropriate (e.g., LT, RT, XS, etc). 

Surgical Debridements - CPT codes 11000-11012 and 11042-11047

  * Dressings applied to the wound are part of the service for CPT codes 11000-11012 and 11042-11047 and may not be billed separately.

  * Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. It is only appropriate to provide an Advance Beneficiary Notice of Non-coverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.

  * Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.

  * The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.

    * For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.

  * CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.

    * Use appropriate modifiers when more than one wound is debrided on the same day.

      * Per MLN MM8863, CMS will continue to recognize the -59 modifier, a modifier used to define a "Distinct Procedural Service," but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. Please see CMS MLN MM8863 for more information.

  * The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.

  * The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.

    * For example, CPT code 11042 defined as "debridement, subcutaneous tissue" should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.

  * Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.

    * For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.

  * The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.

    * For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.

Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical
Debridements

E/M codes are not usually billed in conjunction with a debridement procedure.
When providing and billing surgical debridement, the surgical debridement
service is to include: the pre-debridement wound assessment, the debridement,
and the post-procedure instructions provided to the patient on the date of the
service. When a "reasonable and necessary" E/M service is provided and
documented on the same day as a debridement service, it is payable by Medicare
when the documentation clearly establishes the service as a "separately
identifiable service" that was reasonable and necessary, as well as distinct,
from the debridement service(s) provided.

Low frequency, non-contact, non-thermal ultrasound (MIST Therapy) - CPT code
97610

One 97610 service per day is allowable for a qualifying wound. CPT Code 97610
is not separately reportable for treatment of the same wound on the same day
as other active wound care management CPT codes (97597-97606) or wound
debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).

Debridement and Unna boot

All supply items related to the Unna boot are inclusive in the reimbursement
for CPT code 29580. When both a debridement is performed and an Unna boot is
applied, only the debridement may be reimbursed. If only an Unna boot is
applied and the wound is not debrided, then only the Unna boot application may
be eligible for reimbursement. The National Correct Coding Initiative (NCCI)
Policy Manual for Medicare Services Chapter 4, section G states that
debridement codes (11042-11047, 97597) should not be reported with codes
29580, 29581 for the same anatomic area.

Debridement including removal of foreign material at the site of an open
fracture or open dislocation may be reported with CPT codes 11010-11012. Since
these codes would be reported with a CPT code for treatment of the open
fracture or dislocation, a casting/splinting/strapping code should not be
reported separately.