Article - Billing and Coding: Wound Care (A55909)

CMS National Coverage PolicyN/AArticle TextThis article addresses the CPT/HCPCS and ICD-10 codes associated with L37228 Wound Care policy. The article is to be used in conjunction with the indications and guidelines provided in L37228Wound Care.The listing of the procedure code does not imply coverage. All the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Determinations (LCDs), applicable National Coverage Determinations (NCDs), and medical necessity.The medical record must clearly show that the criteria under Coverage Indications, Limitations, and /or Medical Necessity provided in L37228 Wound Care have been met.For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Coverage Guidelines:Negative Pressure Wound Therapy(NWPT)Coverage of traditional Negative Pressure Wound Therapy (tNPWT) device/unit/type, or supplies is covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)), and providers should consult their DME LCD for specific coverage, parameters, and guidelines.Billing and Coding Guidelines for Wound CareWound Care (CPT Codes 97597, 97598 and 11042-11047)When hydrotherapy (whirlpool) is billed by a therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a therapist was required to perform this service in the given situation.Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.CPT Codes 97597 and 97598 are considered sometimes therapy codes. If billed by a therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these sometimes therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02,Medicare Coverage Policy Manual, Chapter 7  Home Health Services, Section 10.10  Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled.For Part B, CPT code 97602 has been assigned a status indicator "B"(Bundled) in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare Part B. For Part A, CPT code 97602 is designated as a sometimes therapy service.Documentation must support the CPT/HCPCS Code(s) being billed.CPT code 97026 Infrared is not covered per NCD 270.6 Infrared Therapy Devices.Ultra-sound (97035) for Wound Care and phototherapy-ultraviolet (97028) modalities are not payable per the LCD.Coding GuidelinesDebridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042-11047 (Wound debridements) are reported by depth of tissue that is removed and by surface area of the wound. See CPT Manual for coding guidance: When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.CPT codes 11044 and 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and/or bone.Reasons for DenialPerforming bony debridement in POS other than inpatient hospital, outpatient hospital or ASCBilling of debridement by unqualified personal.