Billing and Coding: Wound Care (A55818) (2022)

Article ID
A55818

Article Title
Billing and Coding: Wound Care

Article Type
Billing and Coding


12/07/2017


02/10/2022


N/A


N/A


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Article Guidance

Article Text

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.

FAQs

What is the CPT code for wound care? ›

The wound care (97597-97598) and debridement codes (11042-11047) are used for debridement of wounds that are intended to heal by secondary intention.

What is the CPT code for wound cleaning and dressing? ›

Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary. health care professional acting within the scope of his/her legal authority. 4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material).

What is the coding rule for coding multiple wounds? ›

Documentation guidelines for CPT® codes 11042—11047,

When multiple wounds have the same depth, add together total square centimeters and report one code. For multiple wounds of different depths, report the deepest first and report additional debridement codes with modifier 59.

What is the ICD-10 code for wound care? ›

This article addresses the CPT/HCPCS and ICD-10 codes associated with L37228 Wound Care policy.

Can a nurse bill for wound care? ›

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.

What is the CPT code for wound dressing change? ›

A. The 99211 E/M visit is a nurse visit and should only be used by medical assistant or nurse when performing services such as wound checks, dressing changes or suture removal. CPT code 99211 should never be billed for physician services.

What is the CPT code for wound exploration? ›

CPT® Code 20103 - Wound Exploration-Trauma (eg, Penetrating Gunshot, Stab Wound) Procedures on the Musculoskeletal System - Codify by AAPC.

Does Medicare pay for wound care? ›

Medicare Coverage for Wound Care and Supplies. Original Medicare covers wound care provided in inpatient and outpatient settings. Medicare pays for medically necessary supplies ordered by your doctor. Medicare Part C must provide at least the same amount of coverage as original Medicare, but costs will vary by plan.

Can you bill for debridement and wound vac? ›

For example, if a physician performed debridement of an open wound, did not close the wound, but placed a wound vac at the debridement site to promote healing, a code in the range 97605-97608 could be reportable if appropriately documented.

How do I bill CPT 11045? ›

Rationale: For first 20 sq cm of wound debridement invoving subcutaneous tissue, irrespective of location, we have coded cpt code 11042. For each additional 20 sq cm, or part thereof, an add on code +11045 is used. For 20 sq cm we have code cpt code +11045.

When should you append modifier 91 to CPT code? ›

Modifier 91 is used when multiple, serial laboratory tests are needed in the course of treatment of a patient (e.g., repeat blood glucose tests). Modifier 91 is used when a clinical laboratory test must be repeated on the same date of service and the results are used to assist in managing the treatment of a patient.

When coding wound repairs coders should remember? ›

When coding for wound repair (closure), you must search the clinical documentation to determine three things: The complexity of the repair (simple, intermediate, or complex) The anatomic location of the wounds closed. The length, in centimeters, of the wound closed.

How do you code wound repair? ›

The anatomic location of the wounds closed:

For instance, 12001–12007 refers to simple repairs on the scalp, neck, axillae, external genitalia, trunk, and/or extremities. Codes 12051–12057 indicate intermediate repairs of wounds to the face, ears, eyelids, nose, lips, and/or mucous membranes.

How would you code multiple wound repairs in CPT? ›

Coding Multiple Repairs

When multiple wounds are repaired, check if any repairs of the same classification (simple, intermediate, complex) are grouped to the same anatomic area. If so, per CPT® coding guidelines, the lengths of the wounds repaired should be added together and reported with a single, cumulative code.

What is the ICD-10 code for surgical wound? ›

ICD-10 Code for Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter- T81. 31XA- Codify by AAPC.

What is the ICD-10 code for non-healing surgical wound? ›

998.83 - Non-healing surgical wound | ICD-10-CM.

What is the ICD-10 code for non-healing wound? ›

2. A non-healing wound, such as an ulcer, is not coded with an injury code beginning with the letter S. Four common codes are L97-, “non-pressure ulcers”; L89-, “pressure ulcers”; I83-, “varicose veins with ulcers”; and I70.

What CPT codes can an RN bill for? ›

What codes can an RN bill for? Insurance reimbursement coding is based on the American Medical Association CPT2 coding system. Under that system, the only Evaluation and Management (E/M) code that a Registered Nurse can bill to is 99211.

Can a nurse bill for 99212? ›

A: That depends entirely on what was done and documented. In most cases, the visit would be a level one new patient visit (99201), level two established patient visit (99212), or nurse visit (99211), since only one body area is examined, and the history and/or medical decision-making are straightforward.

What qualifies for a 99211? ›

Code 99211 describes a face-to-face encounter with a patient consisting of elements of both evaluation (requiring documentation of a clinically relevant and necessary exchange of information) and management (providing patient care that influences, for example, medical decision making or patient education).

Does Medicare cover CPT code S0630? ›

2021/2022 HCPCS Code S0630

0088 = "S" CODES ARE UNIQUE TEMPORARY CODES ESTABLISHED BY BCBSA AND HIAA FOR PRIVATE PAYOR USE. THEY ARE NOT VALID NOR PAYABLE BY MEDICARE.

Does Medicare cover CPT code 97602? ›

NOTE: These three codes (97602, 97605, 97606) are “bundled” services and not separately payable by Medicare or billable to the patient.

What is the CPT code 13160? ›

code 13160 (Secondary closure of surgical wound or dehiscence; extensive or complicated), which has a 90-day global period.

What does wound exploration include? ›

"Wound exploration codes focus on the wound that was created traumatically, and minimal repair of that traumatic area. Anything beyond looking around, removing foreign body, and the most basic of repairs, and wound exploration is no longer appropriate," Brame verifies.

Can you bill 25447 and 26480 together? ›

Per the Coder's Desk Reference for CPT 25447 " The trapezium and possibly the base of the first metacarpal are excised and the interposition material, usually either a piece of harvested tendon or fascia, is inserted in the defect." CPT 26480 will always bundle with 25447.

What is active wound care? ›

Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings.

Is wound care considered DME? ›

Because negative pressure wound therapy pumps and supplies are considered DME by Medicare, the qualified healthcare professional is not required to supply the equipment, canisters, dressings, etc.

Does CPT 97597 require a modifier? ›

There are no bilateral T or F modifiers required. Furthermore, if you only bill these two codes together, there is no need to append any modifiers such as a 59 modifier to CPT 97598 when billing with CPT 97597. When it comes to both CPT 97597 and CPT 97598, you should bill these at their full allowed value.

Is PuraPly covered by Medicare? ›

PuraPly™ and PuraPly Antimicrobial (AM)™ Receive Permanent Q-Code, Expanding Medicare Coverage After January 1 to Include Treatment in Private Physician Office Setting.

What is the CPT code for wound dressing change? ›

A. The 99211 E/M visit is a nurse visit and should only be used by medical assistant or nurse when performing services such as wound checks, dressing changes or suture removal. CPT code 99211 should never be billed for physician services.

Does Medicare pay for wound care? ›

Medicare Coverage for Wound Care and Supplies. Original Medicare covers wound care provided in inpatient and outpatient settings. Medicare pays for medically necessary supplies ordered by your doctor. Medicare Part C must provide at least the same amount of coverage as original Medicare, but costs will vary by plan.

When do you use 99211? ›

CPT defines this code as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.” It further states that the presenting problems are usually minimal, and typically five minutes are spent performing or supervising these services.

What is the code for a dressing change? ›

When performed by a physician, dressing changes for burns and debridement of burn tissue should be reported using codes 16020–16030, depending on the size of the burn.

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