11042
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.98
Facility
$55.78
Non-Facility
$132.60
Documentation Required
- Claims must include an ICD-10-CM code that represents the reason the procedure was done, billed to the highest level of specificity, and linked to the appropriate procedure code.
- When a therapist performs active wound care management, the appropriate therapy modifier must be added to the CPT code and a therapy Revenue Code must be submitted; when a non-therapist performs the service, no therapy modifier is used and a non-therapy Revenue Code must be submitted.
- Medical record documentation must support use of surgical debridement codes (11000-11012, 11042-11047), including measurements taken after debridement and documentation of depth and surface area when applicable; documentation substantiating depth for CPT 11044 is encouraged.
- When billing an E/M code on the same day as a debridement, documentation must clearly establish that the E/M was a separately identifiable, reasonable and necessary service distinct from the debridement.
Key Coverage Criteria
- Active wound care management CPT codes 97597, 97598, 97605, 97606, 97607, and 97608 are billable when active wound care management services are performed.
- Surgical debridement CPT codes 11000-11012 and 11042-11047 are appropriate to report when surgical removal of devitalized tissue has been performed and the code selected reflects the deepest level of tissue removed.
- Low-frequency, non-contact, non-thermal ultrasound therapy (MIST Therapy) CPT code 97610 is allowable for treatment of a qualifying wound.
- Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done, billed to the highest level of specificity and linked to the procedure code.
- Active wound care management may be billed using CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608 when medical record documentation supports the active wound procedures described by those codes.
- Surgical debridement may be billed using CPT codes 11000-11012 and 11042-11047 when documentation supports surgical removal of devitalized tissue at the depth and surface area indicated by the selected code.
14 Active Policies
L37228 — Wound Care
J05
A55909 — Billing and Coding: Wound Care
J05
A56617 — Billing and Coding: Debridement Services
J06
L33614 — Debridement Services
J06
L37166 — Wound Care
J09
Related Codes
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