97605
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.54
Facility
$21.04
Non-Facility
$42.09
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.
- CPT 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
- CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.
- Non-implantable pelvic floor electrical stimulation (97032 for probes; G0283 for electrode-based delivery) is covered for treatment of stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
20 Active Policies
A55909 — Billing and Coding: Wound Care
J05
L37228 — Wound Care
J05
L33631 — Outpatient Physical and Occupational Therapy Services
J06
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
L37166 — Wound Care
Related Codes
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