G0463, Hospital outpatient clinic visit for assessment and management of a patient
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical necessity for all services must be documented, preferably with objective measurements of ongoing significant benefit, and the record must indicate the complexity of skills required by the treating clinician.
- Selective debridement (CPT 97597/97598) documentation must specify instruments used and include a thorough objective wound assessment (drainage, color, texture, temperature, vascularity, surrounding tissue condition, and size of targeted area).
- Non-selective debridement (CPT 97602) documentation must state the technique used (e.g., wet-to-moist, enzymatic, abrasion) and include the same objective wound assessment elements required for selective debridement.
- Services provided incident-to must meet incident-to delivery requirements and CPT descriptor requirements, and auxiliary personnel must meet IOM qualification guidelines for hospital staff.
Key Coverage Criteria
- Physicians, NPPs, or therapists acting within their scope of practice and licensure may provide medically necessary skilled debridement and bill CPT 97597, 97598, or 97602.
- Hospital staff may provide wound care including debridement incident-to a physician/NPP when both incident-to service delivery requirements and auxiliary personnel qualification guidelines (IOM Pub 100-02 Ch.15 §§220(A),230.5) are met.
- When therapists deliver wound care, there must be a physician- or NPP-certified therapy plan of care based on a thorough evaluation signed by the treating physician/NPP, and services must be billed with the appropriate therapy modifier.
- Physicians and NPPs may provide CPT 97597, 97598, and 97602 as 'sometimes therapy' services under their treatment plan without a therapy plan of care and may bill these without a therapy modifier.
- Initial medically necessary wound assessments may be billed as a separately identifiable E/M service or as a physical therapy initial evaluation (CPT 97161-97163) when documentation supports medical necessity.
- Whirlpool (CPT 97022) is separately reimbursable when used during the same visit for non-wound-care purposes (e.g., range of motion facilitation) or when used prior to non-selective debridement for the same wound and billed with modifier 59.
1 Active Policy
A53296, Billing and Coding: Wound Care & Debridement Provided by a Therapist, Physician, NPP or as Incident-to Services
Related Codes
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