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 must be documented for all wound care services with objective measurements of ongoing significant benefit or other clear evidence of medical necessity, and the record must indicate the complexity of skills required.
- Documentation for selective debridement must include instruments used (e.g., scalpel, scissors, forceps, high-pressure waterjet) and a thorough objective wound assessment including drainage, color, texture, temperature, vascularity, surrounding tissue condition, and size of target area.
- Documentation for non-selective debridement (CPT 97602) must include the technique used (e.g., wet-to-moist, enzymatic, abrasion) and the same thorough objective wound assessment elements required for selective debridement.
- When therapists deliver wound-care services under a therapy plan, there must be a physician- or NPP-signed certified therapy plan of care based on a thorough evaluation and the services must be billed with the appropriate therapy modifier.
Key Coverage Criteria
- Skilled selective debridement (CPT 97597, 97598) is covered when medically necessary and performed by a physician, NPP, or therapist acting within scope of practice and licensure.
- Skilled non-selective debridement (CPT 97602) is covered when medically necessary and performed by a physician, NPP, or therapist acting within scope of practice and licensure.
- Physical medicine and rehabilitation wound debridement codes (97597, 97598, 97602) may be billed by physicians, NPPs, or therapists when the services are medically necessary skilled debridement.
- An initial wound assessment that is medically necessary may be reimbursable as a separately identifiable E/M service or as a physical therapy initial evaluation (CPT 97161-97163).
- Whirlpool therapy (CPT 97022) is separately reimbursable when used during the same visit before non-selective debridement of the same wound or when used for non-wound-related therapeutic purposes.
- Application supplies for an Unna boot are included in payment for CPT 29580 and the application procedure (CPT 29580) is covered.
2 Active Policies
A53046 — Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services
A53296 — Billing and Coding: Wound Care & Debridement Provided by a Therapist, Physician, NPP or as Incident-to Services
Related Codes
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