Billing and Coding: Wound and Ulcer Care

Refer to Local Coverage Determination (LCD) L38904, Wound and Ulcer Care, for reasonable and necessary requirements. The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Coding Guidelines 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. When the only service provided is the non-surgical cleansing of the ulcer site with or without the applications of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s). The debridement codes listed below are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions. Active Wound Care Management – CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608 Currently, code 97602 is a status B (bundled) code for physician’s services; 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 to the CPT code billed. In addition, the therapy Revenue Code must be submitted for that service when performed in a Part A outpatient facility setting. If a non-therapist performs the service, no therapy modifiers are used, and a non-therapy Revenue Code must be submitted for the service if performed in a Part A outpatient facility setting. Please see MM10176 for more information. For debridement codes 97597, 97598, or 97602: Debridement 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 for the same wound. 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. If muscle substance was debrided, then 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. CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider. 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 Debridement – 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. CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue t