Medicare Wound Care Coding Guidelines 2022

Medicare updates any billing and coding revision through local coverage articles for a clear understanding of Medicare coverage and to avoid billing errors. In this article, we shared Medicare revised wound care coding guidelines 2022 taken from such local coverage articles. Note that procedure codes mentioned in this article may be subject to Correct Coding Initiative (CCI) edits and these revised guidelines do not take precedence over CCI edits.

Also, note that the use of NCCI-associated modifiers should NOT be used to bypass a procedure-to-procedure (PTP) edit unless the proper criteria for use of the modifier are met. Ensure that documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Active Wound Care Management

• Active wound care management can be defined by procedure codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608.
• Currently, code 97602 is a status B (bundled) code on the Medicare Fee Schedule for physician’s services (MFSDB); 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 (GN, GO, GP) to the CPT code billed. In addition, the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service.
• For debridement codes 97597, 97598, or 97602:
  • Debridements 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. The wound depth debrided determines the appropriate code.
  • For example, when only biofilm on the surface of muscular ulceration is debrided, then codes 97597-97598 would be appropriate. But if muscle substances were debrided, 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.
• Generally, the 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 Debridements

• Surgical Debridements can be defined by procedure 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.
• The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.
  • For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.

• CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.
  • Use appropriate modifiers when more than one wound is debrided on the same day.
  • CMS will continue to recognize the -59 modifier, a modifier used to define a ‘Distinct Procedural Service,’ but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. You can refer to CMS Medicare Learning Network MM8863 for more information.

• The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision, and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.
• The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.
• For example, CPT code 11042 defined as “debridement, subcutaneous tissue” should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.
• Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.
  • For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.

• The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating the depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.
  • For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.

E/M Codes in Conjunction with Surgical Debridements

E/M codes are not usually billed in conjunction with a debridement procedure. When providing and billing surgical debridement, the surgical debridement service is to include: the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. When a ‘reasonable and necessary’ E/M service is provided and documented on the same day as a debridement service, it is payable by Medicare when the documentation clearly establishes the service as a "separately identifiable service" that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.

Low frequency, non-contact, non-thermal ultrasound (MIST Therapy) (CPT code 97610)

One 97610 service per day is allowable for a qualifying wound. CPT Code 97610 is not separately reportable for treatment of the same wound on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).

Debridement and Unna boot

All supply items related to the Unna boot are inclusive in the reimbursement for CPT code 29580. When both a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) should not be reported with codes 29580, 29581 for the same anatomic area.

Debridement including removal of foreign material at the site of an open fracture or open dislocation may be reported with CPT codes 11010-11012. Since these codes would be reported with a CPT code for the treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.

As mentioned earlier, we referred local coverage document to share Medicare wound care coding guidelines for 2022. You can refer to the original Medicare document for a detailed understanding.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. Our wound care coding experts stay on top of coding updates and revisions to avoid claim denials. Whether government payers or private payers, our billers and coders ensure accurate insurance collections for your wound care practice. To know more about our wound care billing services, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.

Reference: Billing and Coding: Wound Care (A55818)

CPT Code: Copyright 2022 American Medical Association