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Wound care coding: What you should know?


Article - Wound care coding: What you should know?

Accurate coding in wound care is necessary, mainly for dressing changes and debridement, so your wound care facility can get optimal reimbursement for services.

Providers need to locate the contractor in your area. When providers provide wound care services for patients with private insurance, providers should obtain policy guidelines similar to those of the Centers for Medicare and Medicaid Services (CMS).

If we break down LCD by sections then you can see what information you should learn and put into practice when providing the services that the policy covers. Providers need to use the policy guidelines to understand and evaluate the documentation process and in adding info into the EHR note template in order to add all of the documentation necessities, and support claims filing in order to meet the medical requirements.

Codes for Dressing Changes

According to CMS, “A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).”

If we check for Medicare, they do not pay separately for dressing changes. Actually, they pay services as part of billable E/M or procedure that frequently occurs on the same Date of Service as the dressing change. Providers should include all topical applications, medications, dressings, and ointments used in the office on this Date of Care in the payment for the procedure or visit.

We all know that it’s not correct to use an Advance Beneficiary Notice of non-coverage to circumvent the issue of bundled payment. It’s only correct to provide an ABN of non-coverage for services that you think that could deny due to the absence of medical necessity. As the cost of the dressing change is bundled with other services billed, it would not right to use an ABN of non-coverage to collect payment for the dressing change.

In terms of defining medical necessity, CMS states, “Providers must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of the medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating practitioner/clinician.”

Reimbursement for Re-evaluation/Reassessment of Wounds

Generally, other than an initial evaluation, the assessment of the wound is an integral part of all wound care services codes, and remember these assessments are not separately billable. Initial wound assessment can receive separate reimbursement from payers by using the E/M code. This does not need a 25 modifier in general unless your carrier state requires.

Debridement Codes

CPT Code 11042

Debridement, subcutaneous tissue. This includes the debridement of the epidermis and dermis, if performed, for the first 20 cm2 or less.

CPT Code 11043

Debridement, muscle, and/or fascia. This includes debridement of epidermis, dermis, and subcutaneous tissue, if performed, for the first 20 cm2 or less.

CPT Code 11044

Debridement, bone. This covers the debridement of epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed, for the first 20 cm2 or less.

CPT Code 11045

Debridement, subcutaneous tissue. This includes the debridement of epidermis and dermis, if performed, for each additional 20 cm2 (list separately in addition to the code for the primary procedure).

CPT Code 11046

Debridement, muscle, and/or fascia. This pertains to debridement of the epidermis, dermis, and subcutaneous tissue, if performed, for each additional 20 cm2. List this separately in addition to the code for the primary procedure.

CPT Code 11047

Debridement, bone. This includes debridement of epidermis, dermis, subcutaneous tissue, muscle, and/or fascia, if performed, for each additional 20 cm2. List separately in addition to the code for the primary procedure.

CPT Code 11055

Paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for a single lesion.

CPT Code 11056

Paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for two to four lesions.

CPT Code 11057

Paring or cutting of benign hyperkeratotic lesion. This pertains to corn or callus for more than four lesions.

CPT Code 97597

Debridement. This pertains to the use of a high-pressure water jet with/without suction or sharp selective debridement (with scissors, scalpel, and forceps) for an open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session of total wound(s) surface area for the first 20 cm2 or less.

CPT Code 97598

Debridement. This covers high-pressure water jet with/without suction or sharp selective debridement (with scissors, scalpel, and forceps) for an open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session of total wound(s) surface area. It pertains to each additional 20 cm2 or part thereof. List separately in addition to the code for the primary procedure.

Wound Care billing finds it difficult to integrate the constant changes and so, outsourcing could prove an effective option. At Medical Billers and Coders, we offer quality wound care billing services nationwide. Give us a call to discuss all your worries related to wound care billing.

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