Billing and Coding: Wound and Ulcer Care

N/A

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 type, e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (noncontiguous) skin and other deeper tissue structures.
• When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.
• 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.
    • Per CMS Change Request (CR) 8863, 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. Please see CMS CR 8863 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, or destruction of warts. 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 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.

Paring and Cutting for the Management of a Symptomatic Hyperkeratosis - 11055-11057

• Codes 11055-11057 represent paring. The medical record must reflect the symptomatic nature of the lesion that makes this a coverable service, as the treatment of asymptomatic hyperkeratotic lesions are within the scope of Routine Foot Care. Please refer to Groups 2 and 3 in the ICD 10 Codes That Support Medical Necessity section for further information.

Use of Evaluation and Management (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.

Consultation services rendered by a podiatrist in a skilled nursing facility are covered if the services are reasonable and necessary and do not come within any of the specific statutory exclusions (NCD 70.2).

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, Total Contact Casting and Unna boot

All supply items related to the Unna boot and Total Contact Casting (TCC) are inclusive in the reimbursement for CPT code 29580 and 29445 respectively. When both a debridement is performed and an Unna boot or TCC is applied, only the debridement may be reimbursed. If only an Unna boot or TCC is applied and the wound is not debrided, then only the Unna boot or TCC application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that casting/splinting/strapping shall not be reported separately if a service from the Musculoskeletal System section of CPT (20100-28899 and 29800-29999) is also performed for the same anatomic area. It may be appropriate to use modifier 59 with these strapping codes if performed in a separate anatomical 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 treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The patient's medical record should indicate the specific signs/symptoms and other clinical data supporting the wound care provided. It is expected that the physician will document the current status of the wound in the patient's medical record and the patient's response to the current treatment.
4. The patient's medical record must contain clearly documented evidence of the progress of the wound's response to treatment at each physician visit. This documentation must include, at a minimum:
• Current wound volume (surface dimensions and depth).
• Presence (and extent of) or absence of obvious signs of infection.
• Presence (and extent of) or absence of necrotic, devitalized, or non-viable tissue.
• Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.
5. Identification of the wound location, size, depth, and stage by description must be documented and may be supported by a drawing or photograph of the wound. Photographic documentation of wounds at initiation of treatment as well as either immediately before or immediately after debridement is recommended. This may be of particular benefit for documentation as an adjunct to written documentation of reasonable and necessary services, which require prolonged or repetitive debridement.
6. Medical record documentation for debridement services must include the type of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound and must correspond to the debridement service submitted. A pathology report substantiating depth of debridement is encouraged when billing for the debridement procedures involving deep tissue or bone.
7. In addition, except for patients with compromised healing due to severe underlying debility or other factors, documentation in the medical record must show:
• There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue, or prepare the tissue for surgical management.
• The extent and duration of wound care treatment must correlate with the patient’s expected restoration potential. If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program. Alternatively, palliative care of the patient and wound may be provided to diminish the probability of prolonged hospitalization, etc. If it is determined that the goal of care is not wound closure, the patient should be managed following appropriate covered palliative care standards.
8. Service(s) must include an operative note or procedure note for the debridement service(s). This note should include the following:
• Medical diagnosis.
• Indication(s) and medical necessity for the debridement.
• Type of anesthesia used, if and when used.
• Wound characteristics such as diameter, depth, undermining or tunneling, color, presence of exudates or necrotic tissue.
• Level/depth of tissue debrided and a description of the types(s) of tissue involved and the tissue(s) removed.
• Vascular status, infection, or evidence of reduced circulation.
• Narrative of the procedure to include the instruments used. When debridements are reported, the debridement procedure notes must demonstrate tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone), the method used to debride (i.e., hydrostatic, sharp, abrasion, etc.) and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.
• Patient specific goals and/or response to treatment.
• Immediate post-op care and follow-up instructions.
• The presence or absence of necrotic, devitalized, fibrotic, or other tissue or foreign matter must be documented in the medical record when wound debridement is performed.
9. The medical record must include treatment goals and physician follow-up. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan. Appropriate modification of treatment plans, when necessitated by failure of wounds to heal, must be demonstrated. A wound that shows no improvement after 30 days may require a new approach. Documentation of such cases may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.
10. Appropriate evaluation and management of contributory medical conditions or other factors affecting the course of wound healing (such as nutritional status or other predisposing conditions) should be addressed in the medical record at intervals consistent with the nature of the condition or factor.
11. Documentation must support the use of skilled personnel with the use of jet therapy and wound irrigation for wound debridement.
12. Documentation for low frequency, non-contact, non-thermal ultrasound services (Mist Therapy) should include documented improvements of pain reduction, reduction in wound size, improved and increased granulation tissue, or reduction in necrotic tissue. The services should be medically necessary based on the provider’s documentation of a medical evaluation of the patient's condition, diagnosis, and plan.
13. When the documentation, or lack thereof, does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

Utilization Guidelines:

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The appropriate interval and frequency of debridement depends on the individual clinical characteristics of the patient and the extent of the wound. The extent and number of services provided should be medically necessary and reasonable based on the documented medical evaluation of the patient's condition, diagnosis, and plan.

With the above in mind, only a minority of beneficiaries who undergo debridements for wound care appear to require more than twelve total surgical excisional debridement services involving subcutaneous tissue, muscle/fascia, or bone in a 360 day period, (five debridements of which involve removal of muscle/fascia, and/or bone) in order to accomplish the desired objective of the treatment plan of the wound. When medical necessity continues to be met and there is documented evidence of clear benefit from the debridements already provided, debridement services may be continued beyond this frequency or time frame. It is similarly unlikely that more than four debridements are needed in a month, i.e. 30 days, and again, continuance of care would depend on evidence of benefit to the patient.