Wound Care & Debridement- Provided by Physician, NPP or as Incident-to Services

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
January 29th, 2016

Medical Necessity

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 medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating practitioner/clinician.

Coding

Proper wound care coding requires careful reading of all Current Procedural Terminology (CPT) code descriptors and related CPT Manual instructions. Providers should note that some codes are per session or per wound surface area, not per wound or site.

Evaluation and Management (E/M) Coding Requirements

*Note: For claims with dates of service prior to January 1, 2014: Hospitals may bill any E/M level within the "established patient" category that corresponds to the resources used in the provision of the covered 99211 service in the specific clinic. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled "Incident To" Clarification for OPPS and CAH Outpatient for additional information.

For claims with dates of service on or after January 1, 2014: Hospitals may only bill HCPCS G0463. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled "Incident To" Clarification for OPPS and CAH Outpatient for additional information.

Physical Medicine and Rehabilitation (PM&R) Codes (i.e. 97597, 97598, 97602)

Dressing Change

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).

Evaluation/Re-assessment

In general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable.

Debridement

Selective Debridement Documentation (CPT 97597 & 97598) – Documentation to support selective debridement should include the following:

Non-Selective Debridement Documentation (CPT 97602) – Documentation to support non-selective debridement should include:

Whirlpool

Unna Boot Application

All supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.

High Compression Multi-Layered Bandage Systems

The application of the high compression bandage systems (i.e., Profore, Dyna-Flex, Surepress, Setopress, and other similar product systems) are used to primarily treat lymphedema and venous or stasis ulcers. Providers should note that the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare. However, a brief period of patient and/or caregiver education may be medically necessary and reimbursable. Noridian will cover and separately reimburse for the application training when Medicare coverage requirements are met. Further information may be found in the Noridian article titled High Compression Bandage System Clarification.

References:

Wound Care & Debridement- Provided by Physician, NPP or as Incident-to Services. (2016, January 29). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/wound-care-debridement-provided-by-physician-npp-or-as-incident-to-services-27717.html

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