by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
January 29th, 2016
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.
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
- Only physicians and NPPs (Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) can provide and bill CPT 11000 series debridement codes when the services are appropriate and state licensure allows. These may not be provided as incident-to services by hospital staff.
- Services provided by qualified incident-to hospital staff, must meet both the incident-to service delivery requirements and the CPT descriptor requirements for the specific procedure.
*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.
- A physician or NPP that is acting within their scope of practice and licensure may provide debridement services and use the PM&R codes including CPT 97597, 97598 and 97602.
- These codes must only be billed for services that include medically necessary skilled debridement services.
- Hospital staff acting within their scope of practice and/or licensure may provide wound care, including debridement services, incident-to the services of a physician/NPP.
- Staff providing therapy services incident-to the physician treatment plan must meet the qualification guidelines established for auxiliary personnel as described in the Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 230.5 .
- CPT 97597, 97598, 97602 are considered "sometimes therapy" codes according to the IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20 . As such, these treatment codes may be provided without a therapy plan of care by physician/NPPs or as incident-to services. When these "sometimes therapy" services are provided under a physicians/NPPs treatment plan they should be billed without a therapy modifier.
- Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable E/M or procedure code that, commonly but not necessarily, occurs on the same date of service as the dressing change. If not included in another service, the costs associated with dressing changes may be reported as not separately payable.
- All topical applications (e.g. medications, ointments, and dressings) are included in the payment for the procedure codes.
- It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage (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.
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.
- Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable Evaluation and Management (E/M) service or i.e., physical therapy evaluation CPT 97001.
- Re-assessment/re-evaluation of a wound (which may be completed with a dressing change) is generally considered to be a non-covered routine service. An exception would require documentation clearly supporting that there had been a significant improvement, decline, or change in the patient's condition or functional status that was not anticipated in the plan of care and required further evaluation.
- The evaluation must be provided by a physician/NPP or other qualified incident-to hospital staff.
- Patients may be evaluated by the physician/NPP and the follow-up care may then be provided by qualified hospital incident-to staff working under the physician's plan of care. When a physical therapist provides these incident-to follow-up services and provides an initial therapy evaluation (CPT 97001), the documentation must clearly indicate the medical necessity for these additional evaluative services (as compared to the previously completed physician evaluation of the patient's condition) in order to be separately reimbursable.
- An ABN may be given when medical necessity is not supported for the initial therapy evaluation. However, an ABN may not be given when medical necessity is not supported for a follow-up visit since there is no billable therapy code for a routine re-assessment (i.e. routine wound assessment with/without a dressing change).
- While a physician/NPP may not bill a new patient E/M with modifier 25 for any global service, the hospital may bill the E/M. See the IOM, Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.3 .
- Clear description of instruments used for debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps).
- Thorough objective assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridement.
Non-Selective Debridement Documentation (CPT 97602) – Documentation to support non-selective debridement should include:
- Type of technique utilized i.e., wet-to-moist, enzymatic, abrasion.
- Thorough objective assessment of the wound as described in Selective Debridement above.
- If the patient uses whirlpool for treatment of a wound prior to receiving selective debridement services for the wound during the same visit, then the whirlpool is not separately reimbursable and should not be billed with modifier 59 unless two separate wounds are treated with the different modalities.
- If the patient uses whirlpool for treatment of a wound prior to receiving non-selective debridement services for the wound during the same visit, then the whirlpool is separately reimbursable and may be billed with modifier 59.
- Whirlpool can also be completed during the same visit for non-wound care related purposes. It is appropriate to separately bill CPT 97022 when the whirlpool is used for other purposes not involving wound care i.e., facilitation of range of motion activities.
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.