Procedural Coding for Wound Care Management – Medicare and PMR Billing Guidelines

by | Published on Nov 9, 2017 | Medical Coding News (A), Resources | 0 comments

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Approximately 6.5 million Americans suffer the effects of chronic wounds every day, according to a recent report from Hutch News. A study published in the Journal of Hospital Administration in 2013 reported that wound care services represent a large percentage of reimbursement income for hospital facilities and physicians. Most people with chronic wounds are also under treatment for chronic diseases such as diabetes and obesity, which greatly increase the risk of damage to the skin. From the perspective of a medical coding service provider, the definition of wound care covers wound treatment as well as evaluation and management (E/M).

Wound care involves treatment for various types of damage to the skin and includes:

  • Assessment, management, and cleansing of the wound
  • Simple debridement; and
  • Removal and reapplication of the wound dressings

In-depth understanding of skin anatomy, the codes for wound care services, and documentation requirements are necessary to ensure accurate reporting of wound care services.

Active wound care procedures involve removing devitalized and/or necrotic tissue to promote healing. Medicare’s definition of debridement is: “The removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.” Codes must be assigned based on the deepest level of tissue debrided or removed first, and the total surface area second.

CPT Codes for Active Wound Care Management

  • Wounds not involving subcutaneous tissue
    97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, 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, total wound(s) surface area; first 20 sq cm or less
    +97598   each additional 20 sq cm, or part thereof (these should be list separately in addition to code for primary procedure)


  • Wounds involving subcutaneous tissue
    11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed) first 20 sq cm or less
    +11045   each additional 20 sq cm, or part there of (List separately in addition to code for primary procedure)
  • Wounds involving muscle and/or fascia
    11043 Debridement, muscle and/or fascia (includes epidermis and dermis and subcutaneous tissue, if performed); first 20 sq cm or less
    +11046 each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
  • Wounds involving bone
    11044 Debridement, bone, (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
    +11047 each additional 20 sq cm, or part there of (List separately in addition to code for primary procedure)

Point to Note: Multiple wounds debrided to the same depth

  • If multiple wounds are all debrided to the same depth, the combined measurements of the debrided surface should be used to determine the appropriate code(s)
  • The total surface area of each debrided wound must be documented separately
  • Each debridement may not be reported separately, unless performed on different tissue types.

Medicare Billing Guidelines for CPT Codes 97597, 97598 and 11042-11047

  • Active wound care procedures and debridement services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.
  • 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).
  • CPT codes 97597 and/or 97598 are typically used to bill recurrent wound debridements when medically reasonable and necessary.
  • These two CPT codes are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.
  • CPT codes 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). The mere removal of secretions (cleansing of a wound) does not represent a debridement service.
  • CPT codes 11042-11047 are not appropriate to report the following services: washing bacterial or fungal debris from lesions, 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. These procedures should be reported when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

Physical Medicine and Rehabilitation (PM&R) Codes – 97597, 97598, 97602)

  • CPT Codes 97597, 97598 and 97602 are considered “sometimes” therapy codes.
  • A physician, NPP or therapist 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 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 physicians/NPPs treatment plan they should be billed without a therapy modifier.
  • When wound care services are delivered by therapists, there must be a physician certified therapy plan of care based on a thorough evaluation signed by the treating physician or NPP.
  • CPT 97597, 97598 and 97602 must only be billed for services that include medically necessary skilled debridement services.
  • CPT code 97602 Removal of devitalized tissue from wound(s), non-selective debridement without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion) including topical application(s), wound assessment, and instruction(s) for ongoing care, per sessionis not separately payable.
  • Documentation must support the HCPCS being billed.
  • Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598).
  • Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

Evaluation/Re-assessment is Included in Wound Care Service

  • It is generally inappropriate to report an evaluation and management (E/M) service in addition to a wound care service (e.g., debridement, application of an Unna’s boot, etc.).
  • E/M can be reported in conjunction with would care if, during the wound care encounter, the provider performs (and documents) a significant, separately identifiable service. The E/M service must be unrelated to the scheduled visit for wound care and require medical evaluation and treatment over and above that for the wound care.
  • If E/M service is reported in addition to wound care, append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Documentation Essentials

An AAPC report lists the essentials of wound care documentation as follows:

  • Description of the wound, including size (length x width); depth; total sq cm; appearance; drainage; undermining; peri-wound character; presence of edema, infection, and disease causing underlying problems or complication(s) for the wound healing process.
  • Description of the method of debridement (scalpel, nippers, scissors, curette), and which deepest layer of tissue was removed or debrided (fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm; subcutaneous tissue; muscle and/or bone).
  • Clear description of the tissue being cut away in the chart notes.
  • Specification of which dressings were applied, post-op care instructions provided, progress of the wound, and on follow-up visit notes, future plans.
  • Description of wound improvement or measurable changes (e.g., decrease in drainage, inflammation, necrotic tissue or slough, pain, swelling, wound dimension changes, or declining improvement). Steps done to address the new condition might include oral antibiotics, further testing, biopsy of the wound, consultations requested for vascular intervention, or podiatric consultation for bracing or off-loading.

Coding Errors to Watch Out For

According to a Medscape article, the common issues that can lead to claim denial for wound care services include:

  • Inappropriate use of modifier 25, that is, whether there is a separately billable service
  • Not taking add-on codes into consideration, especially with wound dimensions for the debrided area
  • Use of hyperbaric oxygen when all other wound management modalities have failed not accompanied by physician orders for the procedure
  • Lack of or poorly documented wound dimensions
  • Confusing selective and nonselective debridement
  • Coding multiple layers of debridement per site instead of coding the deepest layer for debridement (for e.g., bone and muscle debridement cannot be coded together for the same site)
  • Coding dressing of wounds separate from an E/M service.

With the complexities involved in coding and billing wound care services, the support of an expert can be invaluable to ensure proper reimbursement. Skilled coders in medical coding companies are knowledgeable about services provided as well as how they are provided and the management modalities and services that are bundled by payers or packaged for payment.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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