Coding Guidelines

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.  This information does not take precedence over CCI edits.  Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. 

Claims must be submitted with an ICD-9-CM code that represents the reason the procedure was done.  The ICD-9-CM code must be billed to the highest level of specificity for that code set.  The ICD-9-CM code must be linked to the appropriate procedure code. 

Active Wound Care Management – HCPCS 97597, 97598, 97602, 97605, and 97606 

These services may be performed by therapists and non-therapists when permitted by the scope of practice requirements of each state.  If a therapist is performing the service the appropriate modifier—GN, GO, GP—must be added to the CPT code billed.  In addition the therapy Revenue Code must be submitted.  If a non-therapist performs the service, NO modifiers are used and a non-therapy Revenue Code must be submitted.  This is shown in the table below:

Currently, code 97602 is a status B (bundled) code on the MFSDB; therefore, separate payment is not allowed for this service. 

Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not to be billed/reimbursed separately.  Codes 97602, 97605 and 97606 include the application of and the removal of any protective or bulk dressings.  However, if a dressing change is performed without any active wound procedure as described by these codes, these codes should not be reported. 

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.

Generally, 97022 (whirlpool) and 97597/97598 should not be reported during the same encounter since the whirlpool is a component of the 97597/97598 codes.  Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment would the service be allowed. 

Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11040-11044. 

Surgical Debridements -  HCPCS 11000-11001 and 11040-11044 

The debridement code submitted should reflect the type and amount of tissue removed during the procedure and not the depth, size, or other characteristics of the wound.  For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed. 

Dressings applied to the wound are part of the service for CPT codes 11000-11001 and 11040-11044 and they may not to be billed/reimbursed separately. 

The use of CPT codes 11040-11044 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, destruction of warts, or burn debridement.  Report these procedures, when they represent covered, reasonable and necessary services, using the CPT or HCPCS code that most closely describes the service supplied. 

Use of E/M Codes in Conjunction with Surgical Debridements 

E/M codes are not usually billed in conjunction with a debridement procedure.  However, on rare occasions there may be unusual circumstances that may require the use of an E/M code in conjunction with a debridement.  In order for the E/M code to be considered in addition to the debridement the patient must receive either:

• An unexpected or unrelated service or procedure
• Care that is over and beyond the usual preoperative and postoperative care 

The need for both services must be clearly stated in the medical record.