Local Coverage Article Billing and Coding

Billing and Coding: Wound Care

A53001

Expand All | Collapse All

Contractor Information

Article Information

General Information

Article ID
A53001
Article Title
Billing and Coding: Wound Care
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
02/10/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2021 American Dental Association. All rights reserved.

Copyright © 2013 - 2022, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

CMS National Coverage Policy

N/A

Article Guidance

Article Text

Refer to Local Coverage Determination (LCD) L35125, Wound 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.

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. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. 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.
  • 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.
  • The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.
    • For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.
  • 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 MLN MM8863, 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 MLN MM8863 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, destruction of warts, or burn debridement. 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.

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. 

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 and Unna boot

All supply items related to the Unna boot are inclusive in the reimbursement for CPT code 29580. When both a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) should not be reported with codes 29580, 29581 for the same anatomic 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.

Coding Information

CPT/HCPCS Codes

Group 1

(25 Codes)
Group 1 Paragraph

Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
CodeDescription
11000 Debride infected skin
11001 Debride infected skin add-on
11004 Debride genitalia & perineum
11005 Debride abdom wall
11006 Debride genit/per/abdom wall
11008 Remove mesh from abd wall
11010 Debride skin at fx site
11011 Debride skin musc at fx site
11012 Deb skin bone at fx site
11042 Deb subq tissue 20 sq cm/<
11043 Deb musc/fascia 20 sq cm/<
11044 Deb bone 20 sq cm/<
11045 Deb subq tissue add-on
11046 Deb musc/fascia add-on
11047 Deb bone add-on
29580 Application of paste boot
29581 Apply multlay comprs lwr leg
97597 Rmvl devital tis 20 cm/<
97598 Rmvl devital tis addl 20cm/<
97602 Wound(s) care non-selective
97605 Neg press wound tx <=50 cm
97606 Neg press wound tx >50 cm
97607 Neg press wnd tx <=50 sq cm
97608 Neg press wound tx >50 cm
97610 Low frequency non-thermal us

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. 

No procedure code to diagnosis code limitations are being established at this time.

Group 1 Codes
CodeDescription
XX000 Not Applicable

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
XX000 Not Applicable

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

CodeDescription
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
074x Clinic - Outpatient Rehabilitation Facility (ORF)
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual, for further guidance.


CodeDescription
027X Medical/Surgical Supplies and Devices - General Classification
036X Operating Room Services - General Classification
042X Physical Therapy - General Classification
043X Occupational Therapy - General Classification
044X Speech-Language Pathology - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
0623 Medical/Surgical Supplies and Devices - Surgical Dressings
0761 Specialty Services - Treatment Room
0977 Professional Fees - Physical Therapy
0978 Professional Fees - Occupational Therapy
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
02/10/2022 R8

Article revised and published on 2/10/2022 to remove outdated MMLN links from the Other URLs section of this article.

01/01/2020 R7

Article revised and published on 01/16/2020 effective for dates of service on and after 01/01/2020. For the following CPT code(s) either the short description and/or the long description has changed. Depending on which description is used in this article, there may not be any change in how the code displays in the document: 97605 and 97607. Minor formatting changes and spelling errors have been corrected throughout the article.

11/21/2019 R6

Article revised and published on 11/21/2019, consistent with CMS Change Request 10901, all coding information from the related LCD has been placed into this article. Due to system changes, the order of the coding section has been revised and new sections for CPT/HCPCS Modifiers and other Coding Information have been added.

04/18/2019 R5

Article revised and published on 04/18/2019 to add the CPT and ICD-10 codes from the related LCD, L35125 Wound Care, in response to CMS Change Request (CR) 10901. Reference to the National Correct Coding guidelines was updated consistent with CMS CR 10868.

11/09/2017 R4

Article published on 11/09/2017 effective for dates of service on and after 11/09/2017 to provide billing/coding information and update the list of CPT codes to reflect the Wound Care final, effective 11/09/2017. This is a revision for the JL Jurisdiction (Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania) and is a new Article for the JH Jurisdiction (Arkansas, Colorado, Louisiana, New Mexico, Mississippi, Oklahoma and Texas).

01/01/2017 R3 Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code either the short description and/or the long description was changed. Depending on which description is used in this Article there may not be any change in how the code displays in the document: 97602.
10/01/2015 R2 Revision due to CPT codes being added back into the Article as they were inadvertently deleted.
10/01/2015 R1 Article revised and published on 01/23/2015 to reflect the annual CPT/HCPCS code updates. HCPCS codes G0456 and G0457 have been deleted and therefore removed from the Article. CPT codes 97607 and 97608 have been added to the Article. For the following CPT/HCPCS code(s) either the short description and/or the long description was changed: 97605 and 97606. Depending on which description is used in this Article, there may not be any change in how the code displays in the document

Associated Documents

Related Local Coverage Documents
LCDs
L35125 - Wound Care
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
02/04/2022 02/10/2022 - N/A Currently in Effect You are here
01/10/2020 01/01/2020 - 02/09/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A