Wound care coding guidelines 2024

Many people involved in wound care, like manufacturers, hospital departments, and doctors, often don't realize how important it is to focus on coding, payment, and coverage. Healthcare workers need to know the special rules for coding wound care properly, as set by the Centers for Medicare and Medicaid Services (CMS). Not sticking to these rules can lead to hefty penalties. So, healthcare pros need to know how to code wound care correctly, ensuring they bill accurately and follow the rules. Proper coding means carefully understanding CPT codes and their instructions. Some codes cover a whole session or a specific area, not just one wound or site. It's crucial to pay attention to these details! This comprehensive guide explores the nuances of mastering wound care coding, focusing on CMS guidelines and best practices for accurate coding and optimal patient outcomes.

Mastering Wound Care Coding: A Comprehensive CMS Guide

The essentials for the wound care coding

To excel in wound care coding, healthcare professionals should adhere to several fundamental principles:

Understand wound care details mentioned in documents

The type of wound and method to heal the wound are mentioned in the document. Wounds come in different types, each needing specific care: Acute wounds (happen suddenly, like cuts or burns), chronic wounds (take more time to heal, such as ulcers from pressure, venous issues, or diabetes), surgical wounds (cuts made during surgeries), and traumatic wounds (caused by accidents or injuries). Identifying the right type is crucial for accurate treatment coding.
Wound care offers various methods to help wounds heal. These include cleaning out the bad stuff from the wound (debridement), using special bandages (dressings), applying healing creams (topical agents), and even using vacuum-like therapy (negative pressure wound therapy). Each method has its secret code, and using the right one is crucial for getting the proper payment.

Proper documentation

Proper documentation for getting appropriate reimbursement includes but is not limited to the following:

• It is necessary to attach the complete wound description (Size, appearance, drainage, infection, etc.)
• It is a must to mention the treatment methods or modalities used for wound care.
• Be specific about how the tissues were cut.
• Include details about the healing process, such as the type of dressing required, the time it takes for the wound to progress, and any upcoming appointments or follow-up visits needed.
• Also, mention any additional medical steps taken, such as antibiotics, biopsies, future tests, consultations with specialists, or vascular interventions.

Medical necessity

Doctors and providers must record why they are doing the services for their patients. If there is no clear proof, like test results, that shows a treatment is helping the patient, the medical record should still have strong reasons explaining why the treatment is needed. The record should also show how skilled the healthcare provider needs to be to carry out the treatment.

CPT codes for basic wound care

Here is the bird’s eye view of the common CPT codes for basic wound care:
97597: Procedural code for open wound (e.g., devitalized epidermis and/or dermis, debris, fibrin, biofilm, exudate), debridement (e.g., sharp selective debridement with forceps, scalpel, and scissors), including topical application, use of a whirlpool, wound assessment, when performed and instruction for ongoing care, total wound(s) surface area; first 20 sq cm or less, per session
97598: Code 97598 is an extension of 97597; debridement is performed on wounds larger than the standard size, each additional 20 sq cm of debridement.
97602 Removal of devitalized tissue from the wound, non-selective debridement, excluding anesthesia (e.g., enzymatic, abrasion, wet-to-moist dressings, larval therapy) including topical application, wound assessment, and instructions for ongoing care, per session.
97605: Negative pressure wound treatment, involving topical applications, wound examination, continued care instructions, total wound surface area less than or approximately equal to 50 sq cm, each session
97606: Total wound surface area greater than 50 sq cm.

Acute wound care management codes

Specific codes like 97597, 97598, and 97602 are classified as "sometimes therapy" codes, and healthcare professionals must bill 97597 and 97598 when they are medically necessary. According to the IOM Medicare Claims Processing Manual, these codes can be provided without a specific therapy plan by physicians or NPPs or as incident-to-services. If a non-therapist offers the service, therapy modifiers are not used, and a non-therapy Revenue Code is applied.
However, when therapists administer these services, there must be a certified therapy plan, depending on a detailed evaluation, signed by the treating physician or NPP and billed using the appropriate therapy modifier. When therapists perform wound care management within their licensed scope, they must include the suitable therapy modifier (GN, GO, GP) and the therapy Revenue Code for billing.
These guidelines are crucial to ensure accurate billing and adherence to CMS therapy guidelines outlined in the IOM Medicare Benefit Policy Manual.

Debridement codes and their documentation requirement

When coding for debridement, you should use specific CPT codes (97597, 97598, or 97602) unless the medical records clearly show that a surgical debridement was done.

• Selective debridement CPT codes 97597, 97598

For selective debridement (CPT codes 97597 and 97598), the documentation should clearly state what tools were used, like water jets, scissors, scalpels, or forceps. 97598 code indicates each additional 20 square centimeters of debridement.
The healthcare provider also needs to assess the wound thoroughly, looking at how it drains, its color, texture, temperature, how well it's supplied with blood, the condition of the surrounding tissue, and the size of the area that needs debridement.

• Non-selective debridement CPT code 97602

Code 97602 is a B status indicator, and hence, separate payment is not allowed. For non-selective debridement (CPT code 97602), the documentation should specify the method used, such as wet-to-moist, enzymatic, or abrasion. Just like selective debridement, a careful wound assessment is crucial, considering all the abovementioned factors.
Using CPT code 97602 alongside CPT codes 97597 and/or 97598 for wound care on the same wound on the same day is not the right approach.

Code for Wound Dressing Change

Dressing used on wounds is included in the services covered by CPT codes 97597, 97598, and 97602. You can't charge extra for them separately. You should only give an Advance Beneficiary Notice of Noncoverage (ABN) for services that might get denied because they're not medically necessary. For instance, offering an ABN for a dressing change isn't needed because the cost is already included in other billed procedures.

Whirlpool (Hydrotherapy)

If a patient gets a whirlpool treatment for a wound and later receives selective debridement services for the same wound during the same visit, the whirlpool cannot be charged separately, unless different wounds are treated. However, if non-selective debridement is performed, the whirlpool can be billed separately with a modifier 59.
If the whirlpool treatment is done on the same body part as the wound care, it can't be billed separately. But if it is for a different body part, separate billing is allowed.

Surgical debridement (11000-11012 and 11042-11047)

When doctors clean wounds, they use codes like 11042-11047 based on the depth and area of the tissue removed.
11042: debridement, subcutaneous tissue, includes epidermis and dermis (if performed, for the first 20 cm sq or less)
11043: debridement, muscle, and/or fascia includes the epidermis, dermis, and subcutaneous tissue (if performed, for the first 20 cm sq or less)
11044: debridement, bone includes the epidermis, dermis, subcutaneous tissue, muscle, and/or fascia (if performed, for the first 20 cm sq or less)
11045: debridement, subcutaneous tissue includes epidermis and dermis (if performed, for each additional 20 cm sq)
11046: debridement, muscle, and/or fascia includes the epidermis, dermis, and subcutaneous tissue (if performed, for each additional 20 cm sq)
11047: debridement, bone includes the epidermis, dermis, subcutaneous tissue, muscle, and/or fascia (if performed, for each additional 20 cm sq)
Coding considerations
For a single wound, the deepest level of tissue removed is noted. If multiple wounds have the same depth, their surface areas are added up, but different depths are not combined. These codes are for hospital settings and cover deep tissue cleaning, not for minor procedures like nail trimming or wart removal. Doctors should use the appropriate codes for specific services provided.
Dressings put on wounds are included in codes 11000 to 11012 and 11042 to 11047. You can't bill separately for dressings. If there is a serious infection requiring deep cleaning (codes 11004 to 11008), those are only for inpatient treatments. When dealing with multiple wounds at different levels, the deepest one determines the depth, and areas are added up if they are at the same depth. These codes are for removing damaged tissue from wounds.

Evaluation & re-assessment codes

When a healthcare professional assesses an initial wound, like when you first go to a doctor, they can bill for this service separately if it's medically necessary. They use codes like 97161-97163 for initial physical therapy evaluations. However, if the follow-up visit involves changing the wound dressing without additional procedures, it is usually not covered separately. This routine service might be included with other services like cleaning the wound.

Codes for modalities

29580: Unna boot

CPT code 29580 describes the application of an Unna boot, a type of compression bandage, to manage edema and promote wound healing. This code is specific to the lower extremities and involves the application of the Unna boot, followed by strapping.

29581: Multilayer compression system including ankle and foot

CPT code 29581, on the other hand, relates to the application of a multi-layer compression bandage system for the management of ulcers in the lower extremities. This code is mainly implemented when a healthcare provider applies compression bandages to treat ulcers on the legs or feet, such as venous stasis ulcers.
Note: When patients undergo both wound cleaning and the application of an Unna boot or a multilayer compression dressing, only the cleaning procedure is eligible for reimbursement. However, if only an Unna boot or a multilayer compression dressing without wound cleaning is used, that application qualifies for reimbursement.

97610: Low frequency, non-contact, non-thermal ultrasound

This is a medical procedural code for the application of “low frequency, non-contact, non-thermal ultrasound ” (MIST therapy), including topical application(s), when performed, wound assessment, and instructions for ongoing care, per day, and is maintained by AMA and can be reported once per day during the treatment session.
When using the code for MIST therapy, which involves using low-frequency, non-contact, and non-thermal ultrasound (with the code 97610), you should make sure to keep track of a few essential details:

• Keep a record of how many times you apply topical treatments during each day's MIST therapy session.
• Note when you perform these therapy sessions and how frequently they occur.
• Be sure to assess the wound regularly and document its progress during the treatment.
• Provide instructions for the ongoing care of the wound to ensure it heals properly.

Medicare covers 80% of the expenses of outpatient therapy services, but they only pay based on the lower of two amounts: the actual charge from the healthcare provider or the set fee schedule. Regarding a specific medical code 97610 reimbursement, the payment is already included in the overall payment for treating the same wound using other wound care procedures or cleaning up wounds.
It's important to note that there are no specific codes for the applicator kits used during MIST therapy. These kits are considered consumable items and aren't separately reimbursed.

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