Billing Guidelines

*A. Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings.
2. 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.
*3. CPT 97597 and/or CPT 97598 are typically used for recurrent wound debridements.
*4. CPT 97597 and/or CPT 97598 are not limited to any specialty.

Coding Guidelines
1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.

*2. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047.

*3. CPT code 11044 or CPT code 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC).

4. The following HCPCS codes are considered a dressing and therefore bundled into the procedure.

Q4104 Integra BMWD skin sub
Q4105 Integra DRT skin sub
Q4107 Graftjacket skin sub
Q4108 Integra matrix skin sub
Q4110 Primatrix skin sub
Q4111 Gammagraft skin sub
Q4112 Cymetra allograft
Q4113 Graftjacket express allograf
Q4114 Integra flowable wound matri
*Q4115 Alloskin, per square centimeter
*Q4116 Alloderm, per square centimeter
*Q4117 Hyalomatrix, per square centimeter
*Q4118 Matristem micromatrix, 1 mg
*Q4119 Matristem wound matrix, per square centimeter
*Q4120 Matristem burn matrix, per square centimeter
*Q4121 Theraskin, per square centimeter

• Electrical Stimulation and Electromagnetic Therapy of Specified Wounds

For the purposes of this LCD, wound care is defined as care of wounds that are refractory to healing or have complicated healing cycles either because of the nature of the wound itself or because of complicating metabolic and/or physiological factors. This definition excludes the following:
• management of acute wounds, or

• the care of wounds that normally heal by primary intention such as clean, incised traumatic wounds, or
• surgical wounds that are closed primarily and other postoperative wound care not separately payable during the surgical global period.

Various methods to promote wound healing have been devised over time. Physicians and health care providers must understand that many of these methods are expensive and unproven by valid scientific literature, and would be considered investigational. Wound care involves the evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the modification of treatment when indicated. Wound evaluations may require a comprehensive medical evaluation, vascular evaluation, orthopedic evaluation, functional evaluation, metabolic/nutritional evaluation, and a plan of care. Reduction of pressure and/or control of infection have been shown to facilitate healing and may reduce the need for repeated debridement services.

Medicare coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient’s record that the wound is improving in response to the wound care being provided. Evidence of improvement includes measurable changes in the following:

• Drainage
• Inflammation
• Swelling
• Pain and/or tenderness
• Wound dimensions (surface measurements, depth)
• Granulation tissue
• Necrotic tissue/slough
• Tunneling or undermining

Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The goal of most chronic wound care should be eventual wound closure with or without grafts, skin replacements, or other surgery (such as amputation, wound excision, etc.). Adjunctive measures include but are not limited to appropriate control of complicating factors such as pressure (e.g., off-loading, padding, appropriate footwear), infection, vascular insufficiency, metabolic derangement and/or nutritional deficiency. With appropriate management, it is expected that, in most cases, a wound will reach a state at which its care should be performed primarily by  the patient

and/or the patient’s caregiver with periodic physician assessment and supervision. Wound care that can be performed by the patient or the patient’s caregiver will be considered to be maintenance care. In rare instances, due to severe underlying debility or other factors such as operability, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound.

Dressing Changes for Wound Debridement

• Wet dressings: Water and medication can be applied to the skin with dressings (finely woven cotton, linen, or gauze) soaked in solution. Wet compresses, especially with frequent changes, provide gentle debridement.

• Dry dressings: Used to provide gentle debridement, protect the skin, hold medications against the skin, keep clothing and sheets from rubbing, or keep dirt and air away. Such dressings may also prevent patients from scratching or rubbing the wound.

• Advanced dressings: Used with increasing frequency to provide gentle debridement in the treatment of acute wounds, chronic venous, diabetic and pressure ulcers. A variety of dressings are available including transparent films, foams, hydrocolloids, and hydrogels.

• Dressing changes (removal and subsequent reapplication) alone do not require the skills of physicians, podiatrists, physical therapists, occupational therapists or wound care nurses and in fact are usually performed by non-physician providers.

1. Medicare would expect that wound care may be necessary for the following types of wounds:
o Surgical wounds that must be left open to heal by secondary intention.
o Infected open wounds induced by trauma or surgery.
o Wounds associated with complicating autoimmune, metabolic, vascular or pressure factors.

Active Wound Care Management 

Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Debridement may be categorized as selective or non-selective.

o Wound Care Selective Debridement (CPT codes 97597, 97598) includes:

* Removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue by sharp dissection including scissors, scalpel, curettes, and tweezers/forceps. This procedure typically requires no anesthesia and there is generally no bleeding associated with it.

o Wound Care Non-Selective Debridement (CPT code 97602) includes:

* Blunt Debridement: Blunt debridement is the removal of necrotic tissue by cleansing, scraping, chemical application or wet to dry dressing technique. It may also involve the cleaning and dressing of small or superficial lesions. Generally this is not a skilled service and does not require the skills of a physician, podiatrist, therapist, or wound care nurse.

* Enzymatic Debridement: Debridement with topical enzymes is used when the necrotic substances to be removed from a wound are protein, fiber and collagen. The manufacturer’s product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinician’s responsibility to comply with those guidelines.

* Autolytic Debridement: This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings.

* Mechanical Debridement: Wet-to-dry or dry-to-dry dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-dry dressings should be used cautiously as maceration of surrounding tissue may hinder healing.

Wound Care Surgical Debridements (CPT codes 11000, 11001, 11004, 11005, 11006, 11008, 11010, 11011, 11012, 11042, 11043, 11044, 11045, 11046, and 11047)

o Conditions that may require surgical debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

o Surgical debridement occurs only if material has been excised and is typically reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including but not limited to necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., and should be accomplished to the margins of viable tissue. Surgical excision includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in some cases.

o These procedures can be very effective but represent extensive debridement. They may be complex in nature and may require the use of general anesthesia.

Negative Pressure Wound Care (NPWT), electrically powered (CPT codes 97605, 97606)

o Negative pressure wound therapy (NPWT) is a method of wound care to manage wound exudates and promote wound closure. The vacuum assisted drainage collection (i.e., NPWT) cleanses the wound by removing fluids and stimulates the wound bed, reduces localized edema, and improves local oxygen supply.

o Electrically powered NPWT (CPT codes 97605, 97606) involves the application of controlled or intermittent negative pressure to a properly dressed wound cavity. Suction (negative pressure) is applied under airtight wound dressings to promote the healing of open wounds resistant to prior treatments.

o Electrically powered NPWT (CPT codes 97605, 97606) for nonhealing wounds is medically necessary when at least ONE of the following conditions is met:

* There are complications of a surgically created wound (e.g., dehiscence, post sternotomy disunion with exposed sternal bone, post sternotomy mediastinitis, or postoperative disunion of the abdominal wall).

* There is a traumatic wound (e.g., preoperative flap or graft, exposed bones, tendons, or vessels) and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments (e.g., the individual has comorbidities that will not allow for healing times usually achievable with other available topical wound treatments).

* There is a chronic, nonhealing ulcer with lack of improvement for at least the previous 30 days despite standard wound therapy, including the application of moist topical dressings, debridement of necrotic tissue (if present), maintenance of an adequate nutritional status, and weekly evaluations with documentation of wound measurements (i.e., length, width, and depth) in ONE of the following clinical situations:

– Chronic Stage III or Stage IV pressure ulcer – Chronic diabetic neuropathic ulcer – Chronic venous ulcer Wound care should employ comprehensive wound management including appropriate control of complicating factors such as unrelieved pressure, infection, vascular and/or uncontrolled metabolic derangement, and/or nutritional deficiency in addition to appropriate debridement. Medicare payment for professional wound care procedures requires that all applicable adjunctive measures are also employed as part of comprehensive wound management. Wound care in the absence of such measures, when they are indicated, is not considered to be medically reasonable and necessary.

2. Debridement will be considered not reasonable and necessary for a wound that is clean and free of necrotic tissue or in the absence of abnormal wound healing.

3. Debridements are considered selective or non-selective unless the medical record supports that a surgical excisional debridement was performed.

4. Selective debridement should only be provided under a certified plan of care.

5. Since the overall goal of care is healing and not palliation, it is neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement as outlined in this LCD cannot be shown in two to four weeks.

6. It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues typically do not regrow very quickly. Such debridements performed more frequently than once a week could be subject to medical review. Coverage for prolonged, repetitive debridement services will be considered through the redetermination process.

The medical record must contain adequate documentation of complicating circumstances to support additional services as reasonable and necessary.

7. Autolytic debridement is contraindicated for infected wounds.

8. Debridement of extensive eczematous or infected skin, represented by CPT codes 11000 and 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furnucles, and localized skin infections.

9. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement.

10.Surgical debridement will be considered not reasonable and necessary when documentation indicates the wound is without infection, necrosis, devitalized, fibrotic, nonviable tissues or foreign matter and has pink to red granulated tissue. When utilized, it is expected that the frequency of debridement will decrease over time.

11. Wound debridement utilizing experimental or investigational methods are considered not reasonable and necessary. Therefore, it would not be reasonable and necessary to report these services with any CPT code.

12.Investigational treatments are noncovered by Medicare as not medically necessary. The patient can be requested to pay for investigational treatment under waiver of liability provisions of Medicare law, but an Advance Beneficiary Notice must be obtained for the beneficiary to be liable for such payment.

13.When performed in conjunction with another wound care service, the dressing change is considered an integral component of that service and is not separately billable.

14.A wound that shows no improvement after 30 days requires a new approach, which may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.

15.Procedures performed for cosmetic reasons or to prepare tissues for cosmetic procedures are statutorily excluded from coverage by Medicare.

16.Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia are included in the reimbursement for wound care services and are not separately payable.

17.The following procedures are considered part of an E/M service or wound care management services, and are not separately covered:

o removal of necrotic tissue by cleansing and dressing, including wet or dry-todry dressing changes;
o cleaning and dressing small or superficial lesions; and
o removal of coagulated serum from normal skin surrounding an ulcer.

18.Disposable non-powered mechanical or single use non-electrically powered or battery powered NPWT (CPT codes 97607, 97608) for any indication is considered not medically reasonable and necessary.

19.NPWT is contraindicated for the following wound types/conditions:

o Necrotic tissue with eschar present
o Untreated osteomyelitis
o Non-enteric and unexplored fistulas
o Malignancy in the wound
o Exposed vasculature
o Exposed nerves
o Exposed anastomotic site
o Exposed organs