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Contractor Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L17543 

LCD Version Number

 

LCD Title

Wound Care

Contractor's Determination Number

04-04-R1

AMA/CPT and ADA/CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 2004 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. CDT-4 codes and descriptions are ©2004 American Dental Association. All rights reserved.

CMS National Coverage Determination

  • Establishment of national policy supersedes all previous contractor policy statements, including Local Coverage Determinations (LCDs).
  • Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
  • Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

Oversight Region

Region III

CMS Consortium

Northeast

Original Determination Effective Date

09/30/2004

Revision Effective Date

10/01/2004

 Indications and Limitations of Coverage and/or Medical Necessity

Description

This policy addresses the care of wounds that are defined as refractory to healing, or have complicated healing cycles either because of the nature of the wound or because of complicating metabolic and/or physiological factors.

Standard wound care includes assessment of a patient's vascular status and correction of any vascular problems in the affected area, controlling infection, optimization of nutritional status (including glucose control), and debridement by appropriate means to remove devitalized tissue.

Staging of Pressure Ulcers: (National Pressure Ulcer Advisory Panel)

·        A stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

·        Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

·        Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

·        Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Non-pressure Ulcers

·        Partial Thickness is the equivalent to a Stage II pressure ulcer and extends through the epidermis and may extend into but not through the dermis.

·        Full thickness is equivalent to a  Stage III or IV pressure ulcer and extends through the epidermis, the dermis and into the subcutaneous tissue.

Indications and Limitations

Medicare would expect that wound care may be necessary for, but not limited to, the following types of wounds:

  • 2nd or 3rd degree burn wounds,
  • Surgical wounds that must be left open to heal by secondary intention,
  • Infected open wounds, induced by trauma or surgery,
  • Wounds associated with complicating metabolic, vascular, or pressure factors,
  • Open or closed wounds complicated by necrotic tissue and eschar, or;
  • Wounds that have various factors which complicate normal healing, such as, subcutaneous fluid and blood collections that require specialized drains or devices.

Wound care involves evaluation and treatment of a wound. Wound care thus involves identifying potential causes of delayed wound healing and modification of treatment as directed by the treating clinician. Determining the agent of delayed wound healing such as vascular disease, infection, diabetes or other metabolic disorders, immunosuppression, unrelieved pressure, radiation injury, and malnutrition will help determine the course of treatment. Evaluations could include comprehensive medical, vascular, orthopedic, podiatric, infectious disease, nursing and physical therapy, and metabolic/nutritional evaluations leading to a treatment plan. The treatment plan may include metabolic corrections including dietary supplementation, specialized wound care, debridement and reconstruction, rehabilitation therapy, possible general, vascular and/or orthopedic surgery, pulsatile lavage with suction, compression therapy and antimicrobial agents.

Wound healing involves several factors and is influenced by the severity of the injury. Partial thickness wounds penetrate the epidermis and involve the dermis. These wounds heal by reepithelialization, which is horizontal movement of epidermal cells across the surface that is injured. Healing also requires collagen synthesis and adequate nutrition. A full thickness wound involves the epidermis and dermis and may include subcutaneous tissue, muscle, tendon, and bone. Full thickness wounds normally heal by means of hemostasis, inflammation, proliferation and maturation.

The coverage of services of nurses and therapists in the performance of wound care will depend on the specific scope of practice formulated by each state. Enterostomal care is beyond the scope of this policy and therefore is not addressed in this policy.

Reasonable and Necessary Wound Care

  • 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. It is neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement cannot be shown in the documentation. Evidence of improvement includes measureable changes in at least some of the following:
    • drainage
    • inflammation
    • swelling
    • pain
    • wound dimensions (length, width, depth, or if a burn, the percent of body surface)
    • granulation tissue
    • necrotic tissue/slough
  • Such evidence should be documented weekly, or at the time of each visit, if visits are less frequent. Generally, a wound that shows no improvement after 30 days requires a new approach , which may include physician reassessment of underlying metabolic, nutritional, infectious or vascular problems inhibiting wound healing, leading to a new treatment approach.
  • In order to be covered under Medicare, a service must be reasonable and necessary. Among the requirements for a reasonable and necessary service are that the service be safe and effective, furnished in the appropriate setting, and ordered and furnished by qualified personnel.
  • In rare instances, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound, when due to severe underlying debility or other factors such as inoperability, it is not expected to improve.

Active Wound Care Management

Active wound care procedures are performed to remove devitalized tissue and promote healing, and involve selective and non-selective debridement techniques.

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. Debridement techniques usually are selective but can be combined with non-selective. Generally, debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. Note: An order for debridement should be written for selective debridement to be performed.

Wound Care Selective - HCPCS 97601

  • Conservative Sharp Debridement: This is the classical method of selective wound debridement. Conservative sharp debridement is a minor procedure that may require topical anesthesia. Scalpel, scissors and tweezers/forceps may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure.
  • High Pressure Hydrotherapy (e.g., whirlpool):  This provides a means where a wound can be submerged in water and an additive agent, if appropriate, for cleansing. Generally, the high pressure water treatments do not require the skills of a therapist to perform. The skills of a therapist may be required to perform an accurate assessment of the patient and the wound to assure the medical necessity of the whirlpool for the specific wound type.
    • Documentation must support the use of skilled personnel in order to be a covered service. The skills, knowledge and judgment of a qualified therapist might be required when the patient's condition is complicated by circulatory deficiency, areas of desensitization, complex open wounds, and fractures.
    • Immersion in the water to facilitate removal of a dressing would not be considered a skilled treatment modality and would not be billable.

Note:    Whirlpool treatment is contraindicated for wounds with venous insufficiency.

  • Lavage (non-immersion hydrotherapy): This is a method of debridement, with or without pulsation, used to provide a water jet to administer a shearing effect to loosen debris within a wound. Some electric pulsatile irrigation devices include suction to remove debris from the wound after it is irrigated. Pulsatile lavage with suction promotes granulation tissue and decreases bacteria in the wound.

Wound Care Non-Selective - HCPCS 97602

The use of HCPCS 97602 is considered a "bundled" service under the Outpatient Prospective Payment System (OPPS). Under the Non-Outpatient Prospective Payments System (Non-OPPS), HCPCS 97602 maybe be billed separately.   This code may be bundled with any therapy code. (See Program Memorandum A-02-129, CR 2503)

  • Blunt Debridement: 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 therapist or 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 manufacturers' product insert contains indications, contraindications, precautions, dosage, and administration guidelines. It would be 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; it is contraindicated for infected wounds.
  • Mechanical Debridement: Wet-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 or desiccation of a healthy wound bed may hinder healing.
  • Hydrotherapy (immersion without jets or agitation) and wound irrigation (non-pulsated) are also forms of mechanical debridement used to remove necrotic tissue. Irrigation at appropriate pressures during dressing changes will promote removal of the wound debris without macerating the surrounding tissue.
    • Documentation must support the use of skilled personnel in order to be a covered service.
    • Immersion in the whirlpool to facilitate removal of a dressing would not be considered a skilled treatment modality and would not be billable.

Dressings

  • There is a vast arena of wound care dressings available.  Clinicians need to be skilled in the indications for each.
  • Dressing changes alone usually do not require the skills of physical therapists or occupational therapists. Documentation must support the need for the skilled intervention.
  • Dressing needs change as the wound(s) heal.
  • Negative pressure dressings: Application of the negative pressure dressing does not generally require the skills of a physical therapist.

Limitations

  • 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.
  • Debridement of the wound(s), if indicated, must be done judiciously and at appropriate intervals. Medicare expects that the frequency of debridement will decrease over time. The frequency of debridement should be determined by the physician in consideration of such features as the wound size and location, and the presence of necrotic, devitalized, or nonviable tissue, or other material in the wound to such a degree that its presence would ordinarily inhibit healing or would promote adjacent tissue breakdown.
  • 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. Wound care that requires synthetic graftskin is covered under the Skin Substitutes LCD.
  • Other adjunctive services to chronic wound care such as skin autografts, allografts, or xenografts, and adjacent tissue rearrangement or transfer are covered on a medically reasonable and necessary basis.
  • 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. 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.
  • This policy does not address the care of wounds that normally heal by primary intention, such as clean, incised traumatic wounds, surgical wounds which are closed primarily, and other postoperative wound care not separately payable during the surgical global period.
  • Electrical stimulation, electromagnetic therapy, hyperbaric oxygen therapy, enterostomal therapy, and skin substitutes are not within the scope of this policy.

Coverage Topic

Outpatient Hospital Services

Bill Type Codes

13X, 21X, 74X, 75X, 83X

Revenue Codes

036X, 042X, 043X, 045X, 049X, 0510, 519, 075X, 0761

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

97001

©

Physical therapy evaluation

97003

©

Occupational therapy evaluation

97601

©

Wound(s) care, selective

97602

©

Wound(s) care, non-selective

© CPT American Medical Association

Does the "CPT 30% Coding Rule" Apply?

N/A

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Medicare is establishing the following limited coverage:

Covered for:

017.00-017.06

 

Skin and subcutaneous cellular tissue 

021.0

 

Ulceroglandular tularemia

022.0

 

Cutaneous anthrax

024

 

Glanders

031.1

 

Cutaneous diseases due to other mycobacteria

039.0-039.9

 

Actinomycotic infections

040.0

 

Gas gangrene

085.1-085.5

 

 Leishmaniasis

116.0

 

Blastomycosis

172.0-172.8

 

Malignant melanoma of skin

173.0-173.8

 

Other malignant neoplasm of skin

174.0-174.9

 

Malignant neoplasm of female breast

175.0

 

Malignant neoplasm of male breast; nipple and areola

198.2

 

Secondary malignant neoplasm of skin

216.0-216.8

 

Benign neoplasm of skin

232.0-232.8

 

Carcinoma in situ of skin

233.0

 

Carcinoma in situ of breast

250.80-250.83

 

Diabetes with other specified manifestations

440.23

 

Atherosclerosis of the extremities with ulceration

440.24

 

Atherosclerosis of the extremities with gangrene

451.0-451.9

 

Phlebitis and thrombophlebitis of upper and lower extremities

454.0-454.2

 

Varicose veins of lower extremities with ulcer and/or inflammation

459.11

 

Postphlebitic syndrome with ulcer

459.13

 

Postphlebitic syndrome with ulcer and inflammation

459.31

 

Chronic venous hypertension with ulcer

459.33

 

Chronic venous hypertension with ulcer and inflammation

608.4

 

Other inflammatory disorders of male genital organs

611.0

 

Inflammatory disease of breast

616.4

 

Other abscess of vulva

616.50-616.51

 

Ulceration of vulva

619.2

 

Genital tract-skin fistula, female

664.00-664.44

 

Trauma to perineum and vulva during delivery

674.10-674.14

 

Disruption of cesarean wound

674.20-674.24

 

Disruption of perineal wound

674.30-674.34

 

Other complications of obstetrical surgical wounds

681.00-681.9

 

Cellulitis and abscess of finger and toe

682.0-682.9

 

Other cellulitis and abscess

683

 

Acute lymphadenitis

685.0-685.1

 

Pilonadal cyst with or without mention of abscess

705.83

 

Hidradenitis

707.00

 

Decubitus ulcer, unspecified

707.01

 

Decubitus ulcer, elbow

707.02

 

Decubitus ulcer, upper back

707.03

 

Decubitus ulcer, lower back

707.04

 

Decubitus ulcer, hip

707.05

 

Decubitus ulcer, buttock

707.06

 

Decubitus ulcer, ankle

707.07

 

Decubitus ulcer, heel

707.09

 

Decubitus ulcer, other site

707.10-707.19

 

Ulcer of lower limbs, except decubitus

707.8

 

Chronic ulcer of other specified sites

730.00-730.20

 

Osteomyelitis, periostitis, and other infections involving bone

872.01

 

Open wound, external, without mention of complication; auricle, ear

872.11

 

Open wound, external, complicated; auricle, ear

873.0-873.1

 

Other open wound of head, scalp, with or without mention of complication

873.41-873.44

 

Other open wound of head, face without mention of complication

873.49

 

 

873.51-873.54

 

Other open wound of head, face; complicated

873.59

 

 

874.8-874.9

 

 

875.0-875.1

 

Open wound of chest (wall); with or without complication

876.0-876.1

 

Open wound of back; with or without complication

877.0-877.1

 

Open wound of buttock; with or without complication

878.0-878.7

 

Open wound of genital organs (external), including traumatic amputation

879.0-879.9

 

Open wound of other and unspecified sites, except limbs

880.00-880.29

 

Open wound of shoulder and upper arm

881.00-881.22

 

Open wound of elbow, forearm, and wrist

882.0-882.2

 

Open wound of hand except finger(s) alone

883.0-883.2

 

Open wound of finger(s)

884.0-884.2

 

Multiple and unspecified open wound of upper limb

885.0-885.1

 

Traumatic amputation of thumb (complete)(partial)

886.0-886.1

 

Traumatic amputation of other finger(s) (complete)(partial)

887.0-887.7

 

Traumatic amputation of arm and hand (complete)(partial)

890.0-890.2

 

Open wound of hip and thigh

891.0-891.2

 

Open wound of knee, leg (except thigh), and ankle

892.0-892.2

 

Open wound of foot except toes(s) alone

893.0-893.2

 

Open wound of toe(s)

894.0-894.2

 

Multiple and unspecified open wound of lower limb

895.0-895.1

 

Traumatic amputation of toe(s) (complete)(partial)

896.0-896.3

 

Traumatic amputation of foot (complete)(partial)

897.0-897.7

 

Traumatic amputation of leg(s) (complete)(partial)

909.2

 

Late effect of radiation

911.1

 

Abrasion or friction burn of trunk

911.3

 

Blister of trunk, infected

911.5

 

Insect bite, nonvenomous, infected

911.9

 

Other and unspecified superficial injury of trunk, infected

912.1

 

Abrasion or friction burn of shoulder and upper arm infected

912.3

 

Blister of shoulder and upper arm infected

912.5

 

Insect bite, nonvenomous, of shoulder and upper arm infected

912.9

 

Other and unspecified superficial injury of shoulder and upper arm, infected

913.1

 

Abrasion or friction burn of elbow , forearm, and wrist; infected

913.3

 

Blister of elbow, forearm, and wrist; infected

913.5

 

Insect bite, nonvenomous, of elbow, forearm, and wrist; infected

913.9

 

Other and unspecified superficial injury of elbow, forearm, and wrist; infected

914.1

 

Abrasion or friction burn of hand(s), except finger(s) alone; infected

914.3

 

Blister of hand(s) except finger(s) alone; infected

914.5

 

Insect bite, nonvenomous, of hand(s), except finger(s) alone; infected

914.9

 

Other and unspecified superficial injury of hand(s) except finger(s) alone; infected

915.1

 

Abrasion or friction burn of fingers, infected

915.3

 

Blister of fingers, infected

915.5

 

Insect bite, nonvenomous, of fingers, infected

915.9

 

Other and unspecified superficial injury of fingers, infected

916.1

 

Abrasion or friction burn of hip, thigh, leg, and ankle; infected

916.3

 

Blister of hip, thigh, leg, and ankle; infected

916.5

 

Insect bite, nonvenomous of hip, thigh, leg, and ankle; infected

916.9

 

Other and unspecified superficial injury of hip, thigh, leg, and ankle; infected

917.1

 

Abrasion or friction burn of foot and toe(s), infected

917.3

 

Blister of foot and toe(s), infected

917.5

 

Insect bite, nonvenomous, of foot and toe(s); infected

917.9

 

Other and unspecified superficial injury of foot and toes, infected

919.1

 

Abrasion or friction burn of other multiple and unspecified sites, infected

919.3

 

Blister of other multiple and unspecified sites, infected

919.5

 

Insect bite, nonvenomous, of other multiple and unspecified sites, infected

919.9

 

Other and unspecified superficial injury of other multiple and unspecified sites infected

941.21

 

Blisters with epidermal loss due to burn (second degree) of ear (any part)

941.23-941.29

 

Burn of face, head, and neck; blisters, epidermal loss (second degree)

941.31

 

Burn of face, head, and neck; full thickness skin loss due to burn (third degree

 

 

NOS) of ear (any part)

941.33-941.39

 

 

942.21-942.25

 

Burn of trunk, blisters, epidermall loss (second degree)

942.29

 

 

942.31-942.35

 

Burn of trunk, full-thickness skin loss (third degree NOS)

942.39

 

 

942.41-942.45

 

Burn of trunk, deep necrosis of underlying tissues (deep third degree) without

 

 

mention  of loss of a body part

942.49

 

 

942.51-942.55

 

Burn of trunk, deep necrosis of underlying tissues (deep third degree) with loss of

 

 

a  body part

942.59

 

 

943.21-943.26

 

Burn of upper limb, except wrist and hand, blisters, epidermal loss (second degree)

943.29

 

 

943.31-943.36

 

Burn of upper limb, except wrist and hand, full-thickness skin loss (third

 

 

degree NOS)

943.39

 

 

943.41-943.46

 

Burn of upper limb, except wrist and hand, deep necross of underlying tissues

 

 

(deep third degree) without mention of loss of a body part

943.49

 

 

943.51-943.56

 

Burn of upper limb, except wrist and hand, deep necrosis of underlying tissues

 

 

(deep third degree) with loss of a body part

943.59

 

 

944.21-944.28

 

Burn of wrist(s) and hand(s); blisters, epidermal loss (second degree)

944.31-944.38

 

Burn of wrist(s) and hand(s); full-thickness skin loss (third degree NOS)

944.41-944.48

 

Burn of wrist(s) and hand(s); deep necrosis fo underlying tissues (deep third

 

 

degree) without mention of loss of a body part

944.51-944.58

 

Burn of wrist(s) and hand(s); deep necrosis of underlying tissues (deep third

 

 

degree) with loss of a body part

945.21-945.26

 

Burn of lower limb, blisters, epidermal loss (second degree)

945.29

 

 

945.31-945.36

 

Burn of lower limb, full thickness skin loss (third degree NOS)

945.39

 

 

945.41-945.46

 

Burn of lower limb, deep necrosis of underlying tissue (deep third degree) without

 

 

mention of loss of a body part

945.49

 

 

945.51-945.56

 

Burn of lower limb, deep necrosis of underlying tissues (deep third degree), with

 

 

loss  of body part

945.59

 

 

946.2

 

Blisters with epidermal loss due to burn (second degree) of multiple specified sites

946.3

 

Full-thickness skin loss due to burn (third degree NOS) of multiple specified sites

946.4

 

Deep necrosis of underlying tissues due to burn (deep third degree) of multiple

 

 

specified sites without loss of a body part

946.5

 

Deep necrosis of underlying tissues due to burn (deep third degree) of multiple

 

 

specified sites with loss of a body part

949.3

 

Full-thickness skin loss due to burn (third degree NOS), unspecified site

949.4

 

Deep necrosis of underlying tissue due to burn (deep third degree) unspecified site

 

 

without loss of a body part

996.52

 

Mechanical complication of prosthetic graft of other tissue not elsewhere classified

997.62

 

Infection (chronic) of amputation stump

998.32

 

Disruption of external operation wound

998.51

 

Infected postoperative seroma

998.59

 

Other postoperative infection

998.6

 

Persistent postoperative fistula, not elsewhere classified

998.83

 

Non-healing surgical wound

 

 

Diagnoses that Support Medical Necessity

N/A

 

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

 

Diagnoses that DO NOT Support Medical Necessity

N/A

Documentation Requirements

  • Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.
  • Signed and dated certification by a physician or non-physician practitioner if services are being performed by a qualified health professional to include the following information:
    • Date of evaluation
    • Start of care date
    • Medical diagnosis with onset date
    • Treatment diagnosis
    • Treatment plan with long and short term goals
    • Character of the wound, such as length, width, depth, color, presence of exudates or necrotic tissue before and after debridement
    • Wound stage
    • Method of debridement
    • Previous therapy administered to include:
      • Date
      • Diagnosis for treatment
      • Modalities administered
        • Periodic (e.g., weekly) progress notes to include current status of the wound, wound measurement, and the treatment provided.
        • Grid reflecting service/HCPCS code, including minutes spent in each service (for therapy sessions), when appropriate
    • It is not appropriate to document wound healing by using a reverse/lower grade. For example, a grade 3 wound should not be described as grade 2 or grade 1 in your documentation during healing.  You must chart the progress by noting an improvement in the characteristics (size dimensions e.g., length, width, depth, or if a burn, the percent of body surface, amount of necrotic tissue, amount of exudate, etc. (AHCPR Pub No. 92-0050)

Utilization Guidelines

  • Medicare will monitor the utilization of this procedure through the Medical Review process.
  • HCPCS codes 97601 and 97602 provide a mechanism for reporting interventions associated with active wound care, but should not be billed in addition to HCPCS codes 11040-11044.
  • HCPCS 97001 would be an allowable service with the start of care.
  • HCPCS 97002 would be a reassessment of the wound and is a part of the description of HCPCS 97601.
  • Use of  97601 and 97602 (Program Memorandum A-02-129, CR 2503)

·        HCPCS 97602 is a packaged service and is not separately paid under the Outpatient Prospective Payment System (OPPS). 

·  The cost of the service is packaged into whatever other service is provided on that date. It is common for HCPCS 97602 to be performed at the time of another physical therapy service and is packaged into payment for the other physical therapy service.

·  If a service coded under HCPCS 97602 is performed at the time of a clinic or emergency visit, the evaluation and management (E/M) service must be documented in accordance with the hospital's documentation guidelines for clinic and emergency visits.

·  If the only service provided to a beneficiary is 97602, the hospital may bill outpatient visit HCPCS 99211. Payment will be packaged into the payment for HCPCS 99211.

·  If a hospital provides and bills for HCPCS 97601 or 97602 and a clinic or emergency department visit, the clinic or emergency visit must be separately identifiable.

  • Debridement of the wound(s) must be performed judiciously and at appropriate intervals. It is rarely necessary to debride a wound more than once daily in the early stages of chronic wound care (approximately the first one to two weeks of care), more than three times a week in the intermediate stages (approximately the second through fourth weeks of care) or more than weekly thereafter.

Sources of Information and Basis for Decision

  • Contractor medical policies
    • Cahaba
    • Mutual of Omaha
    • Palmetto
    • Riverbend
    • TrailBlazer Health Enterprises
  • CareFirst of Maryland Inc, Medicare Part A, “Wound Care by Physical Therapists” Local Medical Policy, 1999
  • Wound Care Centers in Maryland
  • Agency for Health Care Policy and Research, Clinical Practice Guide, Number 15, Publication 95-0653, December 1994.
  • Agency for Health Care Policy and Research, Clinical Practice Guide, Number 3, Publication 92-0047, May 1992.
  • “Wound Management,” PT Magazine of Physical Therapy, February, 2004, pg  60
  • Kloth, Luther C., McCulloch, Joseph M., Wound Healing Alternatives in Management, page 5, 3rd Ed.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from wound care clinics in Maryland.

Start Date of Comment Period

06/08/2004

End Date of Comment Period

07/23/2004

Start Date of Notice Period

08/16/2004

Revision History Number

R1

Revision History Explanation

R1

 

Annual ICD-9 update, ICD-9 code 707.0 expanded to

 

 

5 digits, 707.00-707.09. Per Transmittal 210, CR 3303.

 

 

 

 

 

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 2004 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.