CPT codes 11042, 11043, 11044, 97597, 97602 - Debridement tissue wound care

procedure code and description

11042-Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 square cm or less.  - average fee payment- $120 - $130

11045 (add-on code for 11042) each additional 20 square cm, or part thereof.

 11043 Debridement, muscle and/or fascia (includes epidermis, dermis and subcutaneous tissue, if performed); first 20 square cm or less.

11046 (add-on code for 11043) each additional 20 square cm, or part thereof.

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 square cm or less. procedure  +11047 (add-on code for 11044) each additional 20 square cm, or part thereof.

97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS


Indications

The scope of this LCD does not address debridement of burns (CPT codes 16020-16030) or negative pressure wound therapy (NPWT) (CPT codes 97605 and 97606). This LCD also does not address debridement of extensive eczematous or infected skin, debridement for necrotizing soft tissue infection, or debridement for removal of foreign bodies, including prosthetic materials or mesh (CPT codes 11000 – 11012).

Debridement techniques are performed to remove all tissue necessary to establish a viable margin, thus promoting healing. In addition to necrotic tissue, tissue necessary to establish a viable margin includes senescent cells, rolled skin edges, undermined edges, and abnormal granulation tissue.


Surgical Debridement (CPT 11042-11047)

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 necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., 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. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement. Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97022, 97036, 97597, 97598, or 97602).

Surgical debridement codes as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia.


Selective Debridement (CPT 97597 and 97598)

Selective debridement refers to the removal of specific, targeted areas of devitalized tissue or tissue that limits healing from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. Coverage includes:

Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors and tweezers/forceps may be used and only clearly identified necrotic/devitalized tissue is removed. Generally, there is no bleeding associated with this procedure.

High pressure water jet Pulsed lavage (nonimmersion hydrotherapy) is an irrigation device, 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.

Because coverage under these CPT codes is dependent upon total surface area (in square centimeters), documentation should include this measurement. See 'Documentation' section for details.

Non-Selective Debridement (97022, 97036, 97602)

CPT 97022 and 97036 - Immersion hydrotherapy is only covered as a SOLE method of debridement for Stage 3 or 4 decubiti.

CPT 97602 - See Limitations


Repair and Tissue Transfer

The CPT Manual classifies repairs (closure) (CPT codes 12001- 13160) as simple, intermediate, or complex. If closure cannot be completed by one of these procedures, adjacent tissue transfer or rearrangement (CPT codes 14000-14350) may be utilized. Adjacent tissue transfer or rearrangement procedures include excision (CPT codes 11400-11646) and repair (12001-13160). Thus, CPT codes 11400-11646 and 12001-13160 should not be reported separately with CPT codes 14000-14350 for the same lesion or
injury.


Additionally debridement necessary to perform a tissue transfer procedure is included in the procedure. It is inappropriate to report debridement (e.g., CPT codes 11000, 11042-11047, 97597, 97598) with adjacent tissue transfer (e.g., CPT codes 14000- 14350) for the same lesion/injury.

Skin grafting in conjunction with a repair or adjacent tissue transfer is separately reportable if the grafting is not included in the code descriptor of the adjacent tissue transfer code.

Adjacent tissue transfer codes should not be reported with the closure of a traumatic wound if the laceration is coincidentally approximated using a tissue transfer type closure (e.g., Zplasty, W-plasty). The closure should be reported with repair codes. However, if the surgeon develops a specific tissue transfer to close a traumatic wound, a tissue transfer code may be reported.

Procurement of cultures or tissue samples during a closure is included in the repair or adjacent tissue transfer codes and are not separately reportable.

I. Grafts and Flaps

CPT codes describing skin grafts and skin substitutes are classified by size, location of recipient area defect, and type of graft or skin substitute. For most combinations of location and type of graft/skin substitute, there are two or three CPT codes including a primary code and one or two add-on codes. The primary code describes one size of graft/skin substitute and should not be reported with more than one unit of service.

Larger size grafts or skin substitutes are reported with add-on codes.

The primary graft/skin substitute codes (e.g., 15100, 15120, 15200, 15220) are mutually exclusive since only one type of graft/skin substitute can be utilized at an anatomic site. If multiple sites require different types of grafts/skin substitutes, the different graft/skin substitute CPT codes should be reported with anatomic modifiers or modifier 59 to indicate the different sites.

Simple debridement of a skin wound (CPT codes 11000, 11042-11045, 97597, 97598) prior to a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT codes 15050-15431) and should not be reported separately. If the recipient site requires excision of open wounds, burn eschar, or scar or incisional release of scar contracture, CPT codes 15002-15005 may be separately reportable for certain types of skin grafts/skin substitutes.

1. A CPT Manual instruction following CPT code 67911 (Correction of lid retraction) states that autogenous graft CPT codes (20920, 20922, or 20926) may be reported separately. All other services necessary to complete the procedure are included.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing.

    Debridement services will be considered medically reasonable and necessary when they are provided for the management of wounds and ulcers of the skin and underlying tissue to promote optimal wound healing or to prepare sites for appropriate surgical intervention. The requirements for reasonable and necessary service(s) include safe and effective debridement methods most appropriate to the type of wound, furnished in the appropriate setting, and ordered and/or performed by qualified personnel.

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

This policy does not address metabolically active human skin equivalent/substitute dressings, burns, skin cancer or hyperbaric oxygen therapy.

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 coverage for WOUND CARE on a continuing basis for a particular wound in a patient requires documentation in the patient's record that the wound is improving in response to the WOUND CARE being provided. It is not medically reasonable or necessary to continue a given type of WOUND CARE if evidence of wound improvement cannot be shown.

Evidence of improvement includes measurable changes (decreases) of some of the following:


Drainage (color, amount, consistency)
Inflammation
Swelling
Pain
Wound dimensions (diameter, depth, tunneling)
Necrotic tissue/slough

Such evidence must be documented with each date of service provided. A wound that shows no improvement after 30 days requires a new approach which may include physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment.

Debridement is defined as 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. This LCD applies to debridement of localized areas such as wounds and ulcers. It does not apply to the removal of extensive eczematous or infected skin.

Debridements of the wound(s), if indicated, must be performed judiciously and at appropriate intervals. Medicare expects that with appropriate care, wound volume or surface dimension should decrease by at least 10 percent per month or wounds will demonstrate margin advancement of no less than 1 mm/week. Medicare expects the wound-care treatment plan to be modified in the event that appropriate healing is not achieved.

Surgical debridement is excision or wide resection of all dead or devitalized tissue, possibly including excision of the viable wound margin. This is usually carried out in the operating theatre under anesthesia by a surgeon. It is frequently used for deep tissue infection, drainage of abscess or involved tendon sheath, or debridement of bone.

Sharp debridement is the removal of dead or foreign material just above the level of viable tissue, and is performed in an office setting or at the patient's beside with or without the use of local anesthesia. Sharp debridement is less aggressive than surgical debridement but has the advantage of rapidly improving the healing conditions in the ulcer. These typically are the services of recurrent, superficial or repeated wound care.

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 therapist, nurse, wound nurse, or wound continence ostomy nurse (WOCN).

Enzymatic Debridement is debridement with topical enzymes 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.

At least ONE of the following conditions must be present and documented:
Pressure ulcers, Stage III or IV,

Venous or arterial insufficiency ulcers,

Dehiscenced wounds,

Wounds with exposed hardware or bone,

Neuropathic ulcers,

Complications of surgically-created or traumatic wound where accelerated granulation therapy is necessary which cannot be achieved by other available topical wound treatment.

Selective debridement refers to the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps; and selective removal of necrotic tissue by high-pressure water jet. Selective debridement should only be done under the specific order of a physician.

High Pressure Water Jet / Pulsed Lavage: (non-immersion hydrotherapy) is an irrigation device, 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 irrigation.

Debridement is used in the management and treatment of wounds or ulcers of the skin and underlying tissue. Providers should select a debridement method most appropriate to the type of wound, the amount of devitalized tissue, and the condition of the patient, the setting, and the provider's experience.

Debridements of the wound(s), if indicated, must be performed judiciously and at appropriate intervals. With the appropriate care, wound volume or surface dimension should decrease, once the size and depth of involvement and the extent of the undermining has been established. Interim outcomes should be established for the wound. These short-term goals help the clinician recognize wound improvement and serve to confirm the patient's wound-healing response. Medicare expects the wound-care treatment plan to be modified in the event that appropriate healing is not achieved.

The original debridements are typically true surgical debridements. Repeated debridements are not the same service as the original debridement service. However, once the initial debridement of muscle and/or bone has been performed, there typically is no true necrotic muscle or bone remaining. Subsequent surgical debridement of muscle or bone is usually not necessary. If the medical record demonstrates complicating factors are present that contribute to further necrosis of muscle or bone, then subsequent staged surgical debridement of muscle and/or bone may be deemed necessary. The medical records should indicate the complicating factor(s) and the medical management used to control these complications. Staged debridement of muscle and/or bone greater than two additional debridements, should raise the question of whether the complicating factors are controlled adequately. Further debridement of muscle and/or bone may not be justified without adequate control of the underlying condition(s) leading to the complicating factors (i.e. infection, abscess, vascular insufficiency, nutritional compromise, etc.).

Just because there is a Stage IV pressure ulcer, additional debridements are not necessarily bone and/or muscle debridements. The issue in billing for debridement services is not the stage of the wound; it is what procedure is actually being performed. A Stage III or Stage IV pressure ulcer should be billed with the CPT code that describes the service rendered.


Electrical Stimulation and Electromagnetic Therapy 

Care of chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers through use of Electrical Stimulation (ES) or Electromagnetic Therapy (ET) is covered under the limitations detailed in the CMS Pub 100- 03 National Coverage Determination (NCD) Manual, Chapter 1 – Coverage Determination, Part 4, Section 270.1 – Electrical Stimulation (ES) and Electromagnetic Therapy for Treatment of Wounds. Medicare would not expect ES/ET to be used as the initial treatment modality. The use of ES/ET will be covered as part of a therapy care plan only after standard wound therapy has been tried for at least 30 days and there are no measurable signs of healing. Standard wound care includes: optimization of nutritional status, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes: frequent repositioning of a patient with pressure ulcers (usually every 2 hours), off-loading of pressure and good glucose control for diabetic ulcers, establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. Medicare would not expect the treatment of a wound to include both ES and ET. If measurable signs of healing (e.g., decrease in wound size such as surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue) have not been demonstrated within any 30-day period, ES/ET should be discontinued. Additionally, ES/ET must be discontinued when the wound demonstrates a 100 percent epithelialized wound bed. See the CMS policy for full text.

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.

The following services are not considered debridement:

Mechanical Debridement: Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Hydrotherapy (immersion without jets) and wound irrigation (non-pulsated) are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously as maceration of surrounding tissue may hinder healing.

Documentation must support the use of skilled personnel in order to be considered for coverage. While mechanical debridement is a valuable technique for healing ulcers, it does not qualify as debridement services.

Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.

Scraping the base of the wound bed to induce bleeding, following the removal of devitalized tissue, is not considered to be a separately billable service.

Washing bacterial or fungal debris from lesions.

Removal of secretions and coagulation serum from normal skin surrounding an ulcer.

Dressing of small or superficial lesions.

Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and the shoe pressure eliminated may be a small ulcer but generally does not require true debridement unless the breakdown extends significantly into the subcutaneous tissue.

Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate CPT or HCPCS codes.

Removing a collar of callus (hyperkeratotic tissue) around an ulcer is not debridement of skin or necrotic tissue and should not be billed as debridement unless additional partial full skin thickness tissue directly deep to the callus is removed as well.

Negative Pressure Wound Therapy: 

Negative Pressure Wound Therapy (NPWT) 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.

Low Frequency, Non-Contact, Non-thermal Ultrasound:

Low frequency, non-contact, non-thermal ultrasound is a system that uses continuous low frequency ultrasonic energy to atomize a liquid and deliver continuous low frequency ultrasound to the wound bed. This type of therapy is included in the payment for the treatment of the same wound with other active wound care management or wound debridement. Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

Non-Covered Modalities:

The following Non-Selective Debridement Techniques are not separately billable:
Chemical: necrotic tissue is digested by exogenous proteases in the wound (Enzymes, hypertonic saline). Debridement with topical enzymes is used when the necrotic substances to be removed from a wound are protein, fiber and collagen.

Whirlpool: Whirlpool is considered for coverage if medically necessary for the healing of the wound. Generally, whirlpool 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 medial necessity of the whirlpool for the specific wound type. Documentation must support the use of skilled personnel in order to be considered for coverage. 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 whirlpool to facilitate removal of a dressing would not be considered a skilled treatment modality and would not be billable.

Massage: Massage has not been proven to be effective in wound care and will not be considered for coverage.

Ultra-sound deep thermal modality: The effectiveness of this modality has not been proven in wound care; and therefore will not be considered for coverage.

Infrared: CMS Pub100-03 Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 270.6 – Infrared Therapy Devices. Effective for services performed on and after October 24, 2006, the Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act (the Act). The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues.

Noncontact Normothermic Wound Therapy (NNWT): The NNWT is a device reported to promote wound healing by warming a wound to a predetermined temperature. The device consists of a noncontact wound cover into which a flexible, battery powered, infrared heating card is inserted. There is insufficient scientific or clinical evidence to consider this device as reasonable and necessary for the treatment of wounds within the meaning of SSA 1862(a)(1)(A), and will not be covered by Medicare. (CMS Pub 100-03 Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 270.2 – Noncontact Normothermic Wound Therapy (NNWT)).

Blood-Derived Products for Chronic Non-Healing Wounds: Blood is donated by the patient and centrifuged to produce an autologous gel for treatment of chronic, non-healing cutaneous wounds that persists for 30 days or longer and fail to properly complete the healing process… it contains whole cells including white cells, red cells, plasma, platelets, fibrinogen, stem cells, macrophages, and fibroblasts. The PRP is used by physicians in clinical settings in treating chronic, non-healing wounds, open, cutaneous wounds, soft tissue, and bone. Effective August 2, 2012,… platelet-rich plasma (PRP) – an autologous blood-derived product, will be covered only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds… and the patient is enrolled in a clinical trial. Effective March 19, 2008, upon reconsideration, the evidence is not adequate to conclude that autologous PRP is reasonable and necessary and remains non-covered for the treatment of chronic non-healing, cutaneous wounds. Additionally, upon reconsideration, the evidence is not adequate to conclude that autologous PRP is reasonable and necessary for the treatment of acute surgical wounds when the autologous PRP is applied directly to the closed incision, or for dehiscent wounds. (CMS Pub 100-03 Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 270.3 - Blood-Derived Products for Chronic Non-Healing Wounds).

Dressing changes not separately payable.

Phototherapy-ultraviolet used to promote healing of skin disorders will not be considered for coverage for decubitus ulcers. The safety and effectiveness has not been established. (CMS Pub 100-03 Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 270.4 – Treatment of Decubitus Ulcers.

Trimming of callous or fibrinous material from the margins of an ulcer or from feet with no ulcer present is not considered debridement by this Contractor and would not be considered for coverage.

Nutritional counseling.

Documentation time

Administrative tasks

Maintenance wound care is not covered as debridement services.

    Skin Debridement (procedure  codes 11000-11001)

    procedure  codes 11000 and 11001 describe removal of extensive eczematous or infected skin. Conditions that may require 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).

    procedure  code 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.

    Debridement of Necrotizing Soft Tissue Infections (procedure  codes 11004-11008)

    procedure  codes 11004-11006 describe extensive debridement of skin, subcutaneous tissue, muscle, and fascia to treat necrotizing soft tissue infections. Generally, these debridement procedures are performed on high-risk patients. The code descriptor indicates the specific area that receives treatment.

    procedure  code 11008 describes the concurrent removal of a mesh or prosthetic device.

    Surgical Debridement (procedure  codes 11042-11047)

    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 necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., 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. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement. Unless the medical record shows that a surgical excisional debridement has been performed, debridements should be coded with either selective or non-selective codes (97597, 97598, or 97602).

    Surgical debridement codes (11042-11047), as performed by physicians and qualified non-physician practitioners licensed by the state to perform those services,are reported by depth of tissue removed and by surface area of the wound. These codes can be very effective but represent extensive debridement, often painful to the patient, and could require complex, surgical procedures and sometimes require the use of general anesthesia. Surgical debridement will be considered as “not medically necessary” when documentation indicates the wound is without infection, necrosis, or nonviable tissues and has pink to red granulated tissue.

    Documentation for surgical debridement procedures should include the indications for the procedure, the type of anesthesia if and when used, and the narrative of the procedure that describes the wounds, as well as the details of the debridement procedure itself. The procedure  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, procedure  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.

    It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues do not regrow very quickly.

    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. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. It should be billed no more than once per day, regardless of the number of wounds.

    Selective Debridement (97597 and 97598)

    procedure  codes 97597 and 97598 are used for the removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue. Occasional bleeding and pain may occur. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Selective debridement includes:

        Selective removal of necrotic tissue by sharp dissection including scissors, scalpel, and forceps

        Selective removal of necrotic tissue by high pressure water jet

    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 medical 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 would care if evidence of wound improvement cannot be shown.

    Evidence of improvement includes, but is not limited to, measurable changes in at least some of the following:

        Drainage (color, amount, consistency)

        Inflammation

        Swelling

        Pain

        Wound dimensions (diameter, depth, tunneling)

        Granulation tissue

        Necrotic tissue/slough

    Such evidence must be documented with each visit. A wound that shows no improvement after 30 days requires a new approach, which may include a reassessment, by a qualified professional, of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new plan of care or treatment method.

    In rare instances, the goal of wound care provided in the outpatient setting may only be to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve.

    LIMITATIONS

    The following services are not considered to be wound debridement:

        Removal of necrotic tissue by cleansing, scraping (other than by a scalpel or a curette), chemical application, and wet-to-dry dressing.
        Washing bacterial or fungal debris from lesions.
        Removal of secretions and coagulation serum from normal skin surrounding an ulcer.
        Dressing of small or superficial lesions.
        Removal of fibrinous material from the margin of an ulcer.
        Paring or cutting of corns or non-plantar calluses. Skin breakdown under a dorsal corn that begins to heal when the corn is removed and shoe pressure eliminated is not considered an ulcer and does not require debridement unless there is extension into the subcutaneous tissue.
        Incision and drainage of abscess including paronychia, trimming or debridement of mycotic nails, avulsion of nail plates, acne surgery, or destruction of warts. Providers should report these procedures, when they represent covered, reasonable and necessary services, using appropriate procedure  or HCPCS codes.



CPT 97022, 97597 and 97602 are untimed and are only covered as 1 unit per date of service.

Immersion Hydrotherapy (CPT 97022 and 97036) is considered nonselective debridement, but may be used as an adjunct to selective debridement. In such cases, immersion hydrotherapy is considered covered as part of CPT 97597 and 97598 and is not separately payable (i.e., CPT 97022 and 97036 may not be billed).

Immersion hydrotherapy for the sole purpose of dressing removal is noncovered.

CPT 97602 is not routinely a skilled service, therefore, not routinely covered. However, when a caregiver is not available there may be exceptions for coverage (i.e., reasonable and necessary). No additional E/M code is covered in conjunction with CPT 97602 unless a separate and distinct service is provided. There is no coverage when active debridement is not occurring (i.e., lack of devitalized tissue, no progress in removing devitalized tissue; or dressing changes). CPT 97602 includes the following:

Blunt debridement - This type of debridement is defined as 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.

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 Debridment - 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-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

    12 Hospital Inpatient (Medicare Part B only)
    13 Hospital Outpatient
    22 Skilled Nursing - Inpatient (Medicare Part B only)
    23 Skilled Nursing - Outpatient
    71 Clinic - Rural Health
    74 Clinic - Outpatient Rehabilitation Facility (ORF)
    75 Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
    85 Critical Access Hospital


procedure /HCPCS Codes

    11001 Debride infected skin add-on
    11000 Debride infected skin
    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
    97597 Rmvl devital tis 20 cm/<
    97598 Rmvl devital tis addl 20cm/<


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).


Active Wound Care Management Services

The therapy code list contains 5 HCPCS/CPT codes that represent active wound care services, including CPT codes 97602, 97605, 97606, 97597 and 97598. Three of these CPT codes for wound care (97602, 97605, and 97606) were previously noted as “bundled” services for payment purposes under the MPFS and represented “always therapy” services. For CY 2006, these three codes were changed to “sometimes therapy” services. While CPT code 97602 remains a bundled service under the MPFS, CPT codes 97605 and 97606, which represent services for negative pressure wound therapy, are now valued and active codes under the MPFS. Except as noted below for hospitals subject to the OPPS, the requirements for other “sometimes therapy codes apply.

This instruction implements new payment policy for hospitals subject to the OPPS, five wound care HCPCS/CPT codes - 97602, 97605, 97606, 97597, and 97598, and adds the indicator “?”, as a note to the code list. This indicator “?” signifies that these codes represent “sometimes therapy” services and will be paid under the OPPS when (a) the service is not performed by a therapist, and (b) it is inappropriate to bill the service under a therapy plan of care. Wound care provided meeting these two requirements should not be billed with a therapy modifier (e.g., GP, G0, or GN) or a therapy revenue code (e.g., 42X, 43X, or 44X). As for other “sometimes therapy” codes, these services are considered therapy services when rendered by a therapist. They are also considered therapy services when rendered by physicians and nonphysician practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care. When such services are therapy services as noted above, the appropriate therapy modifier is required.

Requirement Number 4226.3 

Requirements  

Fiscal Intermediaries shall advise OPPS providers to not report a therapy modifier (GP, GO, or GN) or a therapy revenue code (42X, 43X, or 44X) when wound care HCPCS/CPT codes 97602, 97605, 97606, 97597, and 97598 services are not performed by a therapist and it is inappropriate to bill the service under a therapy plan of care. In this circumstance, claims will be reimbursed under the Outpatient Prospective Payment System (OPPS).


Requirement Number 4226.5

Requirements 

Medicare contractors shall advise therapists, physicians, and nonphysician practitioners who are not therapists that an appropriate therapy modifier is required to be included on therapy claims. They shall advise providers to include a therapy modifier for services which are always considered therapy services as well as for all those considered “sometimes therapy”, including HCPCS/CPT codes 97602, 97605, 97606, 97597, and 97598, when the services are deemed therapy services,  i.e.,

a. Rendered by a therapist or

b. Rendered by a physician or nonphysician practitioner, including their incident to services, and integral to an outpatient rehabilitation therapy plan of care.

92610+ 92611+ 92612+ 92614+ 92616+ 95831+ 95832+ 95833+ 95834+ 95851+ 95852+ 96105+ 96110+9 96111+9 97001 97002 97003 97004 97010**** 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039*? 97110 97112 97113 97116 97124 97139*? 97140 97150 97530 97532+ 97533 97535 97537 97542 97597+? 97598+?

ICD-10 Codes that Support Medical Necessity


    The diagnoses listed below are applicable to the procedure /HCPCS codes listed above in both Group 1 (Part A) and Group 2 (Part B).
 

    A48.0 Gas gangrene
    B35.0 Tinea barbae and tinea capitis
    B35.1 Tinea unguium
    B35.2 Tinea manuum
    B35.3 Tinea pedis
    B35.4 Tinea corporis
    B35.5 Tinea imbricata
    B35.6 Tinea cruris
    B35.8 Other dermatophytoses
    B35.9 Dermatophytosis, unspecified
    I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
    I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
    I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
    I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
    I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
    I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
    I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
    I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
    I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
    I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
    I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
    I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
    I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
    I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
    I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
    I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
    I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
    I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
    I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
    I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh
    I70.332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf
    I70.333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle
    I70.334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot
    I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site
    I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh
    I70.342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf
    I70.343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle
    I70.344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot
    I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site
    I70.35 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration
    I70.431 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh
    I70.432 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf
    I70.433 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle
    I70.434 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.435 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
    I70.438 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.439 Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
    I70.441 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
    I70.442 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf
    I70.443 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of ankle
    I70.444 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.445 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot
    I70.448 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.449 Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site
    I70.45 Atherosclerosis of autologous vein bypass graft(s) of other extremity with ulceration
    I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh
    I70.532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf
    I70.533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle
    I70.534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh
    I70.542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf
    I70.543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle
    I70.544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot
    I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot
    I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg
    I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site
    I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration
    I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh
    I70.632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf
    I70.633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle
    I70.634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot
    I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot
    I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg
    I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site
    I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh
    I70.642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf

Documentation Requirements

1. The medical record must clearly show that the criteria listed in LCD GSURG-051 under “Indications and Limitation of Coverage and/or Medical Necessity” have been met.

2. There must be a documented plan of care with documented goals and documented provider follow-up present in the patient's medical record. Wound healing must be a medically reasonable expectation based on the clinical circumstances documented.

3. Documentation of the progress of the wound’s response to treatment must be made for each service billed. At a minimum this must include current wound size, wound depth, presence and extent of or absence of obvious signs of infection, presence and extent of or absence of necrotic, devitalized or non-viable tissue, or other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.

4. When debridements are performed, the debridement procedure notes must document tissue removal (i.e. skin, full or partial thickness; subcutaneous tissue; muscle; and/or bone), the method used to debride (i.e., hydrostatic versus sharp versus abrasion methods), and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.

5. When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

CPT CODE FOR Treatment of Ulcers and Symptomatic hyperkeratoses - 11042, 11043, 11044, 97597

For Medicare purposes, an "ulcer" does not exist until there is a partial thickness skin loss involving epidermis with or without dermis. Some authors will define a "pre-ulcer" condition and others even a "Stage 1 Ulcer" (e.g. "Wagner 0") where the skin is still intact. Such changes do not constitute an "ulcer" for Medicare payment purposes under this policy.

Ulcers may develop because of a combination of ischemia, infection, abscess, trauma, prolonged pressure, repetitive stress, edema, and loss of sensation.

The management of skin ulcers includes:
1. Overall medical and surgical treatment of the cause and
2. Meticulous care of the ulcerated skin and other associated soft tissue with application of medications and dressings, and
3. When reasonable and necessary, debridement of the necrotic and devitalized tissue and
4. Offloading of the external pressure source(s).

The management of a symptomatic hyperkeratosis may involve medical treatment, paring or cutting, shaving, excision, or destruction. This policy addresses only the paring or cutting approach.

This policy does not address treatment of burns or debridement of nails. For treatment of burns, including debridement, refer to the CPT 16000 series. For debridement of nails, refer to CPT codes 11720 and 11721.

When the only service provided is the non-surgical cleansing of the ulcer site with or without the application of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s).

CPT codes 11042-11043, 97597 and 97598 describe debridement of relatively localized areas with or without their contiguous underlying structures. These codes are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions.

CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue type; e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (non contiguous) skin and other deeper tissue structures.

When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.

CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider.

As is the case in all unusual and complicated procedures, the use of Modifier 22 may be appropriate to report and describe inordinately complex services performed. When used, the procedure note should contain a separate section that describes the "unusual" nature of the procedure.

When addressing a specific toe(s) or finger(s) use the respective CPT® HCPCS Level II modifier to identify them on the claim.

Other modifiers may include (but are not to be used alone when the more specific above modifiers are needed to clarify the procedure):

LT Left
RT Right
59 Independent Anatomical Site
XE Separate encounter
XS Separate Structure
XP Separate Practitioner
XU Unusual Non-Overlapping Service

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.


CPT/HCPCS Codes

Group 1 Codes:

10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE

10061 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE

11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS

11043 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS

11044 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS

11045 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

11046 DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

11047 DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION

11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS

11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS

97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS

97598 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)





ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION
E10.620* Type 1 diabetes mellitus with diabetic dermatitis
E10.621* Type 1 diabetes mellitus with foot ulcer
E10.622* Type 1 diabetes mellitus with other skin ulcer
E10.628* Type 1 diabetes mellitus with other skin complications
E10.65* Type 1 diabetes mellitus with hyperglycemia
E10.69* Type 1 diabetes mellitus with other specified complication
E11.620* Type 2 diabetes mellitus with diabetic dermatitis
E11.621* Type 2 diabetes mellitus with foot ulcer
E11.622* Type 2 diabetes mellitus with other skin ulcer
E11.628* Type 2 diabetes mellitus with other skin complications
E11.65* Type 2 diabetes mellitus with hyperglycemia
E11.69* Type 2 diabetes mellitus with other specified complication
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.25 Atherosclerosis of native arteries of other extremities with ulceration
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I83.011 Varicose veins of right lower extremity with ulcer of thigh
I83.012 Varicose veins of right lower extremity with ulcer of calf
I83.013 Varicose veins of right lower extremity with ulcer of ankle
I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot
I83.015 Varicose veins of right lower extremity with ulcer other part of foot
I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg
I83.021 Varicose veins of left lower extremity with ulcer of thigh
I83.022 Varicose veins of left lower extremity with ulcer of calf
I83.023 Varicose veins of left lower extremity with ulcer of ankle
I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot
I83.025 Varicose veins of left lower extremity with ulcer other part of foot
I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg
I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation
I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation
I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I87.011 Postthrombotic syndrome with ulcer of right lower extremity
I87.012 Postthrombotic syndrome with ulcer of left lower extremity
I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity
I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity
I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity
I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I96* Gangrene, not elsewhere classified
K12.2 Cellulitis and abscess of mouth
K62.6 Ulcer of anus and rectum
L03.011 Cellulitis of right finger
L03.012 Cellulitis of left finger
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.111 Cellulitis of right axilla
L03.112 Cellulitis of left axilla
L03.113 Cellulitis of right upper limb
L03.114 Cellulitis of left upper limb
L03.115 Cellulitis of right lower limb
L03.116 Cellulitis of left lower limb
L03.211 Cellulitis of face
L03.221 Cellulitis of neck
L03.222 Acute lymphangitis of neck
L03.311 Cellulitis of abdominal wall
L03.312 Cellulitis of back [any part except buttock]
L03.313 Cellulitis of chest wall
L03.314 Cellulitis of groin
L03.315 Cellulitis of perineum
L03.316 Cellulitis of umbilicus
L03.317 Cellulitis of buttock
L03.811 Cellulitis of head [any part, except face]
L05.01 Pilonidal cyst with abscess
L08.0 Pyoderma
L08.89 Other specified local infections of the skin and subcutaneous tissue
L12.0 Bullous pemphigoid
L59.8 Other specified disorders of the skin and subcutaneous tissue related to radiation
L73.8 Other specified follicular disorders
L89.012 Pressure ulcer of right elbow, stage 2
L89.013 Pressure ulcer of right elbow, stage 3
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *For ICD-10-CM codes E10.65, E10.620, E10.621, E10.622, E10.628, E10.69, E11.620, E11.621, E11.622, E11.628, E11.65, E11.69, the "specified manifestation" is skin ulcer. For clarity one should consider adding a 2nd ICD-10 code (L97.111, L97.112,
L97.113, L97.114, L97.121, L97.122, L697.123, L97.124, L97.211, L97.212, L97.213, L97.214, L97.221, L97.222, L97.223, L97.224, L97.311, L97.312, L97.13, L97.314, L97.321, L97.322, L97.323, L97.324, L97.411, L97.412, L97.413, L97.414, L97.421
L97.422, L97.423, L97.424, L97.511
L97.512, L97.513, L97.514, L97.521
L97.522, L97.523, L97.524, L97.811
L97.812, L97.813, L97.814, L97.821
L97.822, L97.823, L97.824, L98.411
L98.412, L98.413, L98.414, L98.421
L98.422, L98.423, L98.424, L98.491
L98.492, L98.493, L98.494) to define the ulcer.


E75.21* Fabry (-Anderson) disease
G60.0* Hereditary motor and sensory neuropathy
G60.1* Refsum's disease
G60.2* Neuropathy in association with hereditary ataxia
G60.3* Idiopathic progressive neuropathy
G60.8* Other hereditary and idiopathic neuropathies
L11.0* Acquired keratosis follicularis
L84* Corns and callosities
L85.0* Acquired ichthyosis
L85.1* Acquired keratosis [keratoderma] palmaris et plantaris
L85.2* Keratosis punctata (palmaris et plantaris)
L85.8* Other specified epidermal thickening
L86* Keratoderma in diseases classified elsewhere
L87.0* Keratosis follicularis et parafollicularis in cutem penetrans
L87.2* Elastosis perforans serpiginosa
Q81.9* Epidermolysis bullosa, unspecified
Q82.8* Other specified congenital malformations of skin
Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation: * The claim must have at least one of the following seventeen diagnosis codes: E75.21, G60.0, G60.1, G60.2, G60.3, G60.8, L11.0, L84, L85.0, L85.1, L85.2, L85.8, L86, L87.0, L87.2 or Q81.9, Q82.8 and one of the following ten diagnosis codes: L03.311, L03.312, L03.313, L03.314, L03.315, L03.316 or M79.671, M79.672, M79.674, M79.675.


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