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Billing Guidelines for Wound Care in 2023 – Detailed Guide

As chronic diseases such as diabetes and obesity are becoming more and more common, the demand for wound care services has grown significantly in recent years. However, along with this growth, there has also been an increase in the complexity of billing and coding for wound care services. To ensure proper reimbursement and avoid potential legal issues, healthcare providers need to stay up-to-date with the latest wound care billing guidelines.

As we enter 2023, the landscape of wound care billing is changing rapidly. New rules and guidelines are being introduced, and healthcare providers must stay informed in order to navigate this complex system. This blog will provide an overview of the key billing guidelines that healthcare providers should be aware of when providing wound care services. Moreover, we will reveal some tips and best practices for ensuring accurate and timely billing, as well as strategies for avoiding common billing errors.

So no matter if you are a wound care specialist, a primary care provider, or a billing specialist, this blog will provide valuable insights and resources to help you understand the complex wound care billing guidelines.

Wound Care Billing Guidelines 2023

  1. The process of removing dead or contaminated tissue from a wound to facilitate healing is known as debridement. Debridement is often necessary before applying primary dressings or skin substitutes that will be secured with secondary dressings. Debridement also involves removing foreign materials from the wound. These wound care procedures must be billed when a thorough cleaning of the wound is required.

  2. Only when it is medically necessary and justifiable, the patient should be billed for the repeated removal of damaged tissue in wounds using CPT codes 97597 and 97598

  3. The CPT codes 97597 and 97598 do not have any specific restrictions and can be performed by any healthcare professional authorized to do so within the bounds of their legal authority.

  4. The CPT codes 97597 and 97598 can only be used when there is devitalized tissue, meaning dead cells or tissue. Secretions, regardless of their consistency, do not count as devitalized tissue. Therefore, simply cleaning a wound by removing secretions does not qualify as a debridement service.

  5. The CPT codes 11042-11047 should not be used for washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Instead, healthcare providers should use the appropriate CPT codes that accurately describe the services provided and only report these procedures when necessary and reasonable for coverage.

  6. If a physical therapist bills for hydrotherapy using CPT codes 97597 or 97598 as a part of wound care treatment for removing devitalized and necrotic tissue, their documentation should clearly explain the clinical reasoning behind including hydrotherapy and why the specialized skill set of a physical therapist was necessary for this treatment. This documentation is important to demonstrate the medical necessity of the service and ensure accurate billing.

  7. If the whirlpool treatment (97022) is performed on the same body part as the wound care treatments (97597-97598), it cannot be billed separately. However, if the whirlpool treatment is provided for a different body part than the one receiving wound care treatment, it may be billed separately.

  8. The cost of local infiltration, such as a metatarsal/digital block or topical anesthesia, is already covered in the reimbursement for debridement services and cannot be charged separately. Moreover, if the provider who performs the debridement also administers the anesthesia, it is not eligible for separate payment.

  9. CPT Codes 97597 and 97598 are sometimes considered therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency if part of their Plan of Care. If it is a physician or non-physician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care.

  10. Medicare does not provide separate payments for CPT code 97602, which has been given a “B” status indicator in the Medicare Physician Fee Schedule Database (MPFSDB).

  11. The documentation should support the HCPCS code that is being billed.

  12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound using other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). If other active wound management and/or wound debridement is not performed, low-frequency, non-contact, non-thermal ultrasound treatments can be billed separately.
  13. According to the Local Coverage Determination (LCD), modalities such as Infrared (97026), ultrasound thermal (97035), and phototherapy-ultraviolet (97028) are not payable.

Tips For Optimizing Wound Care Billing

Verify Patient Insurance Coverage:

Before providing wound care services, it is essential to verify the patient’s insurance coverage to ensure that the services provided are covered. This not only helps in preventing claim denials but also ensures timely payment for services provided.

Code Accurately:

Accurate coding is essential for successful wound care billing. It is important to use the correct codes for wound care services, including the appropriate ICD-10 codes for the patient’s condition and CPT codes for the specific services provided.

Document Thoroughly:

Thorough documentation is a must if a healthcare service provider wants to get paid for his wound care services. This includes documenting the patient’s condition, the wound care services provided, and any necessary follow-up care.

Stay Up-to-Date on Billing Regulations:

Billing regulations change very frequently, so it is important to stay up-to-date on any changes that can potentially affect wound care billing.

Constantly Monitor Claims:

It is important to monitor claims constantly to ensure that they are being processed correctly and to address any issues or denials as quickly as possible.

Use Electronic Billing:

Electronic billing can greatly help optimize the wound care billing process while reducing billing and coding errors. Moreover, it helps in speeding up payment for services provided.

Train Staff on Billing Procedures:

Properly training the practice staff on billing procedures is another way to ensure that claims are submitted correctly and promptly.

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