OT wound care

We recently had a hand surgeon come on and so our OT is doing a lot more things that she hasn’t had to bill for before.

She is doing more wound care: debridement, dressing changes, et cetera. We aren’t sure if this is a billable item or if there is a code where we can bill based on time. We found a few codes but aren’t sure of the nuances associated with them or if they are even correct for an OT to bill for.

Medical Necessity
Providers must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating clinician.
Proper wound care coding requires careful reading of all Current Procedural Terminology (CPT) code descriptors and related CPT Manual instructions. Providers should note that some codes are per session or per wound surface area, not per wound or site.
Evaluation and Management (E/M) Codes
Therapists cannot bill E/M codes or the 11000 series codes.
Physical Medicine and Rehabilitation (PM&R) Codes (i.e. 97597, 97598, 97602)
· Therapists that are acting within their scope of practice and licensure may provide debridement services and use the PM&R codes including CPT 97597, 97598 and 97602.
· These codes must only be billed for services that include medically necessary skilled debridement services.
· When wound care services are delivered by therapists, there must be a certified therapy plan of care based on a thorough evaluation. The services must be billed using the appropriate therapy modifier and delivered within the CMS therapy guidelines found in the CMS Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220 and 230.
Dressing Change
A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).
· Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable procedure code that, commonly but not necessarily, occurs on the same date of service as the dressing change. If not included in another service, the costs associated with dressing changes may be reported as not separately payable.
· All topical applications (e.g. medications, ointments, and dressings) are included in the payment for the procedure codes.
· It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.
In general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable.
· Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable therapy evaluation, i.e. CPT 97001. Therapists may bill this service only once they have completed a medically necessary initial evaluation to develop a necessary therapy plan of care with the focus of wound care. Note that CPT 97001 is an "always" therapy code and the therapy modifier must be applied.
· Re-assessment/re-evaluation of a wound (which may be completed with a dressing change) is generally considered to be a non-covered routine service. An exception would require documentation clearly indicating that there had been a significant improvement, decline, or change in the patient's condition or functional status that was not anticipated in the plan of care and required further evaluation.
· An ABN may be given when medical necessity is not supported for the initial therapy evaluation. However, an ABN may not be given when medical necessity is not supported for a follow-up visit since there is no billable therapy code for a routine re-assessment (i.e. routine wound assessment with/without a dressing change).
Selective Debridement Documentation (CPT 97597 & 97598) – Documentation to support selective debridement should include the following:
· Clear description of instruments used for debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps).
· Thorough objective assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeting for debridement.
Non-Selective Debridement Documentation (CPT 97602) – Documentation to support non-selective debridement should include:
· Type of technique utilized i.e., wet-to-moist, enzymatic, abrasion.
· Thorough objective assessment of the wound as described in Selective Debridement above.
· If the patient uses whirlpool for treatment of a wound prior to receiving selective debridement services for the wound during the same visit, then the whirlpool is not separately reimbursable and should not be billed with modifier 59 unless two separate wounds are treated with the different modalities.
· If the patient uses whirlpool for treatment of a wound prior to receiving non-selective debridement services for the wound during the same visit, then the whirlpool is separately reimbursable and may be billed with modifier 59.
· Whirlpool can also be completed during the same visit for non-wound care related purposes. It is appropriate to separately bill CPT 97022 when the whirlpool is used for other purposes not involving wound care i.e., facilitation of range of motion activities.
Unna Boot Application
All supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.
High Compression Multi-Layered Bandage Systems
The application of the high compression bandage systems (i.e., Profore, Dyna-Flex, Surepress, Setopress, and other similar product systems) are used to primarily treat lymphedema and venous or stasis ulcers. Providers should note that the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare. However, a brief period of patient and/or caregiver education may be medically necessary and reimbursable. Noridian will cover and separately reimburse for the application training when Medicare coverage requirements are met. Further information may be found in the Noridian article titled High Compression Bandage System Clarification.


Scott Forest, B.S. RT (R)
Clinical Manager
Comprehensive Orthopaedics
and Musculoskeletal Care LLC.
863 N. Main Street Ext. Suite 200
Wallingford, CT 06492
Email: ScottF@comcllc.com
PH: 203.265.3280 ext 1153
FX: 203.741.6569
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