Get the Skinny on Hospital-Based Wound Care CPT Compliance

Hospital outpatient wound care is a growing business line -- but most facilities aren't ready to code and document compliantly for these services. Make sure your facility is in the know and getting proper reimbursement for wound care by going through this expert advice our expert speaker mentioned in a health system conference.

In hospital environment, they do load often the CPT codes into the charge. The issue with that is there a need to be documentation to support that. And how do we know if the person charging doesn’t understand the documentation and know the healthcare coding rules? So, there has to be a unified and collaborative oversight by the HIM department with your charging staff who put through the charges.

As per our expert speaker in a healthcare conference, we don't want to be CDM dependent, meaning we only let the charges go through and no one ever goes back and validates the charge against what's documented and against what code ended up on the UB and confirmed that the code and the rules are being followed and are correct.

Sometimes under the outpatient prospective payment system, there may be little guidances and little rules that we need to follow. Keeping in mind that under OPPS this results in an ambulatory patient category payment and we have an APC for that especially for evaluation and management, especially for our excisional, our surgical debridement codes.

Guidelines and CMS rules are set each year and they can change. And under outpatient prospective payment system, this is the Medicare system that pays under the Center for Medicare and Medicaid Services, CMS.

As far as evaluation and manage or E/M is concerned, many people think of those as just physician services. But they can be used for the evaluation and management of wound care patients. Now, we want to make sure we’re following the guidelines appropriately. And if it's physical therapy, they need to use their particular codes. They may not be able to use the specific evaluation and management because they have exceptions.

And then the surgical range for the debridement - and you'll also need to have supplies and devices that you may be using also in your wound care area. And those are HCPCS codes that may be part of your CDM, charge description master, but should also be listed on your charge form itself.

Within CPT, there is a wound care management section for physicians and non-physician providers. And we do list both physician and non-physician providers. And this has been more of a change in considering these to be both for physician and non-physician and that has happened over the last year and a half mostly due to information from the OIG that has come up. They are recommending and saying that physicians should be using these codes as well.

Under the code 97602 in CPT and it describes the removal of the devitalized tissue from wounds. Notice this is (pleuro). That’s one of the things in wound care management. We do need to advocate for some type of revision. The codes need to describe not one wound but have an add-on code when there's multiples because you all know that that involves more resources and time and effort. This particular code though does say wounds. And so, if you have more than one it doesn’t matter. It would still be what you would code for or charge.

And notice what it includes. It includes the topical applications, the wound assessment of the patient, the instructions for the patient for ongoing care. And this is per session, so per encounter. So your documentation of those above elements, how the wound looks, your assessment of the wound, which we talked about, all of the elements of an assessment, the instructions that are given for ongoing care, it needs to be very clear, concise and detailed in the medical record to support the 97602.

And further describing 97602, you can see that this thus describes the active wound care management of non-selective and the gradual removal of loosely adherent areas of devitalized or necrotic tissues is really the focus. This technique of removal includes preparation of the area, so preparing the area - that’s all part of the scope, to soften and loosen that. It can be achieved by irrigation and irrigating of the wound and using hydrotherapy techniques.

The actual removal of necrotic tissue through the use of non-selective techniques could involve the use of a whirlpool, the pulsed lavage, wet-to-dray, wet-to-moist and the application of even enzymes which are used to facilitate the gradual removal of these tissues. So that would be inclusive in the non-selected.

Healthcare Conference Tip: There is in the Coder’s Desk Reference publication a lay description of that CPT code 97602. And it says that this code is non-selective.

And then they have two additional wound care management codes there also available in slide 38, 97597 and 97598. And here, we have more aggressive type of debridement called selective debridement techniques of removing the devitalized tissue. And you can see that the techniques being used here it can by a physician or another clinician are a lot more aggressive and in fact, often sharp debridement instruments are being used, scissors, scalpel or forceps are being used.

Another newer method of the selective is the autolysis that’s being used to do that autolytic debridement is accomplished. And you would report the 97597 for the total wound surface area less than or equal to 20 cm and the code 97598 for the total wound surface area greater than 20 cm.

Now, when you're charging through your charge description master you're not seeing that particular 97597 CPT code but it's going on the bill. And what you will need to do is have a validation process using - and collaborating with your HIM coding staff to make sure that that code is assigned correctly or charged correctly and supports this type of documentation that you may see.

For the wound care visit for dressing change, you have to watch the documentation carefully about product names that may be used. Some promote that healing process or assist with that like the AQUACEL that you see there and immediate and sustained antimicrobial activity. It locks the bacteria within. And the alginate dressings from seaweed that are highly absorbent.

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