“We suddenly started getting denials the fourth quarter of last year for a handful of Blue Cross Blue Shield and United Health Care plans for CPT 97597. After a little investigation, the code seems to be tied to physical therapy and is triggering the denials. Is there a modifier that we are failing to use? Has anyone else seen this problem?”
Now this is interesting. Prior to January 1, 2011, CPT code 97597 was not used for the excisional debridement of necrotic tissue from within an ulcer either partial thickness (within the dermis, but not to the base of the dermis), and full thickness (to the base of the dermis) by a physician. CPT codes 11040 and 11041 were used for those specific purposes, respectively. CPT codes 97597 and 97598, which are listed within the Medicine/Physical Medicine and Rehabilitation Chapter of the CPT Manual, were specifically designed to be used by physical therapists, not physicians. The original definitions of CPT codes 97597 and 97598 were the following:
CPT 97597: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface area less than or equal to 20 sq cm.
CPT 97598: Removal of devitalized tissue from wound(s), selective debridement, without anesthesia, per session; total wound(s) surface greater than 20 sq cm.
Along came January 1, 2011 and the definitions of CPT codes 97597 and 97598 changed:
CPT 97597: Debridement (e.g., high pressure waterjet w/wo suction, sharp selective debridement with scissors, scalpel & forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudates, 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
CPT 97598: Debridement (e.g., high pressure waterjet w/wo suction, sharp selective debridement with scissors, scalpel & forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis exudates, 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).
These two CPT codes are now specifically designed to be used by physicians, not physical therapists. So here comes Blue Cross Blue Shield and United Health Care and of course, they have found another way to not pay for a procedure that was appropriately performed and billed. CPT code 97597 is not tied to physical therapy. That ship sailed as of January 1, 2011. There is not a modifier that needs to be appended to CPT code 97597 in order to achieve reimbursement. It appears that Blue Cross Blue Shield and United Health Care are using a definition that has not existed for 11 years in order to justify not reimbursing for what was performed. This needs to be appealed and I believe that the documentation that you need to do so is listed above.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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