“I do some part time work in a wound care center. I frequently use CPT 97597 for coding. My biller is telling me not to bill CPT 97597 because it reimburses around $25 or less in a wound care center. However, the facility likes and even encourages me to use CPT 97597. If I do a selective debridement, can I bill CPT 99213 or CPT 99212 instead of CPT 97597? I know that I should not bill CPT 99213-Modifier 25 if there isn’t a separate complaint. Am I required to bill 97597? Is this a scenario that I should be considering CPT 11042?”
I am having a few issues with the information that is contained within the above post. Early in the game, we are informed that you bill for what is performed using the appropriate CPT code that is supported by the documentation within the medical record for the date of service in question. For a biller to tell the provider to not bill CPT 97597 because it reimburses around $25.00 or less in a wound care center is just plain wrong. If what was performed for the specific patient on a given date of service is best defined by CPT 97597, then that is the CPT code that must be billed.
Taking this one step further, instead of billing CPT 97597, but billing E/M code 99213 or 99212 because they reimburse more in the wound care center is highly inappropriate and it might even be interpreted as being fraudulent. It is never appropriate to bill an E/M service in lieu of the correct CPT/procedure code even if the E/M service reimburses a higher amount.
To consider billing CPT 11042 instead of CPT 97597, which appears to be based upon reimbursement, is just another example of poor decision making and what appears to be picking the CPT/procedure code that reimburses at a greater amount.
In this scenario, I think that it is important to look at the definitions/descriptions of both codes:
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 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq. cm or less
The selected ulcer debridement code is based upon the deepest level of necrotic tissue that is excisionally debrided out from within the base of the ulcer. Period. End of story.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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