Pressure Ulcer Wound Care Coding: Your Expert Guide

Refer to Local Coverage Determination (LCD) L38904, Wound and Ulcer Care, for detailed reasonable and necessary requirements. It’s crucial to understand that Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) codes might be subject to National Correct Coding Initiative (NCCI) edits. Always prioritize NCCI guidelines for accurate coding and specific code combinations before submitting claims to Medicare.

Understanding the Basics of Wound Care Coding for Pressure Ulcers

Accurate coding is paramount for appropriate reimbursement in pressure ulcer wound care. Claims must be submitted with the most specific ICD-10-CM code that accurately reflects the reason for the procedure. This ICD-10-CM code must be directly linked to the corresponding procedure code to ensure claim accuracy and avoid denials.

It’s important to note that simple, non-surgical cleansing of a pressure ulcer, even with dressing application, should be billed using the appropriate Evaluation and Management (E/M) code. Debridement codes are not appropriate for this level of service.

Debridement codes are specifically designed for treating skin ulcers, including pressure ulcers, dermal infections, and conditions affecting deeper tissues. They are also applicable for removing embedded debris, such as dirt from abrasions.

Active Wound Care Management Codes for Pressure Ulcers (CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608)

Within active wound care management, code 97602 is currently designated as a status B (bundled) code for physician services. This means separate payment for this service is not typically allowed.

When a therapist, operating within their professional scope and licensure, provides active wound care management, including for pressure ulcers, they must append the appropriate therapy modifier to the billed CPT code. Furthermore, when performed in a Part A outpatient facility, the therapy Revenue Code must be submitted. If a non-therapist provides the service, therapy modifiers are not used, and a non-therapy Revenue Code should be submitted in Part A outpatient settings. For further details, refer to MM10176.

For debridement codes 97597, 97598, or 97602, specifically in the context of pressure ulcer care:

• Selective or Non-Selective Debridement: Coding should utilize selective or non-selective CPT codes (97597, 97598, or 97602) unless surgical debridement is clearly documented in the medical record.
• Dressings Included: Dressings applied as part of the service using CPT codes 97597, 97598, and 97602 are considered inclusive and cannot be billed separately.
• Bundling of Codes: It is incorrect to report CPT code 97602 in conjunction with CPT code 97597 and/or 97598 for wound care performed on the same pressure ulcer on the same date of service. These codes are mutually exclusive when applied to the same wound during a single encounter.
• Code Combination Restrictions: Codes 97597, 97598, and 97602 should not be reported together with codes 11042-11047 for the same pressure ulcer. The depth of debridement determines the appropriate code selection. For instance, for superficial debridement of biofilm on a muscular pressure ulcer, codes 97597-97598 are suitable. However, if muscle tissue itself is debrided, the 11043-11046 series becomes appropriate, depending on the wound area.

Codes 97602, 97605, 97606, 97607, and 97608 inherently include the application and removal of any protective or bulk dressings. Crucially, if only a dressing change is performed without active wound procedures as defined by these debridement codes, these debridement codes should not be used for billing.

CPT codes 97597 and 97598 are applicable for medically necessary debridement, provided their use aligns with LCD guidelines and the performing provider’s scope of practice, especially in pressure ulcer management.

Generally, whirlpool therapy is considered a component of CPT codes 97597/97598 and should not be billed separately during the same patient encounter for pressure ulcer care. Separate billing for whirlpool might be considered only if it represents a distinctly identifiable service for a different condition, supported by detailed documentation, and appropriately modified (e.g., with modifier -59, LT, RT, -XS).

Surgical Debridement Codes for Pressure Ulcers (CPT codes 11000-11012, and 11042-11047)

Similar to active wound care management, dressings applied during surgical debridement of pressure ulcers, represented by CPT codes 11000-11012 and 11042-11047, are included in the service and should not be billed separately.

Medicare does not provide separate reimbursement for dressing changes or for patient/caregiver training in pressure ulcer wound care. Advance Beneficiary Notices of Non-coverage (ABNs) are only appropriate for services anticipated to be denied due to lack of medical necessity. Therefore, an ABN for a routine dressing change is not appropriate, as the costs are bundled into other billable procedures.

Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) is classified as inpatient-only procedures and are generally not applicable to typical pressure ulcer management unless complicated by such infections.

CPT codes 11042-11047 coding is determined not only by pressure ulcer size but more critically by the depth of tissue debridement. This is based on the type of tissue removed (e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) from independent (noncontiguous) skin and deeper tissue structures.

When debriding a single pressure ulcer, report the depth using the deepest level of tissue removed. For multiple pressure ulcers of the same depth, sum their surface areas. Do not combine areas from ulcers debrided at different depths. Medicare Administrative Contractors (MACs) typically allow payment for an aggregate total of one independent tissue debridement per day of service. Requests for payment exceeding four aggregate debridements for one or both feet on a single date of service will likely be denied unless compelling documentation justifies the additional services. Appropriately performed debridement usually does not require repetition for several days.

CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from pressure ulcers.

• Modifiers for Multiple Wounds: Use appropriate modifiers when debriding multiple pressure ulcers on the same day to ensure correct claim processing. CMS continues to recognize the -59 modifier for “Distinct Procedural Service,” but prefers more descriptive modifiers when available, as per CPT guidelines and CMS Change Request (CR) 8863.

The use of CPT codes 11042-11047 is not appropriate for services such as washing bacterial or fungal debris, paring corns or calluses, incision and drainage of abscesses, nail trimming, acne surgery, or wart removal. These procedures, when medically necessary and covered, should be reported using the CPT/HCPCS code that most accurately describes the service provided.

The CPT code selected should reflect the depth of tissue debrided (e.g., skin, subcutaneous tissue, muscle, and/or bone), not the ulcer’s overall extent, depth, or stage. For example, code 11042 (“debridement, subcutaneous tissue”) is correct if only necrotic subcutaneous tissue is removed, even if the pressure ulcer extends to the bone. Removing only fibrin would not warrant billing this code.

Debridement within the surgical field of another musculoskeletal procedure is not separately billable unless it involves debridement at the site of an open fracture or dislocation, which can be reported separately using CPT codes 11010-11012. For example, debridement of muscle and/or bone (codes 11043-11044, 11046-11047) associated with tumor excision is not separately reportable. Similarly, superficial tissue debridement (codes 11042, 11045, 11720-11721, 97597, 97598) within the surgical field of a musculoskeletal procedure is also not separately reportable.

The submitted debridement code should accurately represent the type and amount of tissue removed, as well as the pressure ulcer’s depth and size. When billing CPT code 11044, providing documentation substantiating the depth of debridement is highly recommended. For example, if a pressure ulcer involves exposed bone but the debridement did not remove bone, CPT code 11044 is not appropriate.

Paring and Cutting for Symptomatic Hyperkeratosis (Codes 11055-11057) in Pressure Ulcer Care

Codes 11055-11057 are specific to paring procedures. For these to be considered covered services in pressure ulcer care, the medical record must clearly document the symptomatic nature of the hyperkeratotic lesion. Treatment of asymptomatic lesions falls under routine foot care and may not be covered. Refer to Groups 2 and 3 in the ICD 10 Codes That Support Medical Necessity section for further guidance.

E/M Codes in Conjunction with Surgical Debridement for Pressure Ulcers

Generally, Evaluation and Management (E/M) codes are not billed alongside a debridement procedure. Surgical debridement billing is understood to include the pre-debridement pressure ulcer assessment, the debridement itself, and the post-procedure instructions given to the patient on the same date of service. However, if a “reasonable and necessary” and “separately identifiable” E/M service is provided and thoroughly documented on the same day as a debridement service, it may be payable by Medicare. The documentation must clearly differentiate the E/M service from the debridement service provided.

Consultation services by a podiatrist in a skilled nursing facility are covered if deemed reasonable and necessary and do not fall under statutory exclusions (NCD 70.2).

Low-Frequency, Non-Contact, Non-Thermal Ultrasound (MIST Therapy) – CPT code 97610 for Pressure Ulcers

For pressure ulcer treatment, one 97610 service is allowable per day for a qualifying wound. CPT Code 97610 is not separately reportable if performed on the same pressure ulcer on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598). These services are considered bundled when performed on the same wound on the same day.

Debridement, Total Contact Casting, and Unna Boot for Pressure Ulcers

All supplies related to Unna boots and Total Contact Casting (TCC) are included in the reimbursement for CPT codes 29580 and 29445, respectively. If both debridement and an Unna boot or TCC are applied for a pressure ulcer, only the debridement is typically reimbursed. If only an Unna boot or TCC is applied without debridement, only the boot or TCC application may be eligible for reimbursement. NCCI guidelines state that casting/splinting/strapping should not be separately reported if a Musculoskeletal System CPT code (20100-28899 and 29800-29999) is also performed for the same anatomical area. Modifier 59 may be appropriate with strapping codes if performed in a separate anatomical area.

Debridement, including foreign material removal at an open fracture or dislocation site, can be reported with CPT codes 11010-11012. Since these codes are reported with a CPT code for the open fracture or dislocation treatment, a casting/splinting/strapping code should not be separately reported.

Documentation Requirements for Pressure Ulcer Wound Care Coding

Comprehensive and accurate documentation is essential for compliant Pressure Ulcer Wound Care Coding and reimbursement.

1. All documentation must be maintained in the patient’s medical record and readily available upon request.

2. Every page must be legible and include patient identification information (complete name, dates of service). Documentation must include the legible signature of the responsible physician or non-physician practitioner.

3. The medical record should detail specific signs/symptoms and clinical data supporting the provided wound care. Physician documentation of the current wound status and the patient’s response to treatment is expected.

4. Clear evidence of the pressure ulcer’s response to treatment at each visit must be documented, including at a minimum:

   • Current wound volume (surface dimensions and depth).
   • Presence and extent (or absence) of infection signs.
   • Presence and extent (or absence) of necrotic, devitalized, or non-viable tissue.
   • Presence of other materials in the wound that may impede healing.

5. Detailed description of wound location, size, depth, and stage must be documented, possibly supplemented by a drawing or photograph. Photographic documentation at treatment initiation and immediately before or after debridement is highly recommended, especially for services requiring prolonged or repetitive debridement.

6. Debridement service documentation must include the type of tissue removed and the wound’s depth, size, and characteristics, directly correlating with the submitted debridement code. A pathology report confirming debridement depth is encouraged for deep tissue or bone debridement.

7. Except for patients with compromised healing, documentation must demonstrate:

   • Expectation of substantial impact on tissue healing and viability, infection control, necrotic tissue removal, or surgical preparation.
   • Correlation of wound care extent and duration with the patient’s expected recovery potential. If wound closure is not the goal, the focus shifts to optimizing recovery and establishing a non-skilled maintenance program or palliative care to minimize hospitalization.

8. Service documentation must include an operative or procedure note detailing:

   • Medical diagnosis.
   • Indications and medical necessity for debridement.
   • Type of anesthesia used (if any).
   • Wound characteristics: diameter, depth, undermining, tunneling, color, exudates, necrotic tissue.
   • Level/depth of debrided tissue, type of tissue involved and removed.
   • Vascular status, infection, or reduced circulation evidence.
   • Narrative of the procedure, including instruments used, debridement method (hydrostatic, sharp, abrasion, etc.), and wound character before and after debridement (dimensions, necrotic material, tissue removed, epithelialization).
   • Patient-specific goals and treatment response.
   • Immediate post-op care and follow-up instructions.
   • Documentation of necrotic, devitalized, fibrotic tissue, or foreign matter presence or absence when debridement is performed.

9. Medical records must include treatment goals and physician follow-up plans. Document complicating factors for wound healing and measures taken to control them when debridement is involved. Demonstrate appropriate treatment plan modifications if wounds fail to heal; lack of improvement after 30 days may necessitate reassessment of infection, metabolic, nutritional, or vascular issues, or a new treatment approach.

10. Appropriate evaluation and management of contributory medical conditions or factors affecting wound healing (nutritional status, predisposing conditions) should be addressed in the medical record at intervals consistent with the condition’s nature.

11. Documentation must justify the use of skilled personnel for jet therapy and wound irrigation for debridement.

12. Documentation for low-frequency, non-contact, non-thermal ultrasound services (Mist Therapy) should include documented improvements in pain reduction, wound size reduction, granulation tissue improvement, or necrotic tissue reduction. Medical necessity should be justified by provider documentation of patient evaluation, diagnosis, and plan.

13. Services lacking adequate documentation or not establishing medical necessity will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

Utilization Guidelines for Pressure Ulcer Wound Care Coding

Utilization of pressure ulcer wound care services should align with locally accepted standards of practice and CMS Ruling 95-1 (V).

Wound care must adhere to accepted medical and surgical treatment standards. Debridement frequency depends on individual patient characteristics and wound extent. The extent and number of services should be medically necessary and reasonable based on documented medical evaluation, diagnosis, and plan.

It’s noted that only a minority of beneficiaries requiring debridement for wound care need more than twelve surgical excisional debridement services involving subcutaneous tissue, muscle/fascia, or bone within a 360-day period (including a maximum of five involving muscle/fascia and/or bone). Continued debridement beyond this frequency or timeframe requires documented evidence of medical necessity and clear benefit. Similarly, more than four debridements per month (30 days) are unlikely without documented evidence of patient benefit. Continued care depends on demonstrated patient benefit.