Wound Care - 4S-150AB

Article Title

Wound Care – 4S-150AB-R8

Contractor’s Determination Number

4S-150AB

Contractor Name

TrailBlazer Health Enterprises

Contractor Number

04001 (04101, 04201, 04301, 04401, 04901).
04002 (04102, 04202, 04302, 04402).

Contractor Type

MAC – Part A.
MAC – Part B.

AMA CPT/ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Indian Health Service.
End Stage Renal Disease (ESRD) facilities.
Skilled Nursing Facilities (SNFs).
Rural Health Clinics (RHCs).

Transitioned WPS legacy providers.

Oversight Region

Region IV.
Region VI.

Original Article Effective Date

03/01/2008

03/21/2008

06/13/2008

Article Revision Effective Date

01/01/2011

Article Ending Effective Date

N/A

Article Text

Abstract

For the purposes of the related LCD, wound care is defined as care of wounds that are refractory to healing or have complicated healing cycles either because of the nature of the wound itself or because of complicating metabolic and/or physiological factors. This definition excludes management of acute wounds, the care of wounds that normally heal by primary intention such as clean, incised traumatic wounds, surgical wounds that are closed primarily and other postoperative wound care not separately payable during the surgical global period.

Part A Program Instructions:

Reasons for Denial

All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessary” section of the related LCD.
Service(s) rendered is not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of the related LCD.
The service is considered:

Investigational.
For cosmetic purposes.
A program exclusion.
Otherwise not covered.
Never medically necessary.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
To report these services, use the appropriate CPT/HCPCS code(s).
All coverage criteria must be met before Medicare can reimburse this service.
The diagnosis code(s) must be representative of the patient’s condition.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted, but must be made available upon request.)
GZ: Waiver of liability statement is not on file. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN.)

CPT codes 11042–11047 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT codes 11042–11047 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services.
CPT codes 97597–97598 are used to report selective (including sharp) debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists and licensed occupational therapists.
CPT code 97602 is used to report non-selective debridement.
Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.
Do not use debridement codes when the only wound care service provided is the non-surgical cleansing of the ulcer site, with or without the application of a surgical dressing.
CPT codes 11042–11047 are not appropriate for removal of bacterial materials (including biofilms) without removal of devitalized tissue.
The CPT code selected should report the level of debrided tissue (e.g., partial-thickness skin, full-thickness skin, subcutaneous tissue, muscle and/or bone), not the extent, depth or grade of the ulcer or wound. For example, use CPT code 11042 if only necrotic skin and subcutaneous tissue are debrided even though the ulcer or wound might extend to bone.
Use CPT code 16020, 16025 or 16030 to appropriately represent burn percentage and services provided.
Shaving of calluses resulting in normal skin beneath the callus is routine foot care and would be coverable only under certain circumstances as defined by national policy and must be appropriately coded as such.
See also Bill Type and Revenue Code sections below.

Part B Program Instructions:

Reasons for Denial

All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessary” section of the related LCD.
Service(s) rendered is not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of the related LCD.
The service is considered:

Investigational.
For cosmetic purposes.
A program exclusion.
Otherwise not covered.
Never medically necessary.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
To report these services, use the appropriate CPT/HCPCS code(s).
All coverage criteria must be met before Medicare can reimburse this service.
The diagnosis code(s) must be representative of the patient’s condition.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted, but must be made available upon request.)
GZ: Waiver of liability statement is not on file. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN.)

CPT codes 11042–11047 are used to report surgical removal (debridement) of devitalized tissue from wounds. CPT codes 11042–11047 are payable to physicians and qualified non-physician practitioners licensed by the state to perform the services.
CPT codes 97597–97598 are used to report selective (including sharp) debridement of devitalized tissue and are payable to physicians and qualified non-physician practitioners, licensed physical therapists and licensed occupational therapists.
CPT code 97602 is used to report non-selective debridement in other than outpatient settings.
Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such.
Do not use debridement codes when the only wound care service provided is the non-surgical cleansing of the ulcer site, with or without the application of a surgical dressing.
CPT codes 11042–11047 are not appropriate for removal of bacterial materials (including biofilms) without removal of devitalized tissue.
The CPT code selected should report the level of debrided tissue (e.g., partial-thickness skin, full-thickness skin, subcutaneous tissue, muscle and/or bone), not the extent, depth or grade of the ulcer or wound. For example, use CPT code 11042 if only necrotic skin and subcutaneous tissue are debrided even though the ulcer or wound might extend to bone.
Use CPT code 16020, 16025 or 16030 to appropriately represent burn percentage and services provided.
Shaving of calluses resulting in normal skin beneath the callus is routine foot care and would be coverable only under certain circumstances as defined by national policy and must be appropriately coded as such.
Bill Type and Revenue Codes below DO NOT apply to Part B.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

0360, 042X, 043X, 044X, 045X, 049X, 051X, 052X, 0761, 0977, 0978

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
11042©	Debride skin/tissue
11043©	Debride tissue/muscle
11044©	Debride tissue/muscle/bone
11045©	Deb subq tissue add-on
11046©	Deb musc/fascia add-on
11047©	Deb bone add-on
16020©	Dress/debrid p-thick burn, s
16025©	Dress/debrid p-thick burn, m
16030©	Dress/debrid p-thick burn, l
97597©	Active wound care/20 cm or <
97598©	Active wound care > 20 cm
97602©	Wound(s) care non-selective
97605©	Neg press wound tx, < 50 cm
97606©	Neg press wound tx, > 50 cm
0183T©	Wound ultrasound
G0281	Electrical stimulation, (unattended), for pressure factors
G0329	Electromagnetic therapy, for chronic wounds

Other Comments

N/A