In the United States, over 6.5 million people experience some type of chronic wound every year. So, you can understand that the volume of insurance claims for wound care service is also quite high. Healthcare providers cannot afford claim denials for wound care treatments because that would lead to significant financial losses.
Claims with CPT code 97598 are frequently denied. Why? Because code selection requires precise calculation of wound size and depth. In this guide, our experts have simplified billing for CPT code 97598 as much as possible. So, let’s start.
CPT Code 97598 Description
CPT code 97598 is used to bill selective tissue debridement from open wounds. It is applied when the wound size exceeds 20 cm2. It addresses each additional 20 cm2 or portion thereof beyond the initial wound area. This means that for the first 20 cm2 debridement, CPT code 97597 is used, and then for the remaining wound, 97598 is used in increments of 20 cm2 or smaller portions.
This can be a little confusing, so let’s try to understand this with an example. Let’s suppose a patient has two wounds. The collective size of the lesions is about 50 cm2. The proper billing in this scenario will be CPT code 97597 for the first 20 cm² and CPT code 97598 for the remaining 30 cm² (20 cm² plus 10 cm²). So, you will bill 2 units of CPT 97598 in 20 cm² increments.
Another essential point to note is that 97598 is an add-on procedural code and cannot be billed independently. Additionally, the debridement must involve the removal of necrotic tissue via scalpels, scissors, forceps, or high-pressure waterjet (without or without suction). The mere removal of secretions or basic wound cleansing does not qualify.
Scenarios Where CPT Code 97598 is Applicable
CPT code 97598 can be accurately reported for the following clinical scenarios:
Post-Surgical Wound Complications
Oftentimes, the surgical wounds don’t heal properly. They develop infections. If left untreated, they lead to necrosis. These wounds can expand fast and may require extensive excision of necrotic tissue. Hence, CPT code 97598 becomes applicable for open wound debridements with surface area exceeding the initial 20 cm2.
Diabetic Foot Ulcers
Diabetic foot ulcers represent one of the most common applications for this code. These wounds often require extensive debridement due to their complex nature and tendency to develop significant amounts of necrotic tissue. When treating a diabetic ulcer measuring 35 cm2, you will bill CPT 97597 for the first 20 cm2 and CPT code 97598 for the additional 15 cm2.
Applicable Modifiers for CPT Code 97598
The following modifiers are commonly appended to CPT code 97598 to improve coding accuracy and increase the chances of fair reimbursement collection.
| Modifier | Description | Usage and Application |
|---|---|---|
| 22 | Increased Procedural Services | Used to indicate increased procedural services when the work required to perform the procedure is substantially greater than typically required. |
| 59 | Distinct Procedural Services | Used to indicate distinct procedural services on the same day when debridement is performed on separate anatomical locations or at different patient encounters. |
| XS | Separate Structure | XS indicates that the debridement service is distinct because it was performed on a separate organ or structure on the same service date. |
| XU | Unusual Non-Overlapping Service | This modifier indicates that the debridement service is distinct (even though performed on the same service date) because its components do not overlap with components of the primary service. |
| 76 | Repeat Procedure or Service by the Same Physician | Used for repeat procedures performed by the same physician on the same day. |
| 77 | Repeat Procedure by Another Physician | Indicates repeat procedures performed by a different physician on the same day. |
Please use modifier 59 carefully and thoughtfully. Billers frequently misuse it and then face denials. Only use this modifier when you treat truly distinct wounds or wounds on separate anatomical sites, not simply different areas of the same wound.
CPT Code 97598 – Billing & Reimbursement Guidelines
While coding and billing wound care management services, represented by CPT code 97598, you must consider the following factors to increase your chances of clean claim submission.
Documentation
Accurate documentation is crucial for all CPT codes, including 97598, to justify the medical necessity of procedures. For CPT code 97598, medical records must detail wound measurements (length, width, and depth), the type of devitalized tissue removed, the debridement method, and evidence of medical necessity. Additionally, progress notes should reveal the healing progression and validate the ongoing treatment.
Billing Sequence
We have already discussed this briefly. Always remember that CPT code 97598 is an add-on code. Therefore, you must bill it with CPT code 97597. Providers cannot bill 97598 independently. So, make accurate measurements of the wound area before providing the services.
Medicare Reimbursement
The Medicare reimbursement rate for CPT code 97598 varies for each MAC locality and facility setting. However, according to recent data, the national average reimbursement amount for non-facility settings is $43.34 and $23.29 for the facility settings. You can check the exact amount for your MAC locality via the PFS Lookup Tool.
Wrapping Up
Do you now fully understand the key requirements for using CPT code 97598? The code is for open wound debridement, each additional 20 cm2, and requires 97597 as a primary code.
We have covered all the relevant details, requirements, and restrictions of this CPT code to help you avoid claim denials. However, should a denial occur, our wound care billing services will promptly resolve it for you.
