Do you know when to use different codes for negative pressure wound therapy (NPWT)? The choice depends on the size of the wound! Healthcare providers use this therapy to treat several injuries, including chronic wounds, which affect around 6.5 million Americans each year.
However, they often get confused between different NPWT codes and struggle to get paid for this service. And you know how a lack of proper coding knowledge can lead to more mistakes and frustration.
CPT code 97605 is a popular code for wound care. Let us explain everything about this code so you can use it correctly.
CPT Code 97605 – Description
So, what does CPT code 97605 specifically refer to? Categorized as an active wound management code, CPT code 97605 specifies negative pressure wound therapy (NPWT), also commonly known as vacuum-assisted closure therapy.
As we said earlier, there are several codes for NPWT. So, you might be wondering which wound size and device qualify for this code. Healthcare providers use CPT code 97605 to treat small ulcers, surgical wounds, or traumatic injuries with a total surface area of 50 cm² or less.
During this procedure, a healthcare provider removes fluid or debris from the wound to promote healing. He does that by applying a sealed dressing over the lesion. This dressing is connected to a vacuum-like durable medical equipment (DME) that creates a subatmospheric (negative) pressure, gently pulling fluids or infectious material.
NPWT is useful for treating complex wounds, especially those that heal slowly. The primary goals of this procedure? To reduce wound size and decrease infection risk while promoting tissue regeneration.
Scenarios Where CPT Code 97605 is Applicable
Want to apply CPT code 97605 correctly? Read the following scenarios:
NPWT to Treat Foot Ulcer
Did you know diabetic patients are at a higher risk of developing foot ulcers (open sores or wounds)? In fact, around 1.6 million people in the U.S. suffer from diabetic foot ulcers. Negative pressure wound therapy can help prevent these sores from becoming infected.
Let’s consider this for our first scenario! Suppose a 56-year-old man with type 2 diabetes develops a neurotrophic ulcer on the sole of his left foot. The wound does not respond to standard treatment and is slow to heal. He visits the nearest reliable doctor for consultation.
After examining the ulcer, the provider orders several tests to determine the depth of the wound and identify signs of infection. After confirming the total surface area (30 cm2), the doctor performs negative pressure wound therapy to drain the wound and promote healing.
Since the wound area is less than 50 cm2, the provider uses CPT code 97605 to bill for the procedure.
NPWT to Manage Traumatic Hand Laceration
Lacerations are quite common, with up to 15% of untreated cases becoming complicated. Even simple hand wounds are at a greater risk. Specifically, 5% of hand lacerations become infected. That’s why healthcare providers often perform negative pressure wound therapy to promote healing.
So, for the next scenario, envision a 32-year-old woman with a traumatic hand injury. Let’s suppose she sustains a deep laceration (20 cm²) on her right hand after falling onto broken glass from a ladder. Although the wound initially closes after treatment, it later becomes swollen.
To reduce the risk of infection, the doctor cleans and dries the wound, then applies subatmospheric (negative) pressure to remove excess fluid. Given the wound’s total surface area, he uses CPT code 97605 to report the procedure.
NPWT to Manage Traumatic Pressure Ulcer
Did you know that every year, more than 2.5 million people in the U.S. develop pressure ulcers (bedsores)? Therefore, let’s use this as an example. Consider a 75-year-old woman who is bedridden after breaking her hipbone. Due to limited mobility and poor circulation, she develops a painful and itchy bedsore on her back.
Despite keeping it covered with a dressing, healing is slow. Hence, the patient’s family consults a physician. After evaluating the size (30 cm²) and stage (II) of the pressure wound, the healthcare provider removes excessive fluid and bacteria via suction to improve the blood flow.
Since her bedsore is less than 50 cm², the billing team uses CPT code 97605 to file a claim for the performed procedure.
Applicable Modifiers for CPT Code 97605
You can use the following modifiers with CPT code 97605 to correctly bill for negative pressure wound therapy:
Modifier 53
Did you discontinue negative pressure wound therapy due to some complication, such as bleeding, rupture, or pain? You can append modifier 53 to CPT code 97605, especially if you abandoned the treatment after administering anesthesia.
Modifier 59
Was NPWT distinct from another service or procedure you performed on the same day on the same patient? Use modifier 59 with CPT code 97605 to communicate this information.
Modifier XS
It is always better to use one of the more specific X{EPSU} modifiers instead of modifier 59 to avoid scrutiny. So, if negative pressure wound therapy was distinct from another service because you performed it on a separate structure, apply modifier XS to CPT code 97605.
Modifier 79
Did you perform NPWT during the post-operative period of an unrelated surgery? For example, if you removed excessive fluid from a diabetic ulcer during a patient’s post-operative knee surgery period, you can use modifier 79 with CPT code 97605.
CPT Code 97605 – Billing & Reimbursement Guidelines
For timely and complete reimbursements, you should understand the billing requirements associated with each code. Want to avoid denials for negative pressure wound therapy? Follow these instructions to file accurate claims for CPT code 97605:
Use Code 97605 Correctly (Only for NPWT Using DME)
Due to the close similarity between CPT codes 97605 and 97607, many healthcare providers often use these codes inaccurately. To clarify, 97605 covers the removal of fluids or infectious material via durable medical equipment (DME).
If you have used disposable, non-durable equipment for performing negative pressure wound therapy, use CPT code 97607 instead of 97605.
Use Code 97605 for Managing ≤ 50 cm² Wounds
Wound surface area is also important. CPT code 97605 only applies when you perform NPWT on an ulcer, laceration, or traumatic injury that is less than or equal to 50 cm2.
Document NPWT Thoroughly
Without a strong medical justification, insurance payers will deny your claims. Therefore, maintain complete documentation for negative pressure wound therapy while filing a claim for CPT code 97605. Make sure to record the following details:
- Wound details (size, condition, location)
- Appropriate ICD-10 codes that support NPWT
- Type of equipment used (DME, in this case)
Apply Appropriate Modifiers
When applicable, use appropriate modifiers with CPT code 97605 to convey additional information. We have mentioned several appropriate modifiers in the section above.
Comply with Payer-Specific Rules
We all know that payers have varying policies, some require pre-authorizations, while others ask for specific documentation. In this case, insurers may limit their NPWT coverage to specific DME brands. Therefore, verify each insurance provider’s billing requirements for CPT code 97605 to avoid denials.
Summary
Ready to file a claim for negative pressure wound therapy? CPT code 97605 is often misused due to coding confusion. That’s why we discussed it in so much detail, including what it covers (wound size and equipment type) and how you can use it accurately.
To summarize, CPT 97605 refers to negative pressure wound therapy, which involves applying a vacuum to a wound (50 cm2 or smaller) using specialized DME. Insurance companies pay for this service only if you follow their specific guidelines and submit proper documentation.
Therefore, we highlighted the appropriate modifiers and billing rules to help you avoid denials. But if you cannot spare extra hours on billing, consider partnering with a reliable company. Many top wound care billing services providers, including MediBillMD, can help you receive timely reimbursements.
