CPT 80053, Comprehensive metabolic panel

 

CODE DESCRIPTION

80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide

(bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), Urea Nitrogen (BUN) (84520)

Organ or Disease-Oriented Laboratory Panel Codes

The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.

UnitedHealthcare also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented Panel section states: "Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes."

For reimbursement purposes, UnitedHealthcare differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s) exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.

CPT coding guidelines indicate that Panel CPT code 80047 should not be reported in conjunction with CPT code 80053. If a submission includes CPT 80047 and CPT 80053, only CPT 80053 will be reimbursed.

CPT coding guidelines indicate that, Panel CPT code 80048 should not be reported in conjunction with Panel CPT 80053. If a submission includes Panel CPT 80048 and 80053, only Panel CPT 80053 will be reimbursed. There are 2 configurations for, Panel CPT code 80048:

1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80048.

Panel Code: 80048

Must contain 5 or more of the following Component Codes for the same patient on the same date of service

82310 82374 82435 82565 82947

84132 84295 84520

A submission that includes, Panel CPT code 80053, Panel CPT code 84443 and one of the following Component Codes, either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85027 + 85009 by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service, Panel CPT code 80050.

Panel Code: 80050

Includes the following Panel Code: 80053 

Plus the following Component Code: 84443 

Plus 1 of the following CBC or combination of CBC Component Codes for the same patient on the same date of service: :

85025 85027 + 85027 + 85027 +

85004 85007 85009

When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.

When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.

Panel code 80053, a component of Panel code 80050, includes all components of Panel CPT code 80076 except for code 82248.

Panel, 80053

There are 3 configurations for Panel CPT code 80053:

1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.

Panel Code: 80053

Must contain 10 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82374 82435

82565 82947 84075 84132 84155

84295 84450 84460 84520

2. A submission that includes a Panel CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.

Panel Code: 80053

Includes the following Panel Code: 80048  Plus 2 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 84075 84155 84450

84460

3. A submission that includes, Panel CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as Panel CPT code 80053.

Panel Code: 80053

Includes the following Panel Code: 80051 Plus 6 or more of the following Component Codes for the same patient on the same date of service:

82040 82247 82310 82565 82947

84075 84155 84450 84460 84520

When the Same Individual Physician or Other Qualified Health Care Professional reports the Panel CPT codes 80053 with 80048 or 80076 for the same patient on the same date of service, neither Panel CPT codes 80048 nor 80076 will be reimbursed separately.

CPT Panel Code 80053 includes all of the components of CPT Panel Code 80048 and all the components of CPT Panel Code 80076, except for CPT 82248. Therefore, when performed with all of the components of Panel CPT code 80053, report CPT 82248 separately.

Coding Tip

This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code 80048 cannot be reported in conjunction with 80053.

80053 Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155),

sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests

Code 80053 can not be used in addition to CPT codes 80048 and 80076.

This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived

test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for

* Indicates a mutually exclusive edit

80053 80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520

 

Reimbursement is provided for tests that are performed in a panel if they are reasonable, medically necessary under the applicable medical policy, and otherwise reimbursable under the terms of the member's plan. The plan reserves the right to rebundle individual codes that belong to a panel. If a claim is submitted with individual codes that belong to a panel, our claim reviewers and/or correct coding software logic may rebundle the procedure codes for appropriate reimbursement. If the medical documentation submitted with a claim shows that a panel was ordered and performed but the claim submitted shows the individual components of the panel, claim reviewers may rebundle the codes into the appropriate panel for reimbursement. CPT states the following:

• Tests performed in addition to those specifically indicated for a particular panel should be reported separately from the panel code

Example, If the Electrolyte panel (80051) is billed, individual tests such as 82947 (Assay Glucose Blood Quant), 84520 (Assay of Urea Nitrogen), 82565 (Assay of

Creatinine) and 82550 (Assay of CK (CPK)) should be billed separately from the panel.

• Do not report two or more panel codes that include the same constituent tests performed from the same patient collection

Example, If the Comprehensive Metabolic Panel (80053) is billed, the Basic Metabolic Panel (80047) cannot be billed.

• If a group of tests overlaps two or more panels, you must use the panel that incorporates the greatest number of tests and report the remaining individual tests

Example, if 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium), 84295 (Assay of Serum Sodium), 84520 (Assay of

Urea Nitrogen), and 82947 (Assay Glucose Blood Quant) are billed, two panel codes overlap. The Basic Metabolic Panel (80047) and the Electrolyte Panel (80051) include

codes 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium) and 84295 (Assay of Serum Sodium). The Electrolyte Panel should be billed.

• The panel code should be billed when all individual tests in the panel have been performed and should not be billed separately

Example, If the Lipid Panel (80061) is billed, then procedures 82465 (Assay BLD/Serum Cholesterol), 83718 (Assay of Lipoprotein) and 84478 (Assay of Triglycerides) should have been performed. 

80053 Comprehensive Metabolic Panel

82040 Assay of Serum Albumin

82247 Bilirubin Total

82310 Assay of Calcium

82374 Assay Blood Carbon Dioxide

82435 Assay of Blood Chloride

82565 Assay of Creatinine

82947 Assay Glucose Blood Quant

84075 Assay Alkaline Phosphatase

84132 Assay of Serum Potassium

84155 Assay of Protein Serum

84295 Assay of Serum Sodium

84460 Alanine Amino (ALT) (SGPT)

84450 Transferase (AST) (SGOT)

84520 Assay of Urea Nitrogen

Purpose of Policy

This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.

Scope

This policy applies to all Commercial medical plans.

Reimbursement Guidelines

A. Categories of diagnostic tests covered and not covered as routine/preventive

1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.

2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.

The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.

The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even

when billed with a preventive diagnosis.

Lab Panels

Organ- or disease-oriented lab panels were developed to allow for coding of a group of tests. Providers are expected to bill the lab panel when all the tests listed within each panel are performed on the same date of service. When one or more of the tests within the panel are not performed on the same date of service,

providers may bill each test individually. Providers may not bill for a panel and all the individual tests listed within that panel on the same day. However, other tests performed in addition to those listed on the panel on the same date of service may be reported separately, in addition to the panel code. Providers must

follow CPT coding guidelines when reporting multiple panels. For example, providers cannot report basic panel code 80048 with comprehensive panel code 80053 on the same date of service, because all the lab tests in 80048 are components of 80053.

On May 3, 2019 CMS issued Change Request 11248, which re-implements the Automated Multi-Channel Chemistry (AMCC) Lab Panel Claims Payment System Logic. This logic was introduced in 2017 but was suspended beginning CY 2018, due to the Protecting Access to Medicare Act of 2014 (PAMA). PAMA required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). Under PAMA, reporting entities must report to CMS certain private payer rate information for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate HCPCS code, as one National fee schedule rate rather than individual rates per state.

Prior to PAMA, CMS paid for certain chemistry tests using Automated Test Panels (ATPs). ATPs used claims processing logic to apply a bundled rate to sets of these codes based off how many ATPs were ordered. The claims processing system would not pay more for all ATPs than the associated CPT Panel (80047-80081). Any duplicated chemistry tests across ATPs or separately billed without a 91 modifier are not counted in the ATP test total. Below will further illustrate the logic and the effect on reimbursement. The Ohio rate of the 2017 CLFS is used for this demonstration, as the 2019 CLFS has not been updated with ATP entries as of the time of this article.

Example

A lab receives an order for a Comprehensive Metabolic Panel (80053) and a Lipid Panel (80061). Both panels are processed, results sent to the referring provider and a claim is sent to Medicare for HCPCS 80053 and 80061. The 2017 CLFS indicates payment for each HCPCS code as:

80053 $14.49

80061 $17.45

Total $31.94

Under the ATP payment methodology, payment will be determined based off the total number of unique chemistry tests performed.

Medicare will first strip each panel into its component codes as follows:

80053 HCPCS 80061 HCPCS

82040 82465

82247 83718

82310 84478

82374

82435

82565

82947

84075

84132

84155

84295

84460

84450

84520

CPT 71275 AND 74174

 CPT Code    Description

71275       Computed tomographic angiography, chest (non-coronary), with contrast material(s), including noncontrast images, if performed, and image post-processing 

CPT Code Acceptable S/S Procedure to Pre-Cert

71275 * Thoracic Aortic Dissection

* Thoracic Aortic Aneurysm

* Coarctation

* Aortic Root Dilation CTA Chest

74174 * Abdominal Aortic Dissection

* Mesenteric Ischemia

* Bowel Ischemia

* Stent Obstruction CTA Abdomen and Pelvis

* Thoracic Abdominal Aortic Dissection requires both codes 71275 and 74174

CPT Codes: 71275

Computed tomography angiography (CTA) is a non-invasive imaging modality that may be used in the evaluation of thoracic vascular problems. Chest CTA (non-coronary) may be used to evaluate vascular conditions, e.g., pulmonary embolism, thoracic aneurysm, thoracic aortic dissection, aortic coarctation, or pulmonary vascular stenosis. CTA depicts the vascular structures as well as the surrounding anatomical structures.

Initial Clinical Reviewers (ICRs) and Physician Clinical Reviewers (PCRs) must be able to apply criteria based on individual needs and based on an assessment of the local delivery system.

INDICATIONS FOR CHEST CTA:

For evaluation of suspected or known pulmonary embolism (excludes low risk*)

For evaluation of suspected or known vascular abnormalities:

* For evaluation of a thoracic/thoracoabdominal aneurysm or dissection (documentation of clinical history may include hypertension and reported “tearing or ripping type” chest pain.

* Congenital thoracic vascular anomaly, (e.g., coarctation of the aorta or evaluation of a vascular ring suggested by GI study).

* Signs or symptoms of vascular insufficiency of the neck or arms (e.g., subclavian steal syndrome with abnormal ultrasound).

* Follow-up evaluation of progressive vascular disease when new signs or symptoms are present.

* Primary or secondary pulmonary hypertension.

Preoperative evaluation

* Known or suspected vascular abnormalities seen on prior imaging

* Ablation procedure for atrial fibrillation.

Postoperative or post-procedural evaluation

* Physical evidence of post-operative bleeding complication or re-stenosis.

* Post-surgical follow up when records document medical reason requiring additional imaging

Chest CTA and Abdomen CTA or Abdomen/Pelvis CTA or Pelvis CTA combo:

* For evaluation of extensive vascular disease involving the chest and abdominal cavities such as aortic dissection, vasculitic diseases such as Takayasu’s arteritis, significant post-traumatic or postprocedural vascular complications, etc.

* For preoperative or preprocedural evaluation such as transcatheter aortic valve replacement (TAVR).

ADDITIONAL INFORMATION RELATED TO CHEST CTA:

CTA and Coarctation of the Aorta – Coarctation of the aorta is a common vascular anomaly characterized by a constriction of the lumen of the aorta distal to the origin of the left subclavian artery near the insertion of the ligamentum arteriosum. The clinical sign of coarctation of the aorta is a disparity in the pulsations and blood pressures in the legs and arms. Chest CTA may be used to evaluate either suspected or known aortic coarctation and patients with significant coarctation should be treated surgically or interventionally.

CTA and Pulmonary Embolism (PE) – Note: D-Dimer blood test in patients at low risk* for DVT is indicated prior to CTA imaging. Negative D-Dimer suggests alternative diagnosis in these patients. *Low risk defined as NO to ALL of the following questions:

1) Evidence of current or prior DVT;

2) HR > 100;

3) Cancer diagnosis;

4) Recent surgery or prolonged immobilization;

5) Hemoptysis;

6) History of PE; and another diagnosis is more likely.

CTA has high sensitivity and specificity and is the primary imaging modality to evaluate patients suspected of having acute pulmonary embolism. When high suspicion of pulmonary embolism on clinical assessment is combined with a positive CTA, there is a strong indication of pulmonary embolism. Likewise, a low clinical suspicion and a negative CTA can be used to rule out pulmonary embolism. CTA and Thoracic Aortic Aneurysms – Computed tomographic angiography (CTA) allows the examination of the precise 3-D anatomy of the aneurysm from all angles and shows its relationship to branch vessels. This information is very important in determining the treatment: endovascular stent grafting or open surgical repair.

CTA and Thoracic Aorta Endovascular Stent-Grafts – CTA is an effective alternative to conventional angiography for postoperative follow-up of aortic stent grafts. It is used to review complications after thoracic endovascular aortic repair. CTA can detect luminal and extraluminal changes to the thoracic aortic after stent-grafting and can be performed efficiently with fast scanning speed and high spatial and temporal resolution.

Chest CT

1. Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities may be further evaluated with chest CT with contrast (CPT® 71260).

a. “Abnormalities” through these guidelines may include suspected lung or pleural nodules or masses, pleural effusion, adenopathy or other findings that are not considered benign. 

b. Lung nodule(s) identified incidentally on:

i. Chest CTA without and with contrast (CPT® 71275), or

ii. Chest MRI without contrast (CPT® 71550), or

iii. Chest MRI without and with contrast (CPT® 71552), or

iv. Chest MRA without and with contrast (CPT® 71555) can replaceChest CT with contrast (CPT® 71260) or chest CT without contrast (CPT® 71250) as the initial dedicated study

2. Chest CT without contrast (CPT® 71250) can be used for the following:

a. Patient has contraindication to contrast.

b. Follow-up of pulmonary nodule(s).

c. High Resolution CT (HRCT).

d. Low-dose chest CT (CPT® G0297)

3. Chest CT without and with contrast (CPT® 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification, most often within a lung nodule, needs to be resolved.

4. High resolution chest CT should be reported only with an appropriate code from the set CPT® 71250-CPT® 71270.

a. No additional CPT® codes should be reported for the “high resolution” portion of the scan. The “high resolution” involves additional slices which are not separately billable.

E. Chest CTA (CPT® 71275)

1. Chest CTA (CPT® 71275) can be considered for suspected Pulmonary Embolism and Thoracic Aortic disease.

a. CTA prior to minimally invasive or robotic surgery 

Non-Cardiac Chest Pain Imaging

1. Initial evaluation should include a chest x-ray.1,2

a. If x-ray is abnormal, chest CT with contrast (CPT® 71260) or CTA chest with contrast (CPT® 71275) can be performed.1,2,3,4

 Hemoptysis

A. Chest CT with contrast (CPT® 71260) OR without contrast (CPT® 71250) OR CTA chest (CPT® 71275) may be performed after:

1. Abnormal chest x-ray, or

2. No chest x-ray needed if any of the following:

a. High risk for malignancy with >40 years of age and >30 pack-year smoking history, or

b. Persistent/recurrent with >40 years of age or >30 pack year smoking history, or

c. Massive hemoptysis (=30 cc per episode or unable protect airway).1

CPT CODE 97597, 97598 - Debridement procedure

CPT CODE AND Description 

CPT code 97598 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, 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; each additional 20 sq cm, or part thereof) was identified by the RUC on a list of services that were originally surveyed by one specialty but are now typically performed by a different specialty.

CPT code 97597 (Debridement [eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], open wound, [eg, fibrin, devitalized epidermis and/or dermis, exudate, 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) was included for review as part of the family despite being reviewed at the October 2018 RUC meeting.

Billing Guidelines

Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.

3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.

4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.

5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies

Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse

practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements.

10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.

11. Documentation must support the HCPCS being billed.

12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.

Coding Guidelines

1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.

2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.

3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).

4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.

• 97597 Removal of devitalized tissue from wounds, selective debridement, without anesthesia, wound assessment, topical applications, instructions for ongoing care, total wound surface area first 20 sq cm . May include scalpel, scissors, waterjet

• CPT 15002-15005 are NOT to be used for the removal of nonviable tissue/debris in chronic wounds left to heal by secondary intention. CPT 11042-11047 and CPT 97597- 97598 are to be used for this.

CPT codes 97597 and 97598,

• “to remove devitalized and/or necrotic tissue and promote healing”

• 97597 Selective debridement, without anesthesia – wound area <20 sq cm

• High pressure water jet

• Sharp selective debridement (scissors, scalpel and forceps)

• 97598 Wound area > 20 sq cm

Multiple Levels of Debridement Coding Example:

The patient has five wounds. There is a superficial blister on the right 1st MTPJ, an ulceration that penetrates to subcutaneous tissue beneath the left second metatarsal head, an ulceration that penetrates to subcutaneous tissue on the right anterior leg, an ulceration with necrotic Achilles tendon exposed on the

posterior right heel, and a lateral left fibular malleolus with bone exposed.

1) Debrided 2 x 3cm Right 1st MTPJ skin ulcer = 97597

2) Debrided 2 x 1cm subcutaneous ulceration plantar 2nd metatarsal head as well as the subcutaneous 5 x 4 right leg ulceration = total 22 sq cm = 11042 for the first 20 sq. cm. plus 11045 for additional 2sq. cm.

3) Debrided 7 x 4cm necrotic Achilles tendon ulceration = 11043 for the first 20 sq. cm. and 11046 for additional 8 sq. cm.

4) Debrided 0.5 x 0.5cm necrotic bone on the left lateral malleolus = 11044

CPT 97597

Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/ or dermis, exudate, 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. This code is to be used when only skin structures were debrided. It is to be used for up to and including 20 sq. cm. of tissue debrided. There is a 0 day global and the relative value unit is 2.52.

(CPT 97597/97598 coding example: If you debrided a 47 sq. cm. skin wound, you would code: 97597 x 1 for the first 20 sq. cm., plus 97598 x 2 for sq. cm. 21-40 and sq. cm. 41-47. The total RVU would be 2.52 + 0.79 + 0.79 = 4.10.)

Billing and Coding Guidelines for Wound Care

Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

2. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

3. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

4. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject to the consolidated billing requirements