Coding clarification: coding for wound care

KENT MOORE AND EMILY HILL, PA-C

Many family physicians provide wound care for their nursing facility patients. Coding and billing correctly for such wound care is important to assure appropriate payment and avoid potential allegations of fraud or abuse. One of the challenges in this regard is understanding when to report chemical cauterization of granulation tissue versus debridement, especially as it pertains to Medicare patients.

Coding for chemical cauterization of granulation tissue

According to Medicare claims data, Current Procedural Terminology (CPT) code 17250 for chemical cauterization of granulation tissue (i.e., proud flesh) is a service increasingly reported by family physicians in the nursing facility setting. CPT code 17250 is specific to the application of chemicals such as silver nitrate to excessive healing tissue known as proud flesh or granulation tissue and may include the removal of loose granulation tissue and subsequent hemostasis. The service typically begins with the physician explaining the procedure to the patient and/or family, reviewing risks and complications, and obtaining informed consent. The physician also verifies all required instruments and supplies are available and assists with appropriate positioning to expose and stabilize the procedure site. Lastly, the physician helps drape and prepare the site and scrubs up.

During the procedure itself, the physician gently curettes loose granulation tissue and irrigates the wound with sterile saline. The physician also applies a chemical cauterization agent (e.g., silver nitrate) to granulation tissue and achieves controlled hemostasis. Following the procedure, the physician applies sterile dressing, writes orders for antibiotic and pain medication, as appropriate, and discusses after-care treatment, including home restrictions (e.g., bathing). Finally, the physician dictates the procedure note and completes medical record documentation.

Clinical examples:

A clinical example of code 17250 is a 78-year-old female presenting four months after placement of a gastrostomy tube with excessive granulation tissue. The physician treats the exposed tissue with chemical cauterization. Another example is a patient who presents two weeks after incision and drainage of a paronychia with excessive granulation tissue on the nail bed. The physician treats the exposed tissue with chemical cauterization.

When not to use code 17250:

As noted in the parentheticals below the code in CPT, code 17250 is not intended to be reported in the following situations:

• With removal or excision codes for the same lesion,
• When chemical cauterization is used to achieve wound hemostasis,
• In conjunction with active wound care management 97597, 97598, or 97602 for the same lesion.

Coding for debridement 

Codes 97597, 97598, and 97602 describe a more extensive service than described by code 17250, as follows:

97597 Debridement (e.g., high-pressure waterjet with or 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,

97598 each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure),

97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.

Active wound care procedures are performed to remove devitalized and/or necrotic tissue and promote healing. For instance, code 97597 involves cleansing the wound thoroughly with copious irrigation, then removing proteinaceous slough, fibrin, and debris covering the wound bed with curette, scalpel, and forceps or scissors until healthy tissue is visualized. Code 97598 involves the same service done over an additional surface area. Chemical cauterization (code 17250) to achieve wound hemostasis is included in these procedures and should not be reported separately for the same lesion.

Clinical example:

A clinical example of 97598 involves a 60-year-old male who presents with a neuropathic diabetic ulcer on the left plantar forefoot. The wound edges and the wound bed are viable with granulations but covered with an adherent proteinaceous slough, fibrin, and debris. He undergoes debridement to the depth of dermis.

Medicare payment for wound care services

Correctly coding wound care services in the nursing facility setting is important, given the different ways Medicare pays for such services. Medicare beneficiaries can either be in a Part A covered skilled nursing facility (SNF) stay, which includes medical services as well as room and board, or they can be in a Part B non-covered SNF stay in which Part A benefits are exhausted but certain medical services are still covered, although room and board are not. Under the Balanced Budget Act of 1997, Congress mandated that payment for most services provided to beneficiaries in a Medicare covered Part A SNF stay be included in a bundled prospective payment to the SNF. The SNF is required to bill these bundled services in a consolidated bill to the Part A Medicare administrative contractor. The bundled services cannot be billed separately.

There are a limited number of services specifically excluded from consolidated billing and, therefore, separately payable. Currently, CPT code 17250 is among those excluded from the consolidated billing rule and, therefore, separately reportable. In contrast, CPT codes 97597 and 97598 are subject to the SNF consolidation billing. Reporting 17250 rather than 97597/97598 to avoid consolidated billing would be inappropriate.  

When reporting services, clinicians should use the code that accurately identifies the service performed, per CPT guidelines. It is not appropriate to select a code that approximates the service or to report a code solely for reimbursement purposes. Further, CPT code selection should always be supported by the clinical documentation in the medical record. Selecting the proper code for wound care services requires an understanding of wound care techniques and the code descriptors and guidelines found in CPT.

— Kent Moore, senior strategist for physician payment, American Academy of Family  Physicians, and Emily Hill, PA-C, president of Hill & Associates, a Wilmington, N.C., consulting firm specializing in coding and compliance

Posted on May 11, 2022, by Kent Moore