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slide1. Audio Information The presenter started speaking
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wps.gha.education@wpsic.com<br>
slide2. Maximize Reimbursement: Policy Coverage for Wound Care July 2025<br>
slide3. Housekeeping Training Center webpage
Training Material
Upcoming Events
Encore Presentations
60 to 90 days
Send questions and comments in Chat
After this, tell CMS how we did on the survey<br>
slide4. Disclaimer This material is a tool to assist the provider community. Medicare rules change often.
The basis for answers given today rely on facts given in the question. Medicare rules determine final coverage.
Access CMS’ website for current coverage, regulations and rulings.<br>
slide5. CPT Copyright Notice CPT codes, descriptions, and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.<br>
slide6. Acronyms LCD – Local Coverage Determination
NCD – National Coverage Determination
NPP – Non-Physician Practitioner
POC – Plan of Care
SMART – Specific, Measurable, Attainable, Relevant, Time-based<br>
slide7. Objective & Agenda To learn about the critical elements of wound care policy coverage, billing and documentation
Review policy coverage criteria for wound debridement
Discuss documentation requirements and review findings
Provide insight into billing and coding policy requirements<br>
slide8. Coverage<br>
slide9. Local Coverage Determination (LCD) L37228 Offers coverage guidelines for wound care involving
Debridement
Electrical stimulation and electromagnetic therapy
Negative pressure wound therapy
Low frequency non-contact non-thermal ultrasound (MIST Therapy)
Topical oxygen therapy (TOT)<br>
slide10. Coverage Basics At least one of the following conditions must be present and documented
Pressure injury, Stage II, II or IV
Venous insufficiency ulcers
Arterial insufficiency ulcers, including diabetic, lower extremity
Wounds with exposed hardware or bone
Neuropathic ulcer(s)
Neuro-ischemic ulcer(s)
Diabetic foot ulcer(s)
Complications of surgically created or traumatic wound<br>
slide11. Standard Wound Care Optimal nutritional status
Debridement to remove dead tissue
Maintain clean, moist wound with appropriate moist dressing
Infection prevention and resolution if present Repositioning
Glucose control
Maintain circulation for arterial ulcers
Compression systems for venous ulcers<br>
slide12. Debridement<br>
slide13. Debridement Defined Removal of foreign material, devitalized, or contaminated tissue from an adjacent to a traumatic or infected wound
Exposes surrounding healthy tissue
Goals
Remove devitalized tissue
Decrease risk of infection
Promote wound healing
Prevent further complications<br>
slide14. Selective or Non-Selective Debridement Selective
Targeted
Along margins of viable tissue
Non-selective
Surgical
Sharp
Enzymatic
Wet to moist dressing<br>
slide15. Documentation<br>
slide16. Documentation Requirements Documentation of covered condition
Certified plan of care
Treatment goals
Frequency and duration
Evidence of plan effectiveness including measurable changes
Drainage
Inflammation
Swelling
Pain
Wound dimensions
Necrotic tissue/slough<br>
slide17. Additional Documentation Physician orders
Physician progress notes
Photographic documentation of wounds, if applicable
Treatment records
Wound measurements from start of care
Debridement evidence – tissue removal, method utilized, character of wound before and after debridement
Severity of tissue destruction, undermining or tunneling, necrosis, infection, or evidence of reduced circulation
Complicating factors of healing<br>
slide18. Documentation Continued Contributory medical conditions
Nutritional status
Predisposing conditions
Advance Beneficiary Notice of Non-coverage (ABN), if applicable<br>
slide19. Expectations of Documentation<br>
slide20. Expectation of Improvement Medicare expects wound volume or surface dimensions to decrease over time with
Appropriate care
No medical surgical complications
Documentation could include
Drainage
Inflammation
Swelling
Pain
Wound dimensions
Necrotic tissue or slough<br>
slide21. Measurable Signs of Healing Document the following to support signs of healing
Decrease in wound size
Surface area
Volume
Decrease in amount of exudates
Decrease in amount of necrotic tissue<br>
slide22. Review Findings and Errors<br>
slide23. Incomplete/Insufficient Information No documentation or insufficient documentation of:
Debridement
Measurements
Plan of care or specific components of POC
Required conditions<br>
slide24. No Debridement Evidence Lacking evidence that service was provided
Demonstrating tissue removal
Type of debridement
Method utilized
Instrumentation used
Lacking debridement was to subcutaneous tissue level
Character of wound before and after debridement
Signature and credentials of who performed debridement<br>
slide25. Missing Measurements No pre and/or post measurements
Identified as either pre or post
Including size and depth
Should be measured with every progress report<br>
slide26. Missing POC or Components of POC The plan of care was not submitted
No expected frequency or duration
No detailed description of the wound
No descriptions of potential to heal
No treatment goals or plans
No modifications to plan when the plan isn’t working<br>
slide27. Incomplete Goal Information Document SMART goals
Progress towards goals
If lack of progress – how are goals changing
What wound should look like when goals are achieved<br>
slide28. Missing Complicating Factors and Methods to Control Documentation lacking complicating factors to healing
Documentation must include methods to control or limit complicating factors<br>
slide29. Missing Required Conditions of Coverage Listed in LCD L37228
Must be documented in the plan of care
If laboratory or imaging tests change the diagnosis, it must still meet coverage indications for treatment<br>
slide30. Billing and Coding Guidelines<br>
slide31. Article A55909 – Billing and Coding: Wound Care Use with WPS LCD L37228
Addresses procedure and diagnosis codes related to the LCD
Listing of code in the Article does not imply coverage
Must meet coverage indications, limitations, and/or medical necessity as described in the LCD<br>
slide32. Negative Pressure Wound Therapy (NWPT) NPWT device/unit/type or supplies covered under the Durable Medical Equipment benefit
See Social Security Act section 1861(s)(6)
Consult DME LCD for specific coverage, parameters and guidelines<br>
slide33. Some CPT Codes Included in A55909 Guidance 97597
Debridement (removal of damaged tissue), first 20 square centimeters or less
97598
Each additional 20 square centimeters of debridement 11042-11047
Sharp debridement
More aggressive, removes deeper tissue
Code depends upon depth of tissue removed and the surface area of the wound CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide34. Hydrotherapy When 97597 or 97598 are billed by a therapist, documentation must reflect the skill set of a therapist was required to perform the service in the given situation CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide35. Whirlpool CPT 97022
Not separately billable with 97597 or 97598 unless provided for a different body part than the wound care treatment body part CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide36. Local Infiltration Not Separately Covered Includes
Metatarsal/digital block
Topical anesthesia
Anesthesia administered by or incident to the provider performing the debridement<br>
slide37. “Sometimes” Therapy Codes – 97597 and 97598 For patient under a home health benefit
May be covered by the Home Health agency if part of their plan of care
If billed by a physician or NPP, codes can be paid under Part B even if the beneficiary is under an active home health plan of care CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide38. CPT 97602 Always Bundled Assigned a status code “B” on the Physician Fee Schedule (PFS) Relative Value Files
Never separately payable
Do not bill the patient CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide39. CPT 97026 - Infrared Not covered per NCD 270.6 - Infrared Therapy Devices CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide40. Ultrasound for Wound Care and Phototherapy – Ultraviolet Modalities Reported with 97035 and 97028, these codes are not payable for wound care
Per L37228 CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide41. Reporting codes 11042-11047 for Debridement of Wound Before Topical/Local Anesthesia Applied When this occurs for a single wound, report code based on the depth of tissue that is removed and by surface area of the wound When this occurs for multiple wounds, sum the surface area of those wounds that are the same depth, but do not combine sums from different depths CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide42. More Coding Guidelines Do not report 11042-11047 in conjunction with 97597-97602 for the same wound
CPT codes 11044 and 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC) CPT codes 11043, 11046 and 11044, 11047, are codes that describe deep debridement of the muscle and/or bone CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide43. Reasons for Denial Performing bony debridement in place of service other than inpatient hospital, outpatient hospital, or ambulatory surgery center
Billing of debridement by unqualified personnel<br>
slide44. Questions and Answers<br>
slide45. Customer Service Process Change What:
One NPI/PTAN combination per call
When:
Effective August 4, 2025
Why:
Improve call efficiency
Decrease wait times
Quicker resolution of inquiries<br>
slide46. We Hear You We are committed to making changes to improve your education experience.
Based on survey comments
Chapters to YouTube
Training indicators<br>
slide47. Certificate of Achievement Complete survey
Email contains contact hours<br>
slide48. Follow-up Questions Send your questions by 12:00 PM CT for seven days following the training
Email wps.gha.education@wpsic.com
Subject Line: Today’s Topic
Send claim specific questions to Customer Service<br>
slide49. Survey Let us know what you think!
Take time to complete the survey now.
Survey link in chat
Redirect after closing webinar<br>
slide50. Thanks for attending!<br>
Still hearing music?
Close and restart the session
Change your audio setting by
Choosing “Audio & Video”
Select “Switch Audio”
Call in
The phone information is in the chat
Email for technical difficulties
wps.gha.education@wpsic.com<br>
slide2. Maximize Reimbursement: Policy Coverage for Wound Care July 2025<br>
slide3. Housekeeping Training Center webpage
Training Material
Upcoming Events
Encore Presentations
60 to 90 days
Send questions and comments in Chat
After this, tell CMS how we did on the survey<br>
slide4. Disclaimer This material is a tool to assist the provider community. Medicare rules change often.
The basis for answers given today rely on facts given in the question. Medicare rules determine final coverage.
Access CMS’ website for current coverage, regulations and rulings.<br>
slide5. CPT Copyright Notice CPT codes, descriptions, and other data only are copyright 2024 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.<br>
slide6. Acronyms LCD – Local Coverage Determination
NCD – National Coverage Determination
NPP – Non-Physician Practitioner
POC – Plan of Care
SMART – Specific, Measurable, Attainable, Relevant, Time-based<br>
slide7. Objective & Agenda To learn about the critical elements of wound care policy coverage, billing and documentation
Review policy coverage criteria for wound debridement
Discuss documentation requirements and review findings
Provide insight into billing and coding policy requirements<br>
slide8. Coverage<br>
slide9. Local Coverage Determination (LCD) L37228 Offers coverage guidelines for wound care involving
Debridement
Electrical stimulation and electromagnetic therapy
Negative pressure wound therapy
Low frequency non-contact non-thermal ultrasound (MIST Therapy)
Topical oxygen therapy (TOT)<br>
slide10. Coverage Basics At least one of the following conditions must be present and documented
Pressure injury, Stage II, II or IV
Venous insufficiency ulcers
Arterial insufficiency ulcers, including diabetic, lower extremity
Wounds with exposed hardware or bone
Neuropathic ulcer(s)
Neuro-ischemic ulcer(s)
Diabetic foot ulcer(s)
Complications of surgically created or traumatic wound<br>
slide11. Standard Wound Care Optimal nutritional status
Debridement to remove dead tissue
Maintain clean, moist wound with appropriate moist dressing
Infection prevention and resolution if present Repositioning
Glucose control
Maintain circulation for arterial ulcers
Compression systems for venous ulcers<br>
slide12. Debridement<br>
slide13. Debridement Defined Removal of foreign material, devitalized, or contaminated tissue from an adjacent to a traumatic or infected wound
Exposes surrounding healthy tissue
Goals
Remove devitalized tissue
Decrease risk of infection
Promote wound healing
Prevent further complications<br>
slide14. Selective or Non-Selective Debridement Selective
Targeted
Along margins of viable tissue
Non-selective
Surgical
Sharp
Enzymatic
Wet to moist dressing<br>
slide15. Documentation<br>
slide16. Documentation Requirements Documentation of covered condition
Certified plan of care
Treatment goals
Frequency and duration
Evidence of plan effectiveness including measurable changes
Drainage
Inflammation
Swelling
Pain
Wound dimensions
Necrotic tissue/slough<br>
slide17. Additional Documentation Physician orders
Physician progress notes
Photographic documentation of wounds, if applicable
Treatment records
Wound measurements from start of care
Debridement evidence – tissue removal, method utilized, character of wound before and after debridement
Severity of tissue destruction, undermining or tunneling, necrosis, infection, or evidence of reduced circulation
Complicating factors of healing<br>
slide18. Documentation Continued Contributory medical conditions
Nutritional status
Predisposing conditions
Advance Beneficiary Notice of Non-coverage (ABN), if applicable<br>
slide19. Expectations of Documentation<br>
slide20. Expectation of Improvement Medicare expects wound volume or surface dimensions to decrease over time with
Appropriate care
No medical surgical complications
Documentation could include
Drainage
Inflammation
Swelling
Pain
Wound dimensions
Necrotic tissue or slough<br>
slide21. Measurable Signs of Healing Document the following to support signs of healing
Decrease in wound size
Surface area
Volume
Decrease in amount of exudates
Decrease in amount of necrotic tissue<br>
slide22. Review Findings and Errors<br>
slide23. Incomplete/Insufficient Information No documentation or insufficient documentation of:
Debridement
Measurements
Plan of care or specific components of POC
Required conditions<br>
slide24. No Debridement Evidence Lacking evidence that service was provided
Demonstrating tissue removal
Type of debridement
Method utilized
Instrumentation used
Lacking debridement was to subcutaneous tissue level
Character of wound before and after debridement
Signature and credentials of who performed debridement<br>
slide25. Missing Measurements No pre and/or post measurements
Identified as either pre or post
Including size and depth
Should be measured with every progress report<br>
slide26. Missing POC or Components of POC The plan of care was not submitted
No expected frequency or duration
No detailed description of the wound
No descriptions of potential to heal
No treatment goals or plans
No modifications to plan when the plan isn’t working<br>
slide27. Incomplete Goal Information Document SMART goals
Progress towards goals
If lack of progress – how are goals changing
What wound should look like when goals are achieved<br>
slide28. Missing Complicating Factors and Methods to Control Documentation lacking complicating factors to healing
Documentation must include methods to control or limit complicating factors<br>
slide29. Missing Required Conditions of Coverage Listed in LCD L37228
Must be documented in the plan of care
If laboratory or imaging tests change the diagnosis, it must still meet coverage indications for treatment<br>
slide30. Billing and Coding Guidelines<br>
slide31. Article A55909 – Billing and Coding: Wound Care Use with WPS LCD L37228
Addresses procedure and diagnosis codes related to the LCD
Listing of code in the Article does not imply coverage
Must meet coverage indications, limitations, and/or medical necessity as described in the LCD<br>
slide32. Negative Pressure Wound Therapy (NWPT) NPWT device/unit/type or supplies covered under the Durable Medical Equipment benefit
See Social Security Act section 1861(s)(6)
Consult DME LCD for specific coverage, parameters and guidelines<br>
slide33. Some CPT Codes Included in A55909 Guidance 97597
Debridement (removal of damaged tissue), first 20 square centimeters or less
97598
Each additional 20 square centimeters of debridement 11042-11047
Sharp debridement
More aggressive, removes deeper tissue
Code depends upon depth of tissue removed and the surface area of the wound CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide34. Hydrotherapy When 97597 or 97598 are billed by a therapist, documentation must reflect the skill set of a therapist was required to perform the service in the given situation CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide35. Whirlpool CPT 97022
Not separately billable with 97597 or 97598 unless provided for a different body part than the wound care treatment body part CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide36. Local Infiltration Not Separately Covered Includes
Metatarsal/digital block
Topical anesthesia
Anesthesia administered by or incident to the provider performing the debridement<br>
slide37. “Sometimes” Therapy Codes – 97597 and 97598 For patient under a home health benefit
May be covered by the Home Health agency if part of their plan of care
If billed by a physician or NPP, codes can be paid under Part B even if the beneficiary is under an active home health plan of care CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide38. CPT 97602 Always Bundled Assigned a status code “B” on the Physician Fee Schedule (PFS) Relative Value Files
Never separately payable
Do not bill the patient CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide39. CPT 97026 - Infrared Not covered per NCD 270.6 - Infrared Therapy Devices CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide40. Ultrasound for Wound Care and Phototherapy – Ultraviolet Modalities Reported with 97035 and 97028, these codes are not payable for wound care
Per L37228 CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide41. Reporting codes 11042-11047 for Debridement of Wound Before Topical/Local Anesthesia Applied When this occurs for a single wound, report code based on the depth of tissue that is removed and by surface area of the wound When this occurs for multiple wounds, sum the surface area of those wounds that are the same depth, but do not combine sums from different depths CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide42. More Coding Guidelines Do not report 11042-11047 in conjunction with 97597-97602 for the same wound
CPT codes 11044 and 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC) CPT codes 11043, 11046 and 11044, 11047, are codes that describe deep debridement of the muscle and/or bone CPT only copyright 2024 American Medical Association. All rights reserved.<br>
slide43. Reasons for Denial Performing bony debridement in place of service other than inpatient hospital, outpatient hospital, or ambulatory surgery center
Billing of debridement by unqualified personnel<br>
slide44. Questions and Answers<br>
slide45. Customer Service Process Change What:
One NPI/PTAN combination per call
When:
Effective August 4, 2025
Why:
Improve call efficiency
Decrease wait times
Quicker resolution of inquiries<br>
slide46. We Hear You We are committed to making changes to improve your education experience.
Based on survey comments
Chapters to YouTube
Training indicators<br>
slide47. Certificate of Achievement Complete survey
Email contains contact hours<br>
slide48. Follow-up Questions Send your questions by 12:00 PM CT for seven days following the training
Email wps.gha.education@wpsic.com
Subject Line: Today’s Topic
Send claim specific questions to Customer Service<br>
slide49. Survey Let us know what you think!
Take time to complete the survey now.
Survey link in chat
Redirect after closing webinar<br>
slide50. Thanks for attending!<br>