CPT Code 97598: Debridement of Wound; Skin, Subcutaneous Tissue, Muscle, and Bone

Introduction

CPT Code 97598 is a procedural code used in medical billing and coding to describe debridement of open wounds, specifically for wounds that require selective removal of devitalized tissue using sharp instruments, such as scalpels or scissors. This code is billed per session and applies when the debridement exceeds 20 square centimeters beyond the first wound area.

What is CPT Code 97598?

Definition and Purpose

CPT Code 97598 represents wound debridement that involves the removal of necrotic, devitalized, or infected tissue from an open wound to promote healing. It is commonly used for chronic wounds, burns, ulcers, and post-surgical sites.

Importance in Medical Billing and Coding

This code is critical in medical billing because it ensures proper reimbursement for healthcare providers offering wound care services. Accurate coding prevents claim denials and maximizes reimbursement while ensuring compliance with Medicare, Medicaid, and private insurance policies.

Common Medical Conditions Treated with CPT Code 97598

• Diabetic foot ulcers
• Pressure ulcers (bedsores)
• Venous stasis ulcers
• Post-surgical wound infections
• Traumatic wounds
• Burn injuries

Who Can Bill CPT Code 97598?

Healthcare Professionals Eligible to Use This Code

• Physicians (MD, DO)
• Podiatrists
• Wound care specialists
• Physician assistants (PA) under supervision
• Nurse practitioners (NP)

Settings Where This Code is Applicable

• Hospitals (outpatient and inpatient settings)
• Wound care clinics
• Skilled nursing facilities
• Home healthcare
• Private physician offices

Related CPT Codes with 97598 (Respective Treatments)

Frequently Billed Codes with CPT 97598

• 97597 – Debridement of wound(s), total wound area up to 20 sq cm
• 11042 – Debridement of subcutaneous tissue
• 11043 – Debridement of muscle and/or fascia
• 11044 – Debridement of bone

Comparison with Similar CPT Codes

• 97597 vs. 97598: 97597 covers wound debridement up to 20 cm², whereas 97598 is billed for additional debridement exceeding 20 cm².
• 11042-11044 vs. 97598: The 1104X series applies when the debridement extends beyond the skin into deeper structures, such as subcutaneous tissue, muscle, or bone.

Step-by-Step Billing Method for CPT Code 97598

1. Assess the Wound Size
   
   • Carefully measure the wound to determine if it exceeds 20 square centimeters.
   • Use a ruler or wound measurement device to document length, width, and depth accurately.
   • Ensure that the wound qualifies for CPT 97598, as this code is used for each additional 20 cm² beyond the initial 20 cm², which is billed under CPT 97597.
2. Perform Selective Debridement
   
   • Use sharp instruments such as a scalpel, scissors, or forceps to remove devitalized, necrotic, or infected tissue.
   • Ensure that the debridement is selective—targeting only the necessary areas while preserving healthy tissue.
   • Follow sterile techniques to minimize infection risks.
3. Document Detailed Wound Care Notes
   
   • Record the wound dimensions (length, width, and depth) before and after debridement.
   • Note the type of necrotic tissue removed (e.g., slough, eschar) and the method used for debridement.
   • Include details about patient tolerance, healing progress, and any complications observed.
4. Check Insurance Policies
   
   • Verify with the patient’s insurance provider if pre-authorization is required for CPT 97598.
   • Some insurance plans may have specific coverage limitations or documentation requirements for reimbursement.
5. Bill in Conjunction with CPT 97597
   
   • Use CPT 97597 for the first 20 cm² of debridement.
   • Bill 97598 for each additional 20 cm² beyond the initial wound area.
   • Ensure proper coding and modifier usage if multiple wounds or different anatomical sites are involved.

Proper documentation and coding compliance are essential for accurate billing and insurance reimbursement while ensuring the best patient care outcomes.

Reimbursement Guidelines for CPT Code 97598

Reimbursement rate

Note: This reimbursement rate is average and may not reflect the actual reimbursement you receive. Always verify coverage and rates with individual payers.

Insurance and Medicare/Medicaid Policies

• Medicare typically reimburses this procedure when medically necessary for wound healing.
• Medicaid coverage varies by state; providers should check regional policies.
• Private insurers may require prior authorization or additional documentation.

Documentation Requirements for Successful Claims

• Wound measurements before and after debridement
• Description of the debridement method used
• Photographic evidence (if required by the insurer)
• Clinical necessity justification

How to Maximize Reimbursement for CPT Code 97598

Best Practices to Ensure Full Compensation

• Use correct ICD-10 diagnosis codes linked to the wound condition.
• Submit detailed, clear documentation of the procedure.
• Verify coverage policies with insurance providers beforehand.

Commonly Approved Modifiers and Documentation Tips

• Modifier 25 – When billed alongside an Evaluation and Management (E/M) service.
• Modifier-59 – If debridement is performed on separate anatomical locations.
• Modifier XU – To clarify distinct procedural services.

Common Billing Mistakes and How to Avoid Them

Frequent Coding Errors and Claim Denials

• Billing 97598 without 97597 – These codes are often used together, with 97597 billed first.
• Insufficient documentation – Lack of wound measurements and procedure details.
• Incorrect modifier usage – Leading to claim rejection.

Strategies to Prevent Billing Mistakes

• Ensure accurate wound measurements
• Use appropriate modifiers when needed
• Stay updated on payer policies and reimbursement rules

Importance of Compliance and Audit Readiness

• Conduct regular audits to ensure billing accuracy.
• Train staff on correct coding guidelines.
• Maintain comprehensive patient records for compliance.

Conclusion

CPT Code 97598 plays a vital role in medical billing for wound care services. Proper documentation, correct coding, and adherence to Medicare and insurance policies ensure successful reimbursement. By following best practices and avoiding common billing errors, healthcare providers can maximize their revenue while delivering quality wound care.

FAQs

1. Can CPT Code 97598 be billed alone?

No, 97598 must always be billed in conjunction with 97597, as it applies to debridement exceeding 20 cm².

2. Does Medicare cover CPT Code 97598?

Yes, Medicare covers this code if the procedure is deemed medically necessary and properly documented.

3. How often can CPT Code 97598 be billed?

It can be billed per session when additional debridement exceeding 20 cm² is required.

4. Can a physical therapist bill CPT Code 97598?

No, only physicians, podiatrists, and qualified healthcare providers can bill for this service.

5. What documentation is needed for CPT Code 97598?

Providers must document wound size, depth, debridement method, and medical necessity to ensure successful claims processing.

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