Alabama Widespread Targeted Review Results for CPT 97597 and 97598 (Wound Debridement)
Part A Medical Review has recently completed the 4th quarter widespread targeted prepay review of CPT codes 97597 and 97598 (wound debridement) for claims processed October 1, 2007, through December 31, 2008. Educational articles providing the results of a previous review was posted on the “What’s New” page of the Cahaba web site in November 2007. Results of the current review are summarized below:
Providers reviewed: 5
Claims reviewed: 5
Claims approved: 2
Claims denied: 3
Charges reviewed: $3,168
Charges denied: $924
Error rate: 29%
The review decisions were based on the current LCD for Debridement Services (L1505).
The denials were due to the following reasons:
53603 – The medical record did not verify that the service described
by the HCPCS code was provided
55520 – Inadequate medical documentation submitted
- Whirlpool (97022) is included in 97597/97598
- CPT 97597/97598 is per session and is not billable in multiple units per visit. The use of GP modifier 59 to allow billing of more than one 97597/97598 should only be done if the patient is seen for 2 separate sessions on the same date
- Wound assessment/evaluations (97001) is part of the 97597/97598 code and should not be billed separately unless a complete evaluation as defined in the LCD is performed
The Intermediary again reminds the provider community of the importance of thorough documentation in the medical record to support CMS requirements for appropriate billing of services.
As a result of this review, Part A Medical Review will continue the widespread targeted review of CPT 97597 and 97598 identified by edit number 5142K. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.
Page last updated: March 26, 2008
