Wound Care Billing: A Guide for Providers
Get clarity on wound care billing
With diligent documentation and a knowledgeable billing partner, providers can obtain full reimbursement for wound care services — every time
Due to a number of specific factors, billing for wound care services and procedures is often significantly more complex than billing in other specialties. What’s more, because reimbursement for wound care services, procedures, and associated supplies can be so high, it is especially important for practitioners and billers to work closely together to ensure maximum reimbursement for wound care services and related charges.
To put it simply, a lot of money is on the line. Wound care is reimbursed at a high rate, and a biller with expertise in wound care services can often increase revenue of even a small practice by tens of thousands of dollars per month or more. We know, because we’ve done it.
The key is to invest the time and resources to gain a thorough understanding of the finer points of wound care billing, and then to apply that expertise with diligence and consistency to every charge. Unfortunately, few providers and even fewer medical billing services understand all the nuances, and a lot of revenue is lost.
We’re here to help. Read on:
Prerequisites
As with any specialty, the billing process for wound care services begins with your initial evaluation of the patient. Of course, prior to this appointment, your staff should verify the patient’s insurance coverage, and ensure collection of any copayment.
From a billing standpoint, the key steps during the evaluation itself are to determine the medical necessity of further treatment for the patient’s wound. If wound care treatment is indeed medically necessary, the next step is to obtain pre-authorization from the patient’s insurance company for that treatment.
Documentation Requirements for Wound Care Services
The documentation requirements for wound care services are quite stringent. In order to ensure prompt and full reimbursement, a significant amount of information must be included with the patient’s record, and attached to every claim submission. This includes:
Thorough description of the wound
At a high level, there are four types of wounds. Each wound can be described as either:
Acute
Chronic
Surgical
Traumatic
Each type of wound should then be further described based on its specific characteristics and circumstances. For example, acute wounds can be caused by a cut or burn; a chronic wound is likely associated with a condition such as diabetic foot ulcers, pressure ulcers, venous stasis ulcers, bed sores, or other long term condition; a surgical wound will be due to a medical procedure; and a traumatic wound will be the result of an accident.
Information about the patient’s wound should be documented, including its size, appearance, drainage of fluids, presence or possibility of infection, and any associated medical issues connected to it.
Chronic wounds
Treatment of wounds associated with chronic conditions requires a thorough review of the patient’s medical records, which is often time-intensive. This will also
Description of treatment modalities
Some of the different modes of wound treatment include:
Debridement
For chronic wounds, debridement is often necessary. To properly bill for debridement, the description of the area subject to treatment must include:
Measurements of the debrided area
Measurements of area of selective debridement
Measurements of area of non-selective debridement
Manner of debridement (surgical or non-surgical)
Photos of the treatment area
The medical record should include a detailed description of the layer of tissue which is removed during the debridement. Documentation of the manner of debridement must also include precise detail, such as instruments used in the case of surgical debridement (scalpel, scissors, nippers, curettes), or the specific type of non-surgical debridement employed (mechanical, autolytic, enzymatic, maggot therapy) with additional discussion of exact instruments or treatments used.
For surgical debridement, documentation must also describe how tissues were cut at each stage of the procedure, and which instruments were used at each point.
Dressings used
There are numerous types of dressings now in use to treat different types of wounds at different stages in the healing process. These include low-adherent dressings, films, hydrocolloids, hydrogels, alginates, foams, various types of antimicrobial dressings, and others. Advances in wound dressing technology happen often, and different products may have large differences in both cost and potential reimbursement from insurance payors.
Topical agents used
The specific ointments, topical antibiotics, and other topical agents used during procedures and the follow-up and healing process must also be documented, along with an explanation of the role and purpose of each one in the course of treatment.
Negative pressure therapy
While relatively new, negative pressure therapy has become an increasingly common component of the wound care treatment process. If used, it must be documented appropriately.
Description of wound healing process
Documentation of the healing process must be similarly detailed, and should include information about:
Dressings used
Description and documentation of healing period of the wound
Extent of recovery at each follow-up visit
Images documenting the healing process should be included
Monitoring during follow-up visits should also be documented, with any complications or subsequent developments noted in the record, as well as any prescriptions for antibiotics, referrals to other providers for biopsies, further testing, consulting, or other procedures.
Coding and submitting claims
Documentation and billing for wound care services requires translating all services provides into CPT and HCPCS codes.
The exact manner in which these codes are used does change with some frequency. For example, as of this writing, the official CMS guidance document Billing and Coding: Wound Care has been updated twice since 2022. Thus it is imperative that both providers and especially billers and coders invest the time and resources to stay abreast of any changes.
CPT codes for wound care
CPT codes are used for documentation and billing of procedures related to wound care, including diagnostic, surgical, and medical procedures. There are currently several dozen different CPT codes related to wound care listed in the CMS guidance document.
One critically-important aspect of CPT codes for wound care is that many codes require specific documentation of the surface area of the wound and the treatment area. For example, code 97597 is used for the first 20 square centimeters area of debridement, while code +97598 is used for each additional 20 square centimeters of debrided area. Therefore, accurate documentation of the debrided area, including pictures and measurements, is critical to billing and reimbursement for these procedures.
HCPCS codes for wound care
HCPCS codes are used to document and bill for services and supplies. There are over 100 HCPCS codes used for different supplies and services related to wound care. A list of these codes can be found using the Find A Code wound care code index, among other resources.
Similar to the CPT codes, many wound care-related HCPCS codes describe the surface area of treatment in specific terms. For example, code A6222 is used for a certain type of dressing with a size of 16 square inches or less, while code A6223 is used for the same type of dressing with a size of 16 to 48 square inches.
Billing modifiers for wound care
For many procedures, and especially for complex or unusual courses of treatment, modifiers are necessary both to fully describe the services provided, and to ensure full reimbursement for these services. Some modifiers which are commonly applicable in wound care documentation and billing include:
Left and right side modifiers, -LT and -RT, to indicate location of the wound
The distinct procedural service modifier, -59, to indicate a when more than one distict procedure was performed during a single visit
The evaluation and management (E/M) modifier, -25, can be used when E/M service is provided on the same day as treatment, and the E/M service is sufficiently significant and complex to warrant billing separately
Next Steps
The Promedica Partners team has developed considerable expertise in wound care billing, and has invested heavily in understanding the process to ensure maximum reimbursement for our clients. Even within the field of medical billing, the attention to detail required in wound care billing is rather unusual. Most medical billing services do a poor job with wound care billing, even if they are excellent in most other specialties. Due to our unique expertise, we have been able to dramatically increase revenue for each of our clients, usually within a very short period of time.
If you’d like to talk more about how we can help you improve your wound care billing processes, get in touch with us to learn more.