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Q/A: Payment when reporting CPT code 97602

APCs Weekly Monitor, October 14, 2011

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Q: Members of our hospital outpatient wound care department recently listened to our FI/MAC’s wound care teleconference. Information presented indicates that According to the presentation, CPT^® code 97602 (removal of devitalized tissue from wound[s], non-selective debridement, without anesthesia) is assigned status indicator B (Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type) for which CMS will not separately pay. Is this correct? 

Can you clarify “sometimes therapies,” specifically CPT code 97602? A billing alert lists “sometimes therapies” and the most current CMS notification we found was Transmittal 805/Change Request 4226 issued in 2006. This is confusing; we thought this was a payable procedure.

A. CPT code 97602 is assigned a status of B under the Medicare Physician Fee Schedule (MPFS ). When this service is provided by a discipline that receives reimbursement based on the MPFS, this code is not separately reportable or payable. Instead, it is bundled into other procedures performed.

The most recent Addendum B updates on CMS’ website indicate that CPT 97602 is assigned to status indicator T (significant procedure, multiple reduction applies) under OPPS. The difference exists because this code denotes a “sometimes therapy” procedure.

A procedure designated as “sometimes therapy” a qualified therapist (e.g. physical therapist) may perform under a therapy plan of care. When a qualified therapist provides the service, coders must report the service under a therapy revenue code with the appropriate therapy modifier (i.e., -GP for physical therapist). Payment for therapy services is based on the physician fee schedule; in this situation, CMS will bundle the payment for 96702 into other services provided.

In contrast, when the service is provided in a hospital outpatient department, (e.g., by wound care nurses) it is reported as a hospital outpatient service and payable under the assigned APC for hospitals subject to OPPS.

More information, including a list of services considered “sometimes therapy” is available at CMS’ website and the most recent transmittals concerning these services.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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