Health Information Management

Q/A: NCCI edits and wound care management

APCs Insider, March 4, 2011

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Q: We have been coding active wound care management based on the new 2011 narrative updates and have been receiving the following National Correct Coding Initiative (NCCI) edit: CPT® code 97597 (Debridement, open wound, including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less) is a component code of CPT code 97598 (Removal of devitalized tissue from wound[s]… each additional 20 sq cm, or part thereof) and no modifier is allowed.

The 2011 CPT Professional Edition includes an instruction note to use add-on code CPT 97598 in conjunction with 97597. What is happening? Can you provide an update?

A: Changes to the description of CPT code 97598 for 2011 identify it as an add-on with CPT code 97597 if applicable. Previously, this was not the case; both CPT codes stood alone based on size less than or equal to 20 sq cm or greater than 20 sq cm respectively.

Under OPPS, hospitals have always been one quarter behind physician NCCI edits. For services provided by hospitals during the first quarter of 2011, the NCCI edits (Version 16.3) are not in line with the 2011 CPT changes. Therefore, NCCI edits continue to treat the codes as if they still stand alone.

Now, fast-forward to physician Version 17.0 NCCI edits, which will be effective for hospitals during the second quarter of 2011 (April through June). The same edit is occurring—CPT 97597 is a component code of CPT 97598 and no modifier is allowed.

As you probably know, a CPT add-on code may not stand alone without its counterpart. Reviewing this edit and combination has left many of us wondering how this occurred while the dilemma ensues.

Yes, this is a dilemma and no doubt a major concern for physicians, certified clinicians, and hospital outpatient departments performing and documenting these procedures.

Reviewing some of your Medicare outpatient claims with these two CPT codes and ascertaining your payments is imperative. We have heard the April NCCI edits might resolve the problem and that it will be retroactive to January 1, 2011. Some contractors reportedly have instructed providers to hold claims with code 97598 until after April 1.

We urge our hospital readers to contact their prospective Medicare Administration Contractors (MAC) to make them aware of this problem and facilitate an effective resolution. Remember that these CPT codes have three things in common—APC 0015, status indicator T, and a national unadjusted payment of $103. If the edits remain, hospitals will lose the 50% discount for the second procedure or $51 due to the failure to update the NCCI to reflect the new 2011 narratives.

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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