What Exactly is CPT Code 97598? A Clear Definition
CPT code 97598 is widely used by healthcare specialists in medical billing and documentation. Its official CPT descriptor is: “Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session.”
In simpler terms, this code represents a non-selective method of wound cleaning where both healthy and non-healthy tissue may be removed in the process. It is a per session code, meaning it is billed for each occasion the service is performed.
Why Understanding the “Non-Selective” Nature of 97598 is Critical
The key differentiator for 97598 is the term “non-selective.” This means the debridement technique does not precisely target only necrotic (dead) or devitalized tissue. Common non-selective methods include:
- Wet-to-moist dressings: The removal of the old dressing also pulls away loose debris and slough.
- Mechanical abrasion: Scrubbing the wound surface with gauze or a tool.
- Larval (maggot) therapy: Using sterile maggots to consume devitalized tissue.
Because these methods are not precise, they are considered less complex than selective sharp debridement (represented by codes 11042-11047).
How CPT 97598 Differs from Selective Debridement Codes (11042-11047)
This is the most common area of confusion for healthcare specialists, medical biller and coders. The difference lies in the tool used and the precision of the tissue removal.
- CPT 97598 (Non-selective): Uses non-sharp tools (gauze, irrigation, enzymes). The removal of tissue is a byproduct of the procedure (e.g., changing a dressing).
- CPT 11042-11047 (Selective): Uses a sharp instrument like a scalpel, scissors, or laser. The primary purpose of the procedure is to precisely cut away specific necrotic tissue, leaving healthy tissue intact.
You cannot bill 97598 and a selective debridement code (11042-11047) for the same wound during the same session.
Why Proper Wound Assessment is a Billable Part of 97598
A crucial and often overlooked aspect of 97598 is that it includes wound assessment and patient instruction. This means the simple act of evaluating the wound’s size, depth, drainage, and peri-wound condition, and then educating the patient on ongoing care, is bundled into the code. You cannot separately bill an E/M office visit for this same assessment if the sole reason for the encounter was the debridement. However, if a significant, separately identifiable E/M service is performed (e.g., managing the patient’s diabetes in detail), modifiers may apply.
How to Document 97598 for a Clean and Successful Claim
Thorough documentation is your best defense against denials. Your medical record must clearly support the medical necessity of the debridement. Include:
- Pre-procedure wound description: Size (length, width, depth), location, type of tissue (e.g., “% of slough vs. granulation tissue”), amount of exudate, odor.
- Procedure details: Specific technique used (e.g., “wet-to-moist dressing removed with gauze abrasion”), the amount of devitalized tissue removed (e.g., “moderate amount of yellow slough”), and any topical agents applied.
- Post-procedure wound description: The appearance of the wound after debridement.
- Patient instructions: Note the education provided to the patient or caregiver for ongoing wound care.
Why You Can’t Bill 97598 with Anesthesia
The code descriptor explicitly states “without anesthesia.” This code is intended for debridement procedures that do not require a local, regional, or general anesthetic because they are not expected to be painful to the point of requiring nerve blockage. If anesthesia is required, the wound likely requires a more complex, selective sharp debridement (11042-11047), which does allow for anesthesia.
How to Determine Medical Necessity for 97598
Medicare and other payers will not reimburse for routine wound care. Debridement must be medically necessary. Documentation should answer:
- Why is debridement needed? (e.g., “Debridement performed to remove barriers to healing such as necrotic tissue and biofilm.”)
- How will this procedure promote healing?
- What is the treatment plan? (e.g., “Will perform non-selective debridement weekly until wound bed is clean and ready for advanced modalities.”)
Why Frequency and Consistency Matter for This Code
Billing 97598 daily for the same wound will almost certainly trigger an audit. The frequency of debridement must be justified by the wound’s condition and the overall treatment plan. The standard of care typically involves weekly debridement, or more/less frequently based on factors like wound size, amount of exudate, and goals of care.
How to Use Modifiers with CPT Code 97598
To use modifiers with CPT code 97598 (removal of devitalized tissue, each additional 20 sq cm), ensure the base code 97597 is also billed, and apply modifiers like -59 to indicate distinct procedural services when performed at separate anatomical sites or sessions. Always consult payer-specific guidelines, as documentation must support medical necessity and justify the use of each modifier.
- Modifier -59 (Distinct Procedural Service): Used if you perform 97598 on multiple distinct, separate wounds during the same session. You would bill 97598 for the first wound and 97598-59 for each additional wound.
- Modifier -25 (Significant, Separately Identifiable E/M Service): Appended to an E/M office visit code if, on the same day as the 97598 service, you also performed a separate and significant evaluation and management service that went beyond the standard assessment included in 97598.
What are the Most Common Reasons for 97598 Denials?
The most common reasons for 97598 denials include missing documentation to support medical necessity and failure to bill the primary code 97597 alongside it. Other frequent issues involve incorrect modifier use or exceeding frequency limits set by payers, more detail includes
- Lack of Medical Necessity: The documentation did not justify why debridement was needed.
- Insufficient Documentation: The note failed to describe the pre/post wound status, the technique used, or the tissue removed.
- Incidental to E/M: Billing an E/M service that was not separately identifiable from the bundled assessment of 97598.
- Frequency Edits: Billing too many units in too short a time period without justification.
- Bundling with Other Codes: Attempting to bill 97598 with a selective debridement code for the same wound.
How Medicare and Private Payers View CPT 97598
Medicare Administrative Contractors (MACs) have specific Local Coverage Determinations (LCDs) for wound care that provide strict guidelines on the use of 97598. They often require detailed documentation of tissue type removed and may have frequency limitations. Private payers often follow Medicare’s lead but have their own policies. It is imperative to check your specific payer’s guidelines.
Why Larval Therapy Falls Under This Code
Biological debridement using sterile maggots (larval therapy) is a perfect example of a non-selective debridement. The maggots secrete enzymes that dissolve necrotic tissue, which they then consume. The provider applies the larvae and dresses the wound. The actual debridement is performed by the larvae, not by a sharp instrument, making 97598 the appropriate code for the application and management of this therapy.
How to Choose Between 97597 and 97598
CPT 97597 is for active wound care management, which involves topical application and wound assessment but does not involve the physical removal of tissue. If you are only applying an ointment and a dressing without any mechanical removal of debris, 97597 may be more appropriate. If you are actively removing devitalized tissue through abrasion, irrigation, or enzymatic action, 97598 is the correct choice.
What are the Reimbursement Rates for 97598?
CPT code 97598 refers to the selective debridement of a wound, billed for each additional 20 cm² beyond the initial 20 cm² covered under CPT 97597. It is an add-on code, meaning it cannot be billed alone and must be used in conjunction with 97597. The 2025 Medicare national average reimbursement rate for 97598 is approximately $43.34 per unit in a non-facility setting and about $23.29 per unit in a facility setting. However, these rates can vary based on geographic location and specific Medicare Administrative Contractor (MAC) guidelines. Some reports indicate a local range between $28 and $40, depending on the region.
Interestingly, a case from Florida showed a much lower Medicare reimbursement of $7.09, though this is likely an anomaly or the result of specific modifiers or payer adjustments. Billing for this code requires precise calculation based on wound size—for example, a wound measuring 55 cm² would be billed as 97597 x1 and 97598 x2, since the first 20 cm² is covered by 97597 and the remaining 35 cm² is split into two additional units. Proper documentation is crucial and should include wound size, method of debridement, tissue types removed, and justification of medical necessity.
How to Audit Your Own 97598 Claims to Avoid Penalties
Conducting periodic self-audits is a best practice. Pull a sample of charts where 97598 was billed and check for:
- Documentation Link: Does the note clearly describe a non-selective debridement technique?
- Medical Necessity: Is the reason for debridement stated?
- Modifier Use: Were modifiers -59 or -25 used correctly and only when appropriate?
- Frequency: Is the frequency of billing supported by the clinical picture in the notes? Proactive auditing helps ensure compliance and protects your practice from costly take-backs.
Final Conclusion: Mastering 97598 for Optimal Patient Care and Compliance
Correctly using CPT code 97598 is essential for accurate reimbursement and reflecting the valuable wound care services you provide. Remember, the cornerstone is precise documentation that illustrates the medical necessity and details the non-selective procedure performed.
By understanding its definition, distinctions, and documentation requirements, you can ensure your claims are clean, compliant, and successful. Always refer to the latest CPT manual and your major payers’ specific guidelines for the most current information.