What is CPT Code 97602

What is CPT Code 97602? A Definition for Medical Coders

CPT code 97602 is used for reporting negative pressure wound therapy (NPWT), specifically the initial setup and instruction. Its official descriptor is: “Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.”

This code is distinct from 97605 (>50 sq cm) and 97606 (with installed system) and covers the hands-on work of initiating this advanced treatment.

 

Why CPT 97602 is a Cornerstone of Advanced Wound Care

Negative pressure therapy is a critical modality for complex wounds. Code 97602 allows providers to bill for the clinical expertise required to properly initiate this treatment, which promotes healing by removing exudate, reducing edema, and stimulating granulation tissue.

How to Determine Medical Necessity for 97602

Not every wound qualifies for NPWT. Payers require clear justification. Medical necessity for 97602 typically includes:

1. Chronic wounds (e.g., diabetic ulcers, pressure injuries, venous stasis ulcers) that have failed standard therapy.
2. Subacute and acute wounds.
3. Traumatic wounds.
4. Partial-thickness burns.
5. Flaps and grafts.

Your documentation must clearly state why NPWT is medically necessary for this specific patient at this time.

How the Wound Size (≤50 sq cm) Dictates Code Selection

When the size of a wound is 50 square centimeters or less, it significantly influences the selection of the correct medical billing code. This specific size threshold often distinguishes between codes for simple closures and those for more complex repairs, which might be necessary for larger wounds. The chosen code reflects the complexity of the procedure and the resources required for treatment. This is the primary differentiator. You must measure the wound’s surface area (length x width).

1. CPT 97602: Use for total wound surface area less than or equal to 50 square centimeters.
2. CPT 97605: Use for total wound surface area greater than 50 square centimeters.

Crucial Note: If treating multiple wounds with NPWT in the same session, you must add the surface area of all wounds together to determine the correct code.

 

How to Properly Document a 97602 Service for Audit-Proof Billing

To properly document CPT code 97602 for audit-proof billing, a provider must clearly document the medical necessity of the non-selective debridement. The record must specify the debridement technique (e.g., wet-to-moist, enzymatic), provide a thorough wound assessment including size and characteristics (e.g., tissue type, drainage), and detail the instructions given for ongoing patient care. This comprehensive documentation supports the service and prevents billing denials. Thorough documentation is your best defense against denials. The medical record must include:

1. Indication for NPWT: The medical reason for choosing this therapy.
2. Wound Measurements: Length, width, depth, and total surface area calculation.
3. Wound Description: Location, tissue type (granulation, slough, eschar), exudate amount/type, odor, peri-wound condition.
4. Procedure Details: Confirmation of a new NPWT system, the specific device used, the type of dressing/foam applied, and the pressure setting.
5. Patient/Caregiver Instruction: Detailed note on the education provided for ongoing care and emergency troubleshooting.

 

How the “Including” Language in 97602 Affects Billing

The code descriptor states it includes “topical application(s), wound assessment, and instruction(s) for ongoing care.” This means you cannot separately bill for:

1. A separate E/M service for the wound assessment if it was the sole reason for the visit.
2. Codes for application of topical medications (e.g., 97597, 97598) performed during the same session.
3. The supply of the NPWT device and dressings (these are billed separately with HCPCS Level II codes, like A6550).

 

How to Use Modifiers with CPT Code 97602 Correctly

Proper use of modifiers with CPT code 97602 is essential for accurate reimbursement and to avoid denials. For services performed by a physical or occupational therapist, use the appropriate therapy modifier (GP or GO). The 59 modifier is used to indicate a distinct procedural service, such as when debridement is performed on a separate wound from other procedures on the same date. Modifiers clarify unusual circumstances.

1. Modifier -59 (Distinct Procedural Service): Used if you perform NPWT on multiple separate anatomic sites during the same session. For example, initiating NPWT on a left heel ulcer and a right calf ulcer. Bill 97602 for the first and 97602-59 for the second (ensuring total surface area for each code is still ≤50 sq cm).
2. Modifier -25 (Significant, Separately Identifiable E/M Service): Appended to an E/M code if you perform a significant, separate evaluation and management service beyond the standard pre-procedure workup bundled into 97602.

 

How to Bill for the NPWT Supplies (Pump & Dressings)

CPT 97602 covers the professional service of application. The equipment and supplies are billed separately using HCPCS Level II codes. Common codes include:

1. E2402: Negative pressure wound therapy electrical pump, stationary or portable.
2. A6550: Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories.

 

How 97602 Differs from 97605 and 97606

CPT code 97602 is for non-selective debridement, which is the removal of dead tissue without differentiating between viable and non-viable tissue. In contrast, CPT codes 97605 and 97606 are for negative pressure wound therapy (NPWT), a specialized treatment that uses a vacuum to promote healing. The key difference between 97605 and 97606 is the wound size: 97605 is for wounds ≤ 50 sq cm, while 97606 is for wounds > 50 sq cm. Choosing the right code is critical:

1. 97602: Initial application of NPWT, total wound area ≤50 sq cm.
2. 97605: Initial application of NPWT, total wound area >50 sq cm.
3. 97606: Subsequent management of an already installed NPWT system. This involves dressing changes and canulation of tubing. Do not use 97602 for a dressing change on an existing system.

 

How Often Can You Bill 97602? Understanding Frequency

Code 97602 is for the initial application. It is typically billed only once per wound until the NPWT treatment cycle is complete and the device is discontinued. If the device is removed and then later reapplied to the same wound, you may bill the initial application code again, but you must have documentation supporting the medical necessity for re-initiating therapy.

 

How Medicare and Private Payers Review 97602 Claims

Medicare and private payers scrutinize claims for CPT code 97602 to ensure medical necessity and proper documentation. They look for detailed records specifying the non-selective debridement technique used, a thorough wound assessment with objective measurements, and a clear rationale for the ongoing treatment. Claims may be denied if documentation only describes a simple dressing change or lacks evidence of skilled care. Medicare and most private payers have strict Local Coverage Determinations (LCDs) for NPWT. They will scrutinize claims for:

 

1. Medical Necessity: Was NPWT truly needed?
2. Correct Wound Size: Was the correct code (97602 vs. 97605) used based on accurate measurements?
3. Documentation: Does the note support the code billed?
4. Global Periods: Ensure the service isn’t bundled into a post-operative period.

 

How to Avoid the Top 5 Denials for CPT 97602

To avoid the most common denials for CPT code 97602, ensure complete documentation of the wound’s condition, including size, location, depth, and the specific debridement technique used. Furthermore, always establish and document the medical necessity of the procedure, use appropriate modifiers to indicate distinct services, and verify payer-specific policies to confirm coverage and authorization requirements.

1. Incorrect Wound Size: Billing 97602 for a wound larger than 50 sq cm.
2. Lack of Medical Necessity: Failing to document why NPWT was required.
3. Bundling Issues: Attempting to bill a separate E/M service without a modifier -25.
4. Incorrect Code for Service: Using 97602 for a simple dressing change (use 97606 instead).
5. Insufficient Documentation: The note lacks details on wound size, procedure, or patient instruction.

 

How to Measure Wound Surface Area Accurately for Coding

Accuracy is non-negotiable. Use a disposable ruler or measuring tape. Measure the greatest length (head to toe) and the greatest width (hip to hip) in centimeters. Multiply length x width to get surface area. For irregular wounds, use the longest points or a wound mapping tool.

 

How to Handle Multiple Wounds with 97602

If applying NPWT to more than one wound, you must add the surface areas of all wounds being treated with NPWT together. If the total is ≤50 sq cm, bill 97602 once. If the total is >50 sq cm, bill 97605 once. If the wounds are on separate anatomic sites, you may use modifier -59 to bill multiple units, but the size rule for each unit still applies.

 

How to Document Patient Education for NPWT

To bill for negative pressure wound therapy (NPWT), you must document that you provided patient education for the ongoing care. This includes providing instructions on how to troubleshoot the device, manage the exudate canister, and recognize signs of complications. This documentation is a key part of the CPT codes 97605 and 97606, which include “instruction(s) for ongoing care” as part of the service. Documenting patient/caregiver instruction is a required component of 97602. Note:

1. Who was instructed (patient, family member, home health nurse).
2. The topics covered: how to manage the device, alarm troubleshooting, when to call the provider, and activities of daily living.
3. That the patient/caregiver demonstrated understanding.

 

How the Global Surgical Package Impacts 97602

If NPWT is applied during a global surgical period for the same wound, it is likely bundled into the global surgery payment and not separately billable unless it is for treatment of a new complication or a new condition.

 

How to Code for a Dressing Change (And Why It’s Not 97602)

A routine dressing change on an existing, functioning NPWT system is not billed with 97602. This service is reported with CPT 97606. Code 97602 is reserved for the initial setup of a new system.

 

How to Create a Bulletproof Clinical Note for 97602

To create a bulletproof clinical note for CPT code 97602, a provider must clearly document the medical necessity and the specific non-selective debridement technique used, such as wet-to-moist dressings or enzymatic debridement. The note must also include a detailed wound assessment with objective measurements (e.g., length, width, depth, and tissue types present) and confirm that instructions for ongoing care were provided to the patient. This comprehensive documentation is essential for justifying the service and ensuring proper reimbursement. A strong note should read like a story:

1. History: “Patient presents for NPWT initiation for a chronic diabetic foot ulcer that has failed 4 weeks of standard moist wound care.”
2. Exam: “Wound on plantar surface of right foot. Measurements: 4cm x 3cm x 0.5cm. Surface area: 12 sq cm. Wound bed is 80% red granulation tissue, 20% yellow slough.”
3. Procedure: “NPWT initiated with [Brand Name] device. Polyurethane foam dressing applied, set to continuous negative pressure at 125mmHg. Patient tolerated procedure well.”
4. Education: “Patient and wife instructed on device operation, alarm meanings, and precautions. They verbalized understanding and were given written instructions.”

 

How Technology is Changing the Documentation of 97602

Many EHRs now integrate with wound imaging and measurement tools that can automatically calculate surface area and store photos directly in the patient’s chart. This technology creates an irrefutable audit trail to support your code selection.

 

How to Stay Updated on Changing 97602 Guidelines

Coding rules, especially for high-cost services like NPWT, change frequently. The best ways to stay current are to:

1. Regularly check the AMA’s CPT® updates.
2. Review newsletters and policy updates from your major payers (e.g., Medicare MACs).
3. Invest in ongoing coder education from reputable sources like AAPC or AHIMA.

 

Final Conclusion: Mastering 97602 for Optimal Patient Outcomes and Practice Revenue

Correctly reporting CPT code 97602 ensures you are appropriately reimbursed for the complex care involved in initiating negative pressure wound therapy. By focusing on accurate wound measurement, meticulous documentation of medical necessity, and a clear understanding of code hierarchies and modifiers, you can confidently manage your wound care billing and avoid costly denials. Always consult the most current CPT manual and payer-specific policies for the definitive guidance.