CPT Code 97597 A Complete Guide to Wound Care Billing and Documentation
In the US healthcare system, the CPT code 97597 is one of the most frequently used wound care specialists in wound care billing in outpatient, hospital, and clinic settings. This CPT code refers to the selective debridement of devitalized tissue, performed on open wounds that are 20 square centimeters or less in size of patient. Providers, coders, and billing specialists need to understand its definition, scope, and compliance requirements to avoid denials and ensure accurate reimbursement.
What is Official CPT Code 97597 Definition?
What is Official CPT Code 97597 Definition, Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; first 20 sq cm or less.
What Does CPT 97597 Include?
CPT code 97597 covers the selective debridement of open wounds up to 20 square centimeters, a procedure essential for promoting healing by removing dead or contaminated tissue. This encompasses the use of instruments like scalpels and scissors, along with other methods such as high-pressure water jets, and includes services like wound assessment, whirlpool therapy, and topical applications when performed during the same encounter. This code covers more than just the physical removal of tissue. It also includes:
- Selective removal of non-viable tissue (slough, necrosis, fibrin).
- Wound cleansing and preparation.
- Application of topical medications.
- A detailed wound assessment.
- Education and instructions for ongoing wound management.
What Are Common Clinical Scenarios for CPT 97597?
CPT code 97597 is commonly used in various clinical scenarios where active wound care is needed for a small, open wound of patients. It is frequently applied to the debridement of chronic wounds such as diabetic foot ulcers and pressure ulcers, where dead tissue must be removed to prevent infection and promote healing. Healthcare providers in the USA may use this code in cases such as:
- Diabetic ulcers with necrotic tissue.
- Venous stasis ulcers requiring selective debridement.
- Pressure ulcers with slough or fibrin.
- Traumatic wounds with debris.
- Surgical wounds that fail to heal properly.
CPT 97597 vs. CPT 97598
CPT 97597 and CPT 97598 are both used for selective debridement of open wounds, but they differ based on the wound’s total surface area. CPT 97597 is the primary code for the initial 20 square centimeters or less of debridement. CPT 97598 is an add-on code, used to bill for each additional 20 square centimeter increment (or part thereof) beyond the initial 20 cm². You must always bill 97598 in conjunction with 97597 for larger wounds.
CPT 97597 vs. Excisional Debridement Codes (11042–11047)
CPT 97597 codes for selective debridement, which is the targeted removal of non-viable tissue from a wound’s surface (epidermis and/or dermis) while leaving healthy tissue intact. In contrast, excisional debridement codes (11042-11047) are used for a more aggressive, surgical procedure that involves cutting away tissue to a deeper level, such as the subcutaneous tissue, muscle, or even bone, and are typically performed by a surgeon. You should not report 97597 and the 1104x codes for the same wound during the same encounter.
What Are Documentation Requirements for CPT 97597
Accurate documentation is critical for billing CPT 97597. The medical record must clearly describe the wound’s location, size (in square centimeters), and depth, along with the specific debridement technique used (e.g., sharp selective debridement with a scalpel). It also needs to justify medical necessity by detailing the type and extent of non-viable tissue removed (e.g., necrotic tissue, fibrin) and explaining how the procedure is intended to promote healing. For compliance and audit protection, the provider must document:
- Wound size, depth, and location.
- Type of tissue removed (slough, fibrin, necrotic tissue).
- Instruments used (scissors, scalpel, curette, high-pressure irrigation).
- Amount of tissue removed (area in sq cm).
- Post-procedure wound condition.
- Patient education and instructions provided.
Billing Guidelines for CPT 97597
Proper billing for CPT 97597 requires careful consideration of the wound’s size and the services provided. This code should only be billed for the debridement of wounds that are 20 square centimeters or less; for larger wounds, CPT 97598 must be used as an add-on code for each additional 20 square centimeters. It is important not to bill separately for services such as whirlpool therapy, wound assessments, or topical applications on the same day for the same wound, as these are considered integral parts of the debridement procedure under this code. Key rules include:
- Bill per wound session, not per wound.
- Only use 97597 for wounds ≤20 sq cm; add 97598 for additional wound area.
- Do not bill 97597 with non-selective debridement (97602) on the same wound.
- Use correct modifiers (e.g., -59 or -XS) if treating separate anatomical sites.
Reimbursement for CPT 97597
Reimbursement for CPT 97597 is subject to a variety of factors, including the payer (e.g., Medicare, Medicaid, or private insurance), the patient’s specific plan, and the geographic location where the service is rendered. Generally, Medicare and other insurers determine reimbursement based on Relative Value Units (RVUs) and a conversion factor, which varies by facility and non-facility settings. To ensure proper payment and avoid denials, providers must submit detailed documentation that proves the medical necessity of the debridement and supports the use of this specific code.
- Medicare and most commercial payers reimburse CPT 97597 at an outpatient physician fee schedule rate.
- Reimbursement varies by state and payer but generally ranges between $70–$150 per session.
- Documentation quality directly affects approval and payment.
Frequency Limitations and Payer Rules
Billing for CPT 97597 is subject to specific frequency limitations and payer policies to ensure medical necessity. Medicare, for instance, generally allows one debridement service per wound per 30 days, although exceptions may exist if documentation supports a new wound or a significant change in the existing wound’s condition. Providers should also be aware that some private insurers may require prior authorization for multiple sessions of debridement. Many insurers, including Medicare, have Local Coverage Determinations (LCDs) that limit frequency:
- Debridement may only be covered once every 7 days unless medically necessary.
- Continued use requires documentation of wound improvement (e.g., size reduction, granulation tissue).
- Excessive billing without progress often triggers audits or denials.
ICD-10 Codes Commonly Linked to CPT 97597
CPT 97597 is often linked with ICD-10 codes that describe a variety of chronic, non-healing, or acute wounds. Common diagnoses include diabetic foot ulcers (e.g., E11.621 for Type 2 diabetes with a foot ulcer) and non-pressure chronic ulcers (L97.- codes) related to conditions like venous stasis or atherosclerosis. The use of these codes establishes medical necessity for the debridement by specifying the underlying condition that is hindering wound healing. To ensure payment, 97597 must be paired with an appropriate ICD-10 diagnosis code, such as:
- E11.621 – Diabetic foot ulcer.
- L97.411–L97.429 – Non-pressure ulcers of lower extremities.
- L89.152–L89.159 – Pressure ulcers, sacral region.
- T81.89XA – Non-healing surgical wound.
CPT 97597 and Modifier Usage
Appropriate use of modifiers with CPT 97597 is essential for accurate billing, especially when multiple procedures are performed during the same encounter. The -59 modifier (Distinct Procedural Service) is most commonly used to indicate that the debridement was a separate and distinct service from other procedures performed on the same day. This could be for a second, separate wound site or to unbundle it from another service that would typically be bundled with the debridement. Modifiers clarify billing situations:
- -59: Distinct procedural service (when two procedures are done in separate wounds).
- -XS: Separate structure (more specific than -59).
- -25: When billed with an E/M service on the same day.
Common Billing Errors with CPT 97597
Common billing errors for CPT 97597 often involve incorrect documentation and inappropriate code usage. One of the most frequent mistakes is using CPT 97597 for wounds larger than 20 square centimeters without also billing the add-on code 97598, leading to under-reimbursement. Another key error is the practice of “unbundling,” which involves billing separately for services that are already included in CPT 97597, such as routine dressings, whirlpool therapy, or wound assessment.
- Using 97597 for excisional debridement (should use 11042–11047).
- Not documenting wound measurements.
- Forgetting to bill 97598 for larger wounds.
- Billing multiple units of 97597 instead of adding 97598.
- Overusing the code without evidence of wound improvement.
CPT 97597 in Telehealth and Remote Wound Care
While CPT 97597 itself cannot be billed via telehealth (as it requires a procedure), providers can use telehealth for follow-ups, wound monitoring, and ongoing care instructions, which support medical necessity for future debridement.
Conclusion
CPT 97597 is not just a billing code, it reflects a critical clinical service in wound management. Correct usage requires understanding its scope, documentation needs, payer rules, and distinctions from other debridement codes. By following best practices, healthcare providers can ensure compliance, secure proper reimbursement, and, most importantly, support better patient healing outcomes.