CPT Code 97607 Billing Guide (2025–2026)
CPT 97607 specifically describes NPWT performed with a disposable (non-durable) system on wounds with a total surface area greater than 50 cm², per session. Correctly coding and billing this service is essential to secure full reimbursement and avoid denials, particularly as Medicare and commercial payers tighten policies for 2025 and 2026.
We will provide you the latest AMA CPT® coding rules, CMS policy updates, and payer trends to help physicians, wound-care centers, and coders understand how to document and bill CPT 97607 accurately. We will explore how the code works, why it differs from other NPWT codes, and what 2025–2026 updates mean for revenue cycle management.
What Is CPT Code 97607?
CPT 97607 is defined by the American Medical Association as:
“Negative pressure wound therapy (e.g., vacuum-assisted drainage collection), utilizing disposable, non-durable medical equipment, including topical application(s), wound assessment and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters.”
Key elements include:
- Disposable NPWT system (single-patient use, such as PICO® or SNAP®).
- Total wound surface area >50 cm² (all wounds treated in one session are combined).
- Per session billing (one unit covers all wounds treated in that encounter).
Clinical Example:
A patient with two large pressure ulcers totaling 70 cm² is treated in the outpatient wound clinic. The provider applies a disposable NPWT device, documents wound size, and provides patient education. CPT 97607 is billed once for that session.
Why This Code Exists
Before disposable NPWT systems became common, providers used durable pumps (covered by CPT 97605/97606). Disposable devices simplify treatment—no rental pump, fewer clinic visits—but needed a separate code to reflect different cost structures and coverage rules. CPT 97607 ensures providers are reimbursed appropriately for disposable NPWT services.
How CPT 97607 Works in Wound Care
How the Therapy Is Applied
Disposable NPWT systems are single-use kits that include a dressing and a small suction unit. After cleaning and measuring the wound, the clinician:
- Applies a sterile foam or gauze dressing.
- Seals it with an adhesive drape.
- Connects the portable pump.
- Programs the prescribed negative pressure settings.
Because the pump is disposable, patients can often continue treatment at home without equipment rental.
How Billing Differs From Durable NPWT
Unlike durable NPWT (CPT 97605/97606), billing for CPT 97607:
- Includes the device—no separate HCPCS code for pump rental.
- Is per session, not per day of therapy.
- Requires documentation of disposable equipment and total wound surface area.
2025 Market Trends
- Growth Rate: According to a 2024 Market Data Forecast, the global NPWT market is projected to reach $4.6 billion by 2026, with disposable systems accounting for over 40% of new device adoption.
- Medicare Usage: CMS outpatient claims for CPT 97607 increased by an estimated 18% from 2023 to 2024, reflecting the shift to single-use technology.
- Audit Focus: MACs (Medicare Administrative Contractors) report frequent denials for incomplete wound size documentation and unclear device type.
Table 1. NPWT CPT Code Comparison (Durable vs. Disposable)
| CPT Code | Equipment Type | Surface Area | Per Session/Unit | Common Site of Service |
| 97605 | Durable | ≤50 cm² | Per session | Outpatient/clinic/home |
| 97606 | Durable | >50 cm² | Per session | Outpatient/clinic/home |
| 97607 | Disposable | ≤50 cm² | Per session | Outpatient/clinic/home |
| 97608 | Disposable | >50 cm² | Each additional wound area | Outpatient/clinic/home |
When and Why to Use CPT 97607 Instead of 97606
Correct code selection is the foundation of successful NPWT reimbursement.
Both 97606 and 97607 involve negative pressure wound therapy on wounds greater than 50 cm², but they differ in equipment type:
| Key Factor | CPT 97606 | CPT 97607 |
| Equipment | Durable pump (reusable) | Disposable single-use |
| Supply Billing | Pump often rented separately (HCPCS codes) | Device cost included in CPT charge |
| Typical Setting | Hospital outpatient, long-term care | Outpatient clinic, home health |
| Documentation Focus | Pump settings and maintenance | Device brand, disposable status |
How to Decide
- Identify Equipment Type – If the patient is using a single-use device (e.g., PICO®, SNAP®), CPT 97607 is required even if the wound is >50 cm².
- Measure Wound Area – If total combined wound surface area is ≤50 cm², bill 97605 (disposable) instead.
- Confirm Payer Policy – Some payers require prior authorization for disposable NPWT when wounds are large.
Why it matters in 2025/2026: CMS contractors have announced targeted audits focusing on correct device classification. Mislabeling disposable systems as durable can trigger repayment demands.
How to Bill CPT 97607 Accurately to Avoid Denials
Denials for 97607 often stem from documentation gaps or incorrect modifiers.
Follow these best practices to protect revenue:
5.1 Documentation Essentials
| Required Element | Why It Matters |
| Exact wound measurements (length × width in cm) | Proves total surface area >50 cm² |
| Device type and brand | Confirms disposable equipment |
| Clinical indication | Demonstrates medical necessity |
| Treatment description | Dressing, suction pressure, patient education |
| Prior conservative care attempts (if payer requires) | Supports escalation to NPWT |
Correct Coding Steps
- Bill CPT 97607 once per session for the initial wound area >50 cm².
- If additional distinct wound areas are treated, add CPT 97608 for each additional area.
- Use modifier 59 or X{EPSU} if NPWT is performed with other procedures (e.g., debridement at a different site).
- Report appropriate Place of Service (POS) codes (e.g., 11 = office, 22 = outpatient hospital).
- For Medicare, verify if a Local Coverage Determination (LCD) applies in your MAC region.
2025–2026 Documentation Trends
- Digital Wound Measurement Tools: By 2025, CMS encourages EMR integration of photographic wound measurements to reduce audit disputes.
- Prior Authorization Expansion: Large commercial plans (UnitedHealthcare, Aetna) announced plans to extend NPWT prior authorization to more states by mid-2026.
Checklist: Pre-Claim Verification for CPT 97607
| Step | Verification Item | Responsible Party |
| 1 | Confirm disposable NPWT device | Clinical team |
| 2 | Measure & document total wound area >50 cm² | Clinician |
| 3 | Capture brand/model in EMR | Nurse/tech |
| 4 | Review payer policy & authorization status | Billing staff |
| 5 | Apply correct CPT/HCPCS & modifiers | Coder |
| 6 | Attach wound photos (if payer requires) | EMR admin |
Advanced Billing Scenarios and Problem Solving
Even experienced coders face complex cases.
Below are real-world scenarios with recommended solutions:
| Scenario | Problem | 2025/2026 Best Practice |
| Multiple wounds, same session | Three wounds total 90 cm² | Bill 97607 once; add 97608 if a second distinct wound area requires a separate disposable system |
| Concurrent debridement | Provider performs surgical debridement (CPT 11042) and NPWT | Bill both; use modifier 59 to show distinct procedural service |
| Home health visit | Disposable NPWT applied during skilled nursing visit | Bill 97607 under physician or outpatient clinic if performed in clinic; otherwise use home health revenue codes |
| Patient switches from durable to disposable mid-treatment | Confusion over code selection | Use 97606 for durable sessions, then 97607 for disposable sessions; document device change date |
| Surface area fluctuates | Wound shrinks below 50 cm² after initial visit | Switch to 97605 (disposable ≤50 cm²) on subsequent dates |
Why These Scenarios Matter
Audit data show that nearly 25% of NPWT denials in 2024 were linked to:
- Improper unit reporting when multiple wounds were treated, or
- Failure to update codes when wound size changed.
Pro Tip for 2026: Develop an EMR alert that automatically recommends the correct CPT code when wound size or device type changes.
Quick Reference Table: Common Denial Reasons & Fixes
| Denial Reason | How to Prevent |
| Missing wound measurements | Record exact cm² for each wound and total |
| Device type not documented | Clearly state “disposable NPWT device” in note |
| Code mismatch (97606 vs 97607) | Confirm equipment type before charge entry |
| No prior conservative therapy | Document previous dressings, failed treatments |
| Improper modifier use | Apply 59 or X{EPSU} only when services are distinct |
Reimbursement Rates & 2025/2026 Outlook
Billing CPT 97607 correctly is only half the battle, understanding reimbursement trends is equally important to protect practice revenue.
As disposable negative pressure wound therapy (NPWT) grows in adoption, Medicare and commercial payers are adjusting payment rates and documentation requirements to reflect market costs and clinical outcomes.
2024 National Averages (Baseline)
Based on CMS Physician Fee Schedule (PFS) data and commercial claims analysis:
| Setting | 2024 National Avg. Reimbursement* | Notes |
| Physician Office (Non-Facility) | $155 – $165 per session | Includes device cost |
| Hospital Outpatient | $135 – $145 per session | Packaged payment under OPPS |
| Ambulatory Surgery Center (ASC) | $150 – $160 per session | Device included |
2025 Fee Schedule Updates
As of the 2025 CMS proposed rule (July 2024 release):
- Physician Office: Projected +1.2% increase due to practice expense recalibration.
- Hospital Outpatient (OPPS): Flat payment expected with potential packaging adjustments.
- Commercial Plans: UnitedHealthcare and Aetna announced 2–3% upward adjustments tied to disposable NPWT cost inflation.
Estimated 2025 Medicare Allowables:
| Setting | Projected 2025 Range |
| Physician Office | $157 – $168 |
| Hospital Outpatient | $135 – $147 |
| ASC | $152 – $163 |
2026 Projections & Value-Based Impact
Industry analysts expect greater variability in 2026 due to:
- Value-Based Reimbursement Models: CMS is exploring wound-healing outcome measures to tie payment bonuses/penalties to documented healing rates.
- Device Cost Pressures: Disposable NPWT market projected to grow >8% annually, potentially triggering budget-neutral cuts to base CPT 97607 payments.
Projected 2026 Medicare Allowables:
| Setting | Low Estimate | High Estimate | Key Driver |
| Physician Office | $155 | $170 | Budget neutrality vs. value-based add-ons |
| Hospital Outpatient | $133 | $148 | Packaging changes |
| ASC | $150 | $165 | Device pricing trends |
Why These Trends Matter
- Disposable Cost Sensitivity: Disposable NPWT kits can cost $80–$100 per application. Even a small reimbursement reduction can erode margins if supply costs rise.
- Audit-Driven Downcoding: If documentation fails to prove surface area >50 cm², payers may downcode to CPT 97605 (lower rate).
- Prior Authorization Expansion: Anthem and Humana have already added 97607 to their 2025 prior authorization list in select states.
Payer Policy Watch (2025/2026)
| Payer | Key 2025 Change | Anticipated 2026 Action |
| Medicare (CMS) | Emphasis on photographic wound documentation in EMR | Pilot value-based NPWT payment model |
| UnitedHealthcare | Prior auth required for wounds >75 cm² | Expansion to wounds >50 cm² |
| Aetna | Pre-certification for chronic diabetic ulcers | Bundled payment pilot with wound healing outcomes |
| Blue Cross Plans | Regional LCD updates tightening medical necessity | Standardization of NPWT documentation rules |
How to Prepare Your Practice
Practical Steps to Stay Ahead:
- Monitor CMS PFS Updates – Subscribe to the Federal Register for quarterly fee schedule releases.
- Negotiate Commercial Contracts – Highlight rising disposable supply costs when renegotiating payer contracts for 2025–2026.
- Invest in EMR Analytics – Implement wound measurement tools capable of exporting healing-rate reports for future value-based models.
- Audit Internal Documentation – Conduct quarterly internal audits to confirm wound size calculations and device type notes.
How Payers Differ and Where to Find Policies
Even when you code CPT 97607 correctly, payer-specific rules can still create denials.
Understanding these differences—and knowing where to locate the most current policies—is critical.
8.1 Medicare (Traditional)
Coverage Basis: Local Coverage Determinations (LCDs) issued by each Medicare Administrative Contractor (MAC).
Documentation Focus:
- Objective wound measurements in cm².
- Evidence of prior conservative treatment (e.g., moist dressings, debridement).
- Clear indication of disposable NPWT equipment.
Policy Location:
- Visit the CMS LCD Database → Search “Negative Pressure Wound Therapy.”
- Check your MAC’s site (e.g., Noridian, Palmetto, NGS).
Medicare Advantage (MA)
Must follow Medicare LCDs but may impose stricter prior authorization requirements.
Starting January 2025, CMS requires MA plans to publish PA turnaround times—use this to track compliance.
8.3 Commercial Payers
Commercial insurers vary widely:
| Payer | 2025 Policy Highlights | Prior Auth Requirement |
| UnitedHealthcare | Prior auth for wounds >75 cm² (2025) | Yes, expanding to >50 cm² in 2026 |
| Aetna | Pre-certification for chronic diabetic ulcers | Yes |
| Humana | Requires documentation of failed conservative therapy for all chronic wounds | Yes |
| Blue Cross/Blue Shield | LCD-style criteria; some states require wound photography | Varies by state |
Why These Variations Matter in 2025–2026
Audit Expansion: Commercial carriers are increasing post-payment reviews for disposable NPWT because of its rising cost.
Cross-State Differences: Multi-state providers must track each region’s LCD or policy updates to avoid inconsistent billing.
Pro Tip: Build a payer-policy tracker in your billing software. Update it quarterly with LCD and commercial plan changes to reduce prior authorization delays.
Why 2025–2026 Will Require Better Data Tracking
The next two years will bring heightened scrutiny and technology-driven change to NPWT billing.
Digital Wound Imaging
AI-Based Measurement: Systems such as Swift® or Tissue Analytics can calculate wound area within ±2% accuracy.
Billing Advantage: EMR photo uploads provide visual proof of wound size, reducing denials for “insufficient documentation.”
2025 Trend: CMS encourages image-based documentation for NPWT claims; some MACs already request images during audits.
EMR Integration & Real-Time Alerts
By mid-2026, many major EMRs (Epic, Cerner) will integrate automatic CPT suggestion tools that flag whether 97605, 97606, 97607, or 97608 is appropriate based on wound size and equipment type.
Practices using these alerts can cut coding errors by 20–30%.
9.3 Value-Based Payment Metrics
CMS is piloting a Wound Healing Progress Measure for 2026, rewarding providers who demonstrate:
- ≥40% reduction in wound size within 4 weeks, or
- Documented healing trajectory over a 12-week course.
Practices without reliable tracking may miss future incentive payments.
Secure Data Exchange
HIPAA-compliant photo sharing will become more important as patients transition between home health, outpatient clinics, and physician offices.
Cloud-based wound measurement systems allow secure transfer of images and notes across care settings, improving continuity of documentation.
Quick Action Checklist for 2025 Preparation
| Priority | Why It Matters | Action Item |
| Implement AI wound measurement | Reduces audit risk | Evaluate tools like Swift® by Q1 2025 |
| Integrate CPT auto-suggestion in EMR | Cuts coding errors | Ask EMR vendor about 2026 CPT logic updates |
| Develop payer-policy tracker | Avoids prior auth delays | Update quarterly with LCD/payer rules |
| Capture wound images every session | Supports healing metrics | Train staff to upload during visit |
How is CPT 97607 different from CPT 97605, 97606, or 97608?
- 97607 is used for disposable NPWT (single-use, non-durable) applied to wounds greater than 50 cm².
- 97605 is disposable NPWT for wounds ≤50 cm².
- 97606 is for durable NPWT pumps when the wound is >50 cm².
- 97608 is an add-on code for each additional wound over 50 cm² when disposable NPWT is used in the same session.
Proper selection depends on device type and total wound area, not simply the number of wounds.
How do I accurately measure wound size for CPT 97607?
- Measure the greatest length and greatest width in centimeters and multiply (Length × Width).
- If there are multiple wounds, calculate the total treated area when using 97607.
- Document each wound’s measurement separately to justify primary vs. add-on codes.
How do I bill CPT 97607 when multiple wounds are treated in the same session?
- Use 97607 for the first wound or aggregate wound area if >50 cm².
- For each additional wound meeting criteria, bill 97608.
- Include detailed documentation showing individual wound sizes and treatment sites.
How can I avoid denials for CPT 97607?
- Use the correct CPT code based on wound size and equipment type.
- Attach supporting documentation: wound measurements, device brand/model, treatment rationale.
- Check payer-specific LCDs or policies before the procedure to confirm coverage.
- Use appropriate modifiers (e.g., 59 or XU) when performed with debridement.
How often can CPT 97607 be billed?
- Typically once per wound episode per day, when the provider applies or manages disposable NPWT.
- Home health nursing visits may separately bill for their services, but duplicate provider billing is not allowed.
- Always confirm with the payer’s frequency limits (many follow CMS LCDs).
How do 2025 and 2026 reimbursement rates affect billing?
- CMS projections for 2025 indicate a slight 1–2% increase in NPWT payment rates under the Physician Fee Schedule due to inflation updates.
- 2026 may introduce value-based payment adjustments tied to wound-healing progress, requiring more detailed outcomes documentation.
How do I code CPT 97607 when combined with debridement?
- Bill debridement codes (e.g., 97597–97598) separately if performed.
- Use modifier 59 (or XU for Medicare) to indicate a distinct procedural service, ensuring that documentation clearly supports separate medical necessity.
How do I know which payers require prior authorization?
- Medicare: Prior authorization is generally not required, but documentation must meet LCD criteria.
- Commercial payers: Many require prior authorization—especially for wounds >75 cm² (lowering to >50 cm² in some 2026 policies).
- Check each payer’s provider portal or call the utilization management department before treatment.
Where can I find the latest payer policies and coverage updates?
- Medicare LCD Database on cms.gov (search “Negative Pressure Wound Therapy”).
- Commercial payer portals (UnitedHealthcare, Aetna, Humana, BCBS).
- AMA CPT® Assistant and MLN Connects® newsletters for code updates.
- Specialty resources like the Wound Healing Society for clinical guidance.
How will technology improve CPT 97607 billing in 2025 and 2026?
- AI wound imaging will provide precise wound measurements and automatic CPT recommendations.
- EMR integration will flag missing documentation before claims submission.
- Real-time payer policy alerts will help providers match documentation to current coverage criteria, reducing audits and post-payment recoupments.