July 9, 2020
I’m a pediatric orthopedic surgeon. Some of my team are reporting the NPWT codes 97605 and 97606 when applying wound vacs after closing at the completion of their surgical cases. As a result, I am told by my coders that NCCI Standards of Medical Practice edits are being generated.
The NCCI guidelines define the edit as follows:
Standards of medical/surgical practice: Under Medicare, all services necessary to complete a procedure based upon standard medical/surgical practice are included in the procedure. Many procedures that are typically necessary to complete a more comprehensive procedure have been assigned independent HCPCS/CPT codes because they may be performed independently in other settings. The service described by HCPCS/CPT code ____ (the column two HCPCS/CPT code) is typically included when performing the procedure described by HCPCS/CPT code ____ (the column one HCPCS/CPT code) and is therefore bundled into HCPCS/CPT code _____ (the column one HCPCS/CPT code.)
The physicians and coders disagree about how to handle these edits. Some of the physicians believe the wound vacs are billable because they are applied to the skin which constitutes a different body system. The coders think the wound vacs are dressings which are included in the global surgical fee and would not billable. Both groups have asked Compliance to weigh in on the issue. After multiple discussions with the physicians and coders, we are unable to provide a definitive answer. Could I please ask you for your advice regarding this issue? What is the right answer?
There are two layers to the issue; CPT rules and payor editing rules.
First, from a CPT perspective, the “wound vac” codes in the range of 97605-97608 are only reportable when placed at an open wound site. For example, if a physician performed debridement of an open wound, did not close the wound, but placed a wound vac at the debridement site to promote healing, a code in the range 97605-97608 could be reportable if appropriately documented. Codes 97605 and 97606 are used for placement of a non-disposable wound vac device, while codes 97607 and 97608 are used if the wound vac is disposable. The codes are further differentiated by the wound size, either greater than 50 sq cm, or less than or equal to 50 sq cm.
If the wound site has been surgically closed, and a wound vac is placed over the closed wound site, then the use of the wound vac is not separately reportable, as it is being used as a dressing.
In the case of a “codeable” wound vac, we next have to consider any payor rules that apply when other services are performed at the same time. For example, debridement code 11044 does not have an NCCI edit with code 97605, thus you should not have any issues reporting the two codes together. Similarly, you should not find NCCI edits between the decompressive fasciotomy codes and the wound vac codes – another type of procedure where it is not unusual to have delayed surgical closure of the wound site.
In some cases you may find that there are NCCI edits between surgical CPT codes and the wound vac codes, and in those circumstances Medicare would not allow separate reporting. As a pediatric surgeon you may not be subject to Medicare claims, but your private or Medicaid plans may say that they “follow NCCI.” As we discussed during the Power Coding in the ER and OR course, these edits are not always consistent with CPT guidelines, which would allow reporting both codes. Again, this only comes up if you perform a surgical procedure but do not close the wound site, and then place the wound vac at that location, and there is an NCCI edit between the surgical and wound vac codes.
*This response is based on the best information available as of 07/09/20.