Wound care billing is complex, and even small documentation or coding errors can lead to claim denials. One of the most commonly misunderstood codes in wound care is CPT 97598. If your practice regularly performs selective debridement, you must understand how to bill this code correctly to avoid payment delays and revenue loss.
In this guide, we will walk through practical strategies to Avoid Denials for CPT 97598: Wound Care Billing Best Practices. You will learn what the code represents, why claims get denied, and how to strengthen your documentation and billing workflows.
Understanding CPT 97598
CPT 97598 is an add-on code used for selective debridement of open wounds. It is reported in addition to CPT 97597 when the total wound surface area exceeds 20 square centimeters. CPT 97597 covers the first 20 square centimeters, and CPT 97598 is billed for each additional 20 square centimeters or part thereof.
Selective debridement involves removing devitalized tissue, such as slough, fibrin, or necrotic tissue, using sharp instruments, a high-pressure waterjet, or scissors. The goal is to promote wound healing by preparing the wound bed.
According to the American Medical Association CPT code set, add-on codes like 97598 cannot be billed alone and must always be reported with the primary procedure code. Understanding the correct definition and billing rules is the first step in reducing denials.
Why CPT 97598 Claims Get Denied
Many denials occur because billing teams do not fully understand how payers interpret this code. Here are the most common reasons:
1. Missing the Primary Code
CPT 97598 is an add-on code. If it is submitted without CPT 97597, the claim will automatically be denied. Billing software edits often catch this error, but it still happens.
2. Inadequate Documentation of Surface Area
Payers require clear documentation of the total wound size in square centimeters. If the chart does not support more than 20 square centimeters, 97598 will be denied.
3. Lack of Medical Necessity
Insurance companies expect documentation explaining why debridement was medically necessary. If the note does not describe necrotic tissue or delayed healing, the claim may be rejected.
4. Confusion with Excisional Debridement Codes
Selective debridement codes like 97597 and 97598 are different from surgical debridement codes in the 11042 to 11047 range. Billing the wrong family of codes can trigger audits or denials.
5. Frequency Limits
Some payers place limits on how often selective debridement can be performed. Submitting claims too frequently without strong documentation may raise red flags.
Documentation Requirements to Support CPT 97598
Strong documentation is the foundation of clean claims. To Avoid Denials for CPT 97598: Wound Care Billing Best Practices must focus heavily on chart accuracy.
Here is what should always be documented:
Wound Location and Type
Specify the anatomical location and wound etiology. For example, a diabetic foot ulcer, pressure ulcer, or venous stasis ulcer.
Wound Measurements
Document length, width, and depth. Clearly calculate and record the total surface area in square centimeters. If multiple wounds are treated, document each separately and explain how the total was calculated.
Tissue Removed
Describe the type of tissue removed, such as slough, necrotic tissue, or fibrin. This confirms that selective debridement was performed.
Instrument Used
Identify the technique used. For example, a pair of scissors, a scalpel, or a curette.
Level of Debridement
Selective debridement involves the removal of nonviable tissue without excising healthy tissue. The note should reflect this distinction.
Patient Response and Plan of Care
Include post-procedure status and next steps in treatment.
Clear documentation not only reduces denials but also protects your practice during audits.
Coding Best Practices for CPT 97598
Accurate coding ensures compliance and proper reimbursement. Below are proven strategies to strengthen your billing process.
Verify Total Surface Area
Before billing 97598, confirm that the total debrided area exceeds 20 square centimeters. For example:
- 18 sq cm total: Bill 97597 only
- 35 sq cm total: Bill 97597 and one unit of 97598
- 60 sq cm total: Bill 97597 and two units of 97598
Always double-check calculations.
Use Appropriate Modifiers
If multiple wounds are treated at different anatomical sites, modifiers may be necessary depending on payer requirements. Review payer-specific guidelines before submission.
Monitor National Correct Coding Initiative Edits
The National Correct Coding Initiative outlines bundling rules that affect wound care billing. Reviewing NCCI edits can help prevent improper code combinations.
Common Billing Errors That Increase Denials
Even experienced billing teams can make mistakes. Watch for these common problems:
Incorrect Units
Billing too many units of 97598 without supporting documentation is a common cause of denials.
No Clear Debridement Description
If the note only states that wound care was performed, it is insufficient. The provider must specify debridement.
Mismatched Diagnosis Codes
Diagnosis codes must reflect conditions that justify debridement. For example, chronic ulcers or non-healing wounds. Using unspecified codes can lead to denials for medical necessity.
Failure to Track Payer Policies
Commercial insurers may have stricter documentation standards than Medicare. Always verify policy updates.
Medical Necessity and Payer Expectations
Medical necessity is a major factor in reimbursement. Payers want to see that debridement is required for wound healing and that conservative measures alone are not sufficient.
To support medical necessity:
- Document signs of infection or necrotic tissue
- Note delayed healing progress
- Include prior treatment attempts
- Show measurable improvement over time
If debridement is performed repeatedly without documented progress, insurers may question continued treatment.
Regular internal audits can help identify patterns before they become costly problems.
Internal Audits and Compliance Monitoring
One of the most effective ways to Avoid Denials for CPT 97598: Wound Care Billing Best Practices is to implement routine chart audits.
Conduct Pre Submission Reviews
Have a coding specialist review wound measurements and documentation before submitting claims.
Track Denial Trends
Monitor denial codes and payer feedback. If you notice repeated rejections for insufficient documentation, address the issue through provider education.
Provide Ongoing Training
Wound care coding rules evolve. Regular staff training ensures everyone stays up to date on compliance standards.
Improving Workflow Between Providers and Billing Teams
Denials often result from communication gaps between clinicians and billing staff. Strong collaboration improves clean claim rates.
Standardize Documentation Templates
Create wound care templates that prompt providers to include required details such as surface area and tissue type.
Encourage Real-Time Clarifications
If documentation is unclear, billing staff should request clarification before submission.
Use Technology Wisely
Electronic health records can automate wound measurement calculations and flag missing information.
Efficient workflows reduce errors and speed up reimbursement.
Appeals Process for Denied CPT 97598 Claims
Even with best practices in place, denials can occur. A structured appeal process helps recover lost revenue.
Review the Denial Reason
Understand whether the denial is related to medical necessity, documentation, frequency limits, or coding errors.
Submit Supporting Documentation
Include detailed wound measurements, progress notes, and prior treatment history.
Correct and Resubmit if Necessary
If the issue was a coding error, correct it promptly and resubmit the claim.
Persistent denial tracking enables your practice to refine processes and prevent recurring errors.
Final Thoughts
Wound care billing requires precision, detailed documentation, and a strong understanding of payer policies. CPT 97598 is particularly sensitive because it is an add-on code tied directly to surface-area calculations and medical-necessity requirements.
By focusing on accurate wound measurements, clear clinical documentation, proper code pairing, and regular compliance audits, your practice can significantly reduce rejections.
When you implement these strategies to Avoid Denials for CPT 97598: Wound Care Billing Best Practices, you protect your revenue, improve clean claim rates, and maintain compliance with payer standards.
A proactive approach not only prevents financial loss but also supports sustainable growth for your wound care practice.
FAQs
What is CPT 97598 used for?
CPT 97598 is an add on code used for each additional 20 square centimeters of selective wound debridement beyond the first 20 sq cm.
Can CPT 97598 be billed alone?
No, CPT 97598 must always be billed with the primary code CPT 97597.
Why do CPT 97598 claims get denied?
Claims are commonly denied due to insufficient wound size documentation, missing medical necessity, or incorrect code pairing.
How can I reduce denials for CPT 97598?
Ensure accurate wound measurements, detailed documentation, correct unit reporting, and compliance with payer guidelines.