10/18/2021

Healthfirst Denials-97597

On Healthfirst Medicare and Medicaid claims we are getting denials when billing for debridement of ulcer CPT code 97597 with modifier RT or LT with diagnosis code L89.891 and L8.892. Denial remarks state modifier invalid or missing. Additionally, we are also getting denied on x-rays also stating modifier invalid or missing. We have always received payment in the past using these codes and modifiers. Has something changed?

When billing for a wound debridement under CPT code 97597 and 97598, no site modifiers should be reported with these procedure codes. The definition of this service is based on the total surface area treated, regardless if it is on the left or right side, or on different locations of the foot & ankle. If a patient presents with multiple wounds that are equal or less than 20 square centimeters, then only one unit of CPT 97597 should be billed. For every additional 20 square centimeters treated, a unit CPT 97598 should be billed with no site modifiers.

Regarding x-rays, site modifiers are required for these diagnostic services to be paid. If these services are being denied by Healthfirst, ensure that the diagnosis codes that are linked to the x-ray are appropriate for the left or right side. If a -LT modifier is reported for a diagnosis code for the right side (or vice versa), it will cause the charge to deny. In addition, if an unspecified diagnosis code is billed when a code can be specific to laterality, it will also cause the x-ray to be denied even with a valid site modifier.