02/17/2017

GHI Denial-CPT Code 97597 (Modified)

Denial of code 97597 by GHI. The claim was rejected and the reason given was that "The principal diagnosis code is missing or invalid."

Emblem Health does not have any published medical policies for CPT code 97597 that would give information regarding medical necessity guidelines for wound care. As per CMS policy, the CPT codes 97597 and 97598 should be used for debridement of superficial ulcers (skin, dermis and/or epidermis), whenever necrotic tissue is present in an open wound. They may also be indicated in cases of abnormal wound healing or repair. These services will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue. A call should be made to Emblem to confirm whether or not the CPT listed in the inquiry is subject to policy restrictions.

L89.892 Stage 2: Abrasion, blister, partial thickness skin loss involving epidermis and/or dermis

Stage 3: Involves necrotic tissue, therefore the ICD-10 code used on the claim would not support this CPT.

Below is the link for the other wound care codes that will only cover a stage III or IV pressure ulcer, along with other covered conditions:

http://www.emblemhealth.com/~/media/Files/PDF/_med_guidelines/MG%20VAC%20dC2v2.pdf