Podiatry Coding & Billing Alert

Question: Our podiatrist debrided a patient’s foot wound, then applied skin substitute. We billed Q4159, 15275 and 97597, and Medicare paid for the Q4159 and 15275 but denied 97597 stating that it was bundled. The doctor feels this is incorrect as 97597 is considered the prepping and/or debriding of the wound, and the 15275 is the application of the graft.

When I look the codes up, the NCCI edits show they are payable together. So my question is: should I use modifier 59 to unbundle the services?

AAPC Forum Participant

Answer: In this case, your doctor is incorrect, and Medicare policy is not to pay for both 15275 (Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area) and 97597 (Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less). However, there is a scenario in which Medicare will pay for both services.

The reason for the Medicare denial in your situation is laid out in Chapter 3 of the Medicare National Correct Coding Initiative (NCCI) 2023 Coding Policy Manual, which tells you that “debridement of a skin wound (e.g., CPT^® codes 11000, 11042-+11047, 97597, +97598) before a graft/skin substitute is included in the skin graft/skin substitute procedure (CPT^® codes 15050-15278) and shall not be reported separately” (www.cms.gov/ files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf).

So, while you are correct in saying NCCI allows you to override the edit with an NCCI-associated modifier such as modifier 59 (Distinct procedural service) when you bill 15275 along with 97597 when 97597 is the column 2 code in the edit pair, you are only able to do so under specific circumstances.

The exception: You can bill 15275 and 97597-59 when your podiatrist treats multiple wounds. So, if they debride one wound, then debride a second, separate wound and treat it with a skin substitute such as Q4159 (Affinity, per square centimeter), you would be able to unbundle the services and get paid in full for both.