Active Wound Care Management Codes

pjwalsh72

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Can anyone tell me what needs to be documented in the medical record in order for a physician to bill Active Management Codes 97597 or 97598? I'm new at this. Thanks
 

jek521

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Our physician (working in an outpatient wound care center) first documents the wound dimensions (e.g. 1cm x 0.4cm x 2.5cm), as well as the status of the wound (overall appearance, odor, drainage). A description of the procedure follows (type of instrumentation, anesthetic, dressing, post-op instructions) with post-procedure dimensions that should not change in wound care. If the dimensions change, look to the debridement codes in the integumentary system.

Of note, CPT Assistant indicated that 97597/97598 are intended for use by non-physicians. However, our Part B carrier has confirmed that they'll cover these codes when performed by a physician.
Jen
 
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