Wound Care 97597 & 97598

kathymoon

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Lansing, Michigan
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I am in Michigan. Our MAC is WPS. I am getting rejections from Medicare for 97597 and 97598 as not medically necessary. The diagnosis is L97821 and L97871, non-pressure ulcers of the legs. I assume it is rejecting due to the diagnosis. Medicare requested records and have reviewed and rejected. I need to appeal but I'm not sure what I'm fighting. The LCD (34587) list the acceptable diagnoses as all pressure ulcers and no other diagnoses.

So a couple of questions. Note: Medicare has already reviewed the documentation.
What can I appeal? The documentation states "selective" debridement. So the only other option would be an E&M code?? :confused:
The documentation states: Lower extremity wound, or venous insufficiency with venous ulcer. None of which ICD-10 codes are listed in the LCD.
Not sure where to go from here. Would really appreciate some feedback.

THX
 

espressoguy

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Tacoma, WA
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I am in Michigan. Our MAC is WPS. I am getting rejections from Medicare for 97597 and 97598 as not medically necessary. The diagnosis is L97821 and L97871, non-pressure ulcers of the legs. I assume it is rejecting due to the diagnosis. Medicare requested records and have reviewed and rejected. I need to appeal but I'm not sure what I'm fighting. The LCD (34587) list the acceptable diagnoses as all pressure ulcers and no other diagnoses.

So a couple of questions. Note: Medicare has already reviewed the documentation.
What can I appeal? The documentation states "selective" debridement. So the only other option would be an E&M code?? :confused:
The documentation states: Lower extremity wound, or venous insufficiency with venous ulcer. None of which ICD-10 codes are listed in the LCD.
Not sure where to go from here. Would really appreciate some feedback.

THX

I am answering this question from home so I don't have my books in front of me. The L97.xxx codes are for chronic non-pressure ulcers and are covered as a Group 1 code in your LCD. Was L97.871 a typo as Mr. Google can't find the code? Secondly, you state that you are assuming this was denied for diagnosis. What does the EOB state as the reason for denial?

Debridement codes require very specific documentation. Here is an article from the AAPC which outlines the documentation requirements:

Meet Documentation Criteria for Excisional Debridement

Since your MAC has reviewed the documentation perhaps the documentation requirements weren't met.
 
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