Coding

“I do some part time work in a wound care center. I frequently use CPT 97597 for coding. My biller is telling me not to bill CPT 97597 because it reimburses around $25 or less in a wound care center. However, the facility likes and even encourages me to use CPT 97597. If I do a selective debridement, can I bill CPT 99213 or CPT 99212 instead of CPT 97597? I know that I should not bill CPT 99213-Modifier 25 if there isn’t a separate complaint. Am I required to bill 97597? Is this a scenario that I should be considering CPT 11042?”

“After watching some E/M presentations, it was suggested that hospital consultations should be billed with CPT 99252-CPT 99255. When we billed these codes, our EMR system and our clearing house rejected the codes. They are saying effective 1/1/2010, CMS has announced that they will reject codes. Are we billing the right codes?”

“I have a patient who had a bunionectomy. The patient was diagnosed with a post- operative infection within the global period which required evaluation and management. I billed Medicare for an office visit, but Medicare will not pay. What am I doing wrong? I used 24 as a modifier.”

“I have a patient with a possible 1st proximal phalanx cyst vs infection that I plan to do an exploratory procedure and collect some bone cultures / swabs on. MRI was inconclusive. If I get in there and the bone appears necrotic/infected, I will have on the consent form to allow for a PIPJ arthroplasty. So, we'll get prior auth for all these procedures prior to surgery. But, for the initial planned procedure, how would this be coded?”

Overuse of skin substitutes (CTPs) to help heal wounds/ulcers has especially come under fire in recent years. Medicare spent more than $10 BILLION on these products in 2024 – more than DOUBLE what was spent the year prior.

“A new patient was seen with heel pain. X-rays were taken at an outside facility, and I independently interpreted these and reviewed the labs. Based on medical decision making, I believe I should be coding E/M code 99204. The patient had one new, acute problem (previously undiagnosed) and I independently interpreted tests. To me this is a no brainer, but my office staff argues that they believe it should be E/M code 99203.”

“The patient initially had a gastroc recession at the right lower extremity. Our surgeon performed a debridement procedure for the right foot ulceration. It was performed in the clinic, and we planned to code it as CPT 11042. However, the patient is in the 90-day post op period from initial surgery that was performed 4 weeks ago. Is a modifier necessary to submit for payment? Is it 79?”

“We received a request for medical records from Qlarant, who apparently is contracted with Medicare to review records for medical (and, of course, payment) necessity. In this case, they’ve asked for chart notes for ten different patients, one date of service for each patient. We’ve never been subjected to this type of review previously and want to do everything possible to make sure that we submit the appropriate and sufficient records and that we submit them in the appropriate manner. Obviously, we’re also concerned that this inquiry is a fishing expedition that could trigger some larger audit. Is there any advice that you can provide that might help us through this process? In our review of the records that were requested we did notice a few minor billing errors, but we believe that the records substantiate payment for all treatment that was performed.”

As of December 24, 2025, CMS has withdrawn (not delayed) the Local Coverage Determinations (LCDs) for skin substitute grafts that were scheduled to take effect on January 1, 2026. Because these unified policies have been eliminated, there is currently no revised version of that specific LCD scheduled for 2026.

“Diabetic pt came in for “At Risk,” Routine foot care. This patient is coded with E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.