Medicare Compliance & Reimbursement

Physicians can bill for 97605-97606.

Cutting-edge wound care technology will now receive the reimbursement it deserves.

Heads up: Medicare will pay for vacuum-assisted collection (VAC) codes 97605-97606. Last year, these new codes had a status indicator of "B", meaning they were bundled with any other service your physician provided. But this year, they gained a status of "A," meaning they're covered separately, says Marvel Hammer with MJH Consulting in Denver, CO.

Also, instead of the zero relative value units (RVUs) they had last year, these codes now have positive RVUs for 2006. But payment to the physician will still equal less than $20 in most areas. The payments aren't based on the size of the wound, says Suzan Hvizdash, medical auditor for University of Pittsburgh Physicians' department of surgery in Pittsburgh.

Your local carrier may have its own requirements for the diagnoses it will support for 97605 or 97606. A typical policy makes clear that VAC will be covered "as an adjunct to standard treatment in carefully selected patients who have failed all other forms of treatment." Generally accepted "indications of use" include:

· Chronic Stage III or IV pressure ulcers;
· Neuropathic ulcers;
· Venous or arterial insufficiency ulcers;
· Chronic ulcers of mixed etiology present for at least 30 days;
· Dehisced wounds or wounds with exposed orthopedic hardware or bone;
· Acute wounds; or
· Poststernotomy mediastinitis.

Contraindications for coverage of 97605-97606 typically (but not exclusively) include:

· Necrotic tissue with eschar in the wound, if debridement is not attempted;
· Untreated osteomyelitis within the vicinity of the wound;
· Cancer in the wound; or
· A fistula to an organ or body cavity within the vicinity of the wound.

Tip: Contact your local carrier for a complete list of covered ICD-9 codes.

Most payors will continue to provide coverage for up to four months, until adequate wound healing has occurred or when documentation shows that a measurable degree of wound healing has failed to occur over the prior month (whichever comes first).

Myth: Some coders believe that only non-physician practitioners are allowed to bill for 97605-97606. In fact, while wound care codes 97597-97602 are reserved for NPPs, physicians can bill for 97605-97606, says Hvizdash. "Our physician extenders usually bill the UNNA boot and debridement codes. Our doctors usually bill the debridement and paring codes," she explains.

When her clinic bills for both debridements and VAC in the same session, the carrier always denies the VAC code, notes Hvizdash. She always appeals, but the carrier upholds the denial on the grounds that the VAC is part of the debridement. UPMC's coder may try billing HCPCS code A6550 when the provider changes the patient's VAC dressing.