Dear Healthcare Practitioners: On Thursday, July 4th, Monarch Labs will not be shipping orders for Friday delivery due to the holiday and FedEx being closed. We will only be shipping orders Monday and Tuesday, July 1st and 2nd, for overnight delivery. Until then, all orders will be shipped Monday thru Thursday for overnight delivery. For same day shipping, please place your order no later than 1PM PST. At this time, we are not shipping international orders. For Canadian orders, Veterinarians only, please contact us about shipping to the US/Canadian border. We apologize for any inconvenience.

Coding, Insurance and Reimbursement

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to Correct Coding Initiative (CCI) edits. This information does not take precedence over CCI edits.  Per CMS Medicare Learning Network (MLN) Medicare Matters number MM8863, the use of NCCI-associated modifiers should NOT be used to bypass a procedure-to-procedure (PTP) edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.

Active Wound Care Management – CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608

  • Currently, code 97602 is a status B (bundled) code on the Medicare Fee Schedule for physician’s services (MFSDB); therefore, separate payment is not allowed for this service.

  • A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifier (GN, GO, GP) to the CPT code billed. In addition the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. Please see MM10176 for more information.

  • For debridement codes 97597, 97598, or 97602:

    • Debridements should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed. 

    • Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately. 

    • It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service. 

    • Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047. The wound depth debrided determines the appropriate code.

      • For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. But if muscle substance were debrided, the 11043-11046 series would be appropriate, depending on the area.
       
  • Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.

  • Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier 59 or a more specific modifier as appropriate (e.g., LT, RT, XS, etc). 

Additional information can be found at these resources:

 

Remember: Insurance claims are first reviewed by a screener whose job is to eliminate as many claims as possible. If they are unfamiliar with maggot therapy, their preliminary determination may be that maggot therapy is not a covered service. This response is incorrect, and a thorough appeal will nearly always be accepted, if the treatment was consistent with official (FDA-sanctioned) indications. Monarch Labs can help with appeals.

Remember, too, that reimbursement also depends on the location where care is delivered, and the personnel delivering that care. For example, many policies pay a flat rate for hospitalizations, nursing home stays, etc.

If your patients’ third party payor refuses to compensate you for your maggot therapy services (procedure and/or supplies), be sure to inform us immediately.