Hospital-based Outpatient Wound Care Departments (HOPDs)

Hospital-based Outpatient Wound Care Department (HOPD) coding, Medicare payment, and coverage information

Current Procedural Terminology (CPT®) codes

The American Medical Association established two (2) CPT® codes for negative pressure wound therapy (NPWT) using disposable medical equipment, including the PICO Single Use Negative Pressure Wound Therapy System. Please note that these codes also include reimbursement for the equipment. Therefore,
CPT® codes 97607 and 97608 should only be reported when a new PICO NPWT pump with a 7-day battery is furnished to the patient. If the physician or other qualified healthcare professional (QHP) writes orders for wound assessment and replacement of the fluid management component before the 7-day battery life of the PICO pump is exhausted, the HOPD should code and bill for the work that was performed during that visit (eg appropriate level of clinic visit, surgical debridement, selective debridement, etc.).

CPT® CodeDescription
97607 Negative pressure wound therapy (e.g. vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.
97608 Negative pressure wound therapy (e.g. vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters.

Calendar Year (CY) 2017 Medicare Hospital Outpatient Prospective Payment System (HOPPS)

For CY 2017, Medicare assigned CPT® codes 97607 and 97608 to Ambulatory Payment Classification (APC) Group 5052 Level II Skin Procedures with status indicator “T”. Therefore, the payment for 97607 and 97608 will be reduced by 50% when medically necessary and billed on the same date of service as another procedure with a “T” status indicator.

Medicare HOPPS Payment Rates* for PICO Single Use Negative Pressure Wound Therapy System, when covered by the Medicare Contractor

CPT® CodeAPC groupStatus indicatorTotal Medicare APC AllowableMedicare Payment Rate*Patient Coinsurance
97607 5052 T $292.62 $234.09 $58.53
97608 5052 T $292.62 $234.09 $58.53
*The national average 2017 Medicare rates for the hospital outpatient setting are calculated from the Outpatient Prospective Payment System (OPPS), November 2016. Any payment rates listed are Medicare national averages that may be subject to change without notice. Actual payment to a hospital will vary based on geographic location and may also differ based on policies and fee schedules outlined as terms in your health plan and/or payer contracts. Payment rates do not account for sequestration. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html

NOTE:

Ensure that reported charges reflect both the PICO Single Use NPTW System and, if appropriate, the work to assess the wound, apply it, and provide instructions for ongoing care. CPT® codes 97607 and 97608 include the disposable NPWT device.   

 

NOTE:

Payment rates from non-Medicare payers will depend on each hospital’s contract with each payer. Ensure that reported charges associated with CPT® codes 97607 and 97608 reflect the cost of the PICO Single Use Negative Pressure Wound Therapy System, as well as, the work to assess the wound, apply it, and provide instructions for ongoing care.  Unlike CPT® codes 97605 and 97606 that describe traditional negative pressure wound therapy using durable medical equipment that is billed separately from the procedure; CPT® codes 97607 and 97608 include the cost of the disposable negative pressure wound therapy device.  Hospitals may want to contemplate these differences when setting charges.

Coverage and questions

Before applying PICO Single Use Negative Pressure Wound Therapy System, all HOPDs should confirm or clarify coverage and coding from each patient’s insurance plan, as each payer may have differing formal or informal policies or decisions. For assistance with insurance benefit verification or any questions, call 1-888-705-0061 Monday through Friday 8:00 am to 5:00 pm EST.

Click on this link to download a copy of the Hospital-based Outpatient Wound Care Department (HOPD) coding, Medicare payment, and coverage information.

For detailed product information, including indications for use, contraindications, effects, precautions and warnings, please consult the product’s Instructions for Use (IFU) prior to use.

CPT® is a registered trademark of the American Medical Association
Smith & Nephew, Inc. provides this content for informational purposes only. The information contained herein is gathered from various sources on November 15, 2016 and is subject to change without notice. Smith & Nephew, Inc. cannot guarantee success in obtaining coverage or payment. Reimbursement for medical products and services is affected by numerous factors. It is always the provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for services that are rendered. Actual codes and/or modifiers used are at the sole discretion of the treating physician and/or facility. Providers should contact their third-party payers for specific information on their coding, coverage, and payment policies. This guide is in no way intended to promote the off label use of any product.