Physicians and other qualified healthcare professionals

Physicians and other qualified healthcare professionals 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 PICO fluid management component before the 7-day battery life of the PICO Pump is exhausted, he/she should code and bill for the work that was performed during that visit (eg, appropriate evaluation and management level, 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 Physician Fee Schedule

Provided that the NPWT service is medically necessary, all physician and QHP claims submitted for the application of a PICO Single Use Negative Pressure Wound Therapy System with CPT® codes 97607 and 97608 will be carrier priced in CY 2017, under the Medicare Physician Fee Schedule, on an individual claim basis by each Medicare Administrative Contractor (MAC). Please contact the MAC that processes your claims for its allowable payment amounts. In addition, physicians and other QHPs should take the opportunity to educate the medical director of their MAC why the payment for 97607 and 97608 needs to be adequate to pay for the disposable PICO Device, as well as for the work to assess the wound, to apply PICO, and to provide instructions for ongoing care.

When submitting claims for PICO, include the following information in field 19 of a paper claim or in the narrative field of an electronic claim:

  • Product name
  • Product size
  • Product number
  • Invoice price for each product

NOTE:

Ensure that reported charges reflect both the PICO Single Use NPTW System and the work to assess the wound, apply it, and provide instructions for ongoing care.  The charges associated with CPT® codes 97607 and 97608 should include the disposable NPWT device.  Thus the charges for CPT® codes 97607 and 97608 likely will be different from the charges for CPT codes 97605 and 97606 that describe NPWT using traditional durable medical equipment and do not include the cost of the durable medical equipment itself.  

Medicare Physician Fee Schedule Payment Rates for PICO Single Use Negative Pressure Wound Therapy System, when covered by the MAC

CPT® CodeTotal Medicare allowable in officeTotal Medicare allowable in facility
97607 Carrier priced Carrier priced
97608 Carrier priced Carrier priced
For Calendar Year 2017, CPT® Codes 97607 and 97608 have a status indicator of “C” meaning that Carriers/MACs price these codes and establish RVUs and payment amounts for these services on an individual case-by-case basis following review of documentation. See 2017 Medicare Physician Fee Schedule: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html

NOTE:

Payment rates from non-Medicare payers will depend on each physician’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. Physicians may want to contemplate these differences when setting charges.

Global Surgery Payment

In the final CY 2017 Medicare Physician Fee Schedule rule, Addendum B, CMS has assigned 97607 and 97608 a global surgery indicator of “XXX” Global concept does not apply. Other CPT® codes may be assigned a global surgery period of 0, 10 or 90 days, or “YYY” which is established by the contractor.

NOTE:

Non-Medicare payers may or may not pay for the use of PICO during a global surgery period. Physicians or other QHPs should review the global surgery section of their contract with each payer.

Coverage and questions

Before applying PICO Single Use Negative Pressure Wound Therapy System, all physicians and other QHPs 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, 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 Physicians and other qualified healthcare professionals 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.