Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare part B for wound care debridement services billed on dates of service from January 1, 2024 through December 31, 2025. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Debridement is the process of removing unhealthy or foreign tissue from a wound to reduce infection, clean the area, and promote healing. Debridement continues until healthy tissue is exposed and can be performed using methods such as cutting, scraping, scrubbing, or irrigation. Wound debridement services are coded based on the depth of tissue removed and the surface area of the wound.

The surgical debridement Current Procedural Terminology (CPT) codes include 11042–11047. These codes report on depth of tissue that is removed and total surface area of the wound(s). This code series is used for surgical debridement involving deeper tissue levels when no direct primary closure, such as grafting, is anticipated. Proper coding for surgical debridement requires documentation of both the post‑debridement wound measurement and the tissue depth removed, which may range from subcutaneous tissue to bone.

Wound care CPT codes are 97597–97598. These codes apply to active wound care to the epidermis and dermis. Active wound care management refers to procedures performed to remove devitalized and/or necrotic tissue to promote healing and may require multiple sessions. The CPT code 97597 involves debridement of open wound(s) and includes topical application(s), wound assessment, use of whirlpool, when performed, and instructions for the ongoing care of a wound. Add-on code 97598 is reported for each additional 20 sq cm or part thereof. Methods include high-pressure water jet and sharp selective debridement techniques using scissors, scalpels, and/or forceps.

According to CPT guidelines, 97597 and 97598 must not be reported in conjunction with code(s) 11042–11047 for the same wound on the same date of service (DOS).

In June 2024, Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC), completed research and data analysis on wound care services furnished for beneficiaries during a home health episode of care by either a Part B clinician or a home health provider. The SMRC identified a potential area of vulnerability when surgical wound debridement codes were billed to Part B for the same beneficiary on the same DOS as other wound care services.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with part B services, surgical debridement CPT codes 11042-11047, and wound care CPT codes 97597-97598 billed with date of service January 1, 2024 to December 31, 2025.

The SMRC will conduct coding reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. The operative note or procedure report for the date of service under review to include the following:
   1. Tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone)
   2. Level of debridement in square centimeters
   3. The method used to debride (i.e., hydrostatic, sharp, abrasion, etc.)
   4. Measurement of wound surface area after debridement
2. Documentation to support the code(s) and modifiers billed
3. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
4. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
5. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
6. Medical record documentation to support national and local requirements
7. Any other supporting/pertinent documentation
8. If medical record documentation is submitted via esMD, beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation

References

Social Security Act (SSA), Title XVIII

• Section (§)1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1861(s)(1) Physician Services
• §1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• §1893(a)(b) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §424.5(a)(6) Conditions for Medicare Payment-Basic Conditions, Sufficient Information

Internet Only Manual (IOM) Pub. 100-02, Medicare Benefit Policy Manual (MBPM)

• Chapter (Ch.) 16 General Exclusion from Coverage

IOM Pub. 100-04, Medicare Claims Processing Manual (MCPM)

• Ch. 1 General Billing Requirements
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch 3 Verifying Potential Errors and Taking Corrective Actions

Local Coverage Article (LCA)

• A55909 Billing and Coding: Wound Care

Other

• American Medical Association (AMA). Current Procedure Terminology (CPT) 2024-2025 Professional Edition
• Current Procedural Terminology (CPT) Assistant. Wound Debridement Vs. Active Wound Care Management. October 2016. Volume 26, Issue 10. Retrieved from WoundDebridementCodes.pdf (coa.org)

Last Updated Jun 19, 2026