Wound Care · Coding · Payment Integrity
Two Wound Care Problems, Not One
Debridement coding and skin substitutes share a specialty and almost nothing else, and the controls for one do nothing for the other
Most of what circulates about wound care fraud blends two different services, paid two different ways, with two different failure modes. An organization that reads about one and tightens controls on the other has aimed at the wrong exposure.
A compliance officer reads that Medicare spending on skin substitutes went from about $400 million a quarter to nearly $3 billion in two years. She calls a meeting. By the end of the quarter her wound care team has rebuilt its debridement documentation, added a depth field to every note, and retrained the nurses on surface area.
None of that was wrong. It was aimed at the wrong problem. The spending figure she read was about skin substitutes, which are products applied to a wound. Her team tightened controls on debridement, which is a procedure performed on one.
Meanwhile the exposure that figure actually pointed to, three years of skin substitute application billing at prices that no longer exist, sat unaudited. The scene is a composite. The confusion behind it is not, and it runs through most of what has been written on the subject.
This brief pulls the two apart. Debridement is a coding problem with stable rules and ongoing audit exposure. Skin substitutes are a product problem whose payment method was rebuilt on January 1, 2026, which moved the risk from next year's billing to the last three years of it.
Why you will not find a dollar figure in this brief
Medicare payment for any of these codes is the sum of three relative value units, each adjusted for geography, times a conversion factor that changes every year. No single national dollar figure is correct for any wound care code, and every one in circulation traces to a vendor site rather than the CMS relative value file. The CY2026 conversion factor is $33.40 for most practices, and CMS applied a negative 2.5 percent efficiency adjustment to the work values of non-time-based codes, a set that includes every debridement code discussed here. A figure carried over from 2025 is stale by construction.
01
What the Debridement Codes Actually Measure
The hierarchyCPT 97602 (non-selective debridement: wet-to-dry dressings, enzymatic agents) is bundled and pays nothing separately in any setting. CPT 97597 and 97598 (selective debridement without anesthesia, using forceps, curette, scalpel, or waterjet) are reported per session by total wound surface area, first 20 square centimeters and each additional 20. CPT 11042 through 11047 (debridement by depth) turn on the deepest tissue actually removed, subcutaneous tissue, muscle or fascia, or bone, and the area treated at that depth. The payment gradient across these three tiers is steep, it tracks documented depth, and depth is a narrative element a clinician controls. That is the whole structure of the risk.
Two corrections worth memorizingCPT 11042 is not an excisional debridement code. Its descriptor reads "debridement, subcutaneous tissue," and excisional debridement is an inpatient procedure concept from a different code set. Importing it into a CPT audit makes reviewers look for the wrong thing in the note. And silver nitrate is chemical cautery, not selective debridement, so applying it is not a 97597 service. A checklist that teaches otherwise produces the miscoding it exists to prevent.
Two Wound Care Problems, Not One
September 23, 2026
02
What Changed in Skin Substitutes This Year
What OIG foundThe HHS Office of Inspector General's September 2025 data snapshot reported that Medicare Part B spending on skin substitutes in non-institutional settings rose from about $400 million in the third quarter of 2022 to nearly $3 billion in the third quarter of 2024, and exceeded $10 billion for calendar year 2024. Cost per enrollee was four times higher for patients treated at home than in a physician's office, the typical home patient received 2.6 times as many units, and home care accounted for more than half of the spending. Those figures describe skin substitutes. They say nothing about debridement, and using them to characterize debridement upcoding overstates what they show.
What CMS did about itIn the CY2026 Physician Fee Schedule final rule (CMS-1832-F), effective January 1, 2026, CMS stopped paying product-specific prices for most skin substitutes and set a single national rate of roughly $127 per square centimeter, regardless of product. CMS projected the change would cut Part B skin substitute spending by about $9.4 billion in 2026, and industry analyses put the per-service reduction for the highest-priced products near 90 percent. The margin that drove the conduct is gone. What that leaves is a look-back audit of 2023 through 2025 application billing and, where problems surface, the 60-day overpayment obligation.
| Debridement coding risk | Skin substitute risk |
|---|
| Codes |
97597, 97598, 97602; 11042 through 11047 |
15271 through 15278 application codes, plus product Q-codes |
| The failure |
Routine or selective care billed at surgical depth; service not rendered |
Medically unnecessary or unapplied product; kickbacks; unit inflation |
| Payment driver |
Depth of tissue removed and surface area |
Product price per square centimeter, until 2026; now a flat national rate |
| Where it stands |
Stable coding rules; ongoing audit exposure |
Payment rebuilt January 1, 2026; coverage rules withdrawn December 24, 2025 with no replacement timeline |
The coverage side moved the other way. On December 24, 2025, CMS announced that all seven Medicare Administrative Contractors were withdrawing, effective immediately, the local coverage determinations for skin substitutes in diabetic foot and venous leg ulcers that were to take effect January 1. Only three contractors, Novitas, CGS, and First Coast, now carry active product-specific policies. Elsewhere, coverage runs on general medical necessity. Payment is uniform and low while coverage criteria depend on jurisdiction, which is the reverse of what the industry had prepared for.
The benchmark that does not exist
A widely repeated rule holds that a visiting clinician bills 97597 on 75 percent of patients and 11042 on 25 percent, and that billing 11042 more than 80 percent of the time triggers an upcoding flag. Neither figure has a source. No published peer distribution for this code pair exists. The harm is precise: an agency billing 11042 on 60 percent of visits reads that rule and concludes it is safe. Use the practice's own Comparative Billing Report instead, and track the provider's own ratio over time. A change in that ratio is evidence. A comparison against an invented norm is not.
7x
Skin substitute spending
About $400 million to nearly $3 billion per quarter, Q3 2022 to Q3 2024 (OIG)
$9.4B
Projected 2026 reduction
CMS estimate for Part B skin substitute spending under the flat national rate
6%
National share of beneficiaries receiving grafts
DOJ's own benchmark in a 2026 affidavit; the clinic under review was at 38.5 percent
Two Wound Care Problems, Not One
September 23, 2026
03
What the Enforcement Cases Actually Hold
Three cases, three different lessonsVohra Wound Physicians agreed in November 2025 to pay $45 million to resolve allegations of billing surgical debridement when only routine wound care was done, in nursing homes and skilled nursing facilities, under a five-year corporate integrity agreement that monitors its record systems as well as its claims. Vohra disputes the allegations and admits no liability. The useful allegation is the narrow one: the software automatically appended Modifier 25 to evaluation and management claims billed alongside procedures, whether or not a separate service was furnished. That is a configuration a compliance officer can test this week. Apex Medical, a graft marketing company rather than a treating provider, and its owners agreed to pay about $309 million in civil liability after criminal sentencing for a $1.2 billion fraud built on unnecessary allografts and roughly $279 million in distributor kickbacks. That is a supplier lesson, not a documentation one. Expert Wound Care in Pasadena is the subject of an April 2026 seizure affidavit alleging $46.6 million in skin substitute claims for 78 beneficiaries over eight months. There is no indictment as of this writing, and every figure remains an allegation. The case began with the clinic's bank flagging the account.
| Measure, skin substitute grafts | National average | The clinic in the affidavit |
|---|
| Allowed amount per claim |
$16,837 |
About $37,449, more than twice the average |
| Share of a provider's beneficiaries receiving grafts |
6 percent |
38.5 percent, more than six times the average |
| Share of a provider's claims that are grafts |
About 7 percent |
63 percent, about nine times the average |
Those are the government's own screening comparisons in a live matter, and they describe grafts, not debridement. Two things make this specialty easy to abuse and hard to audit from the claim alone. Care in the home happens behind closed doors, without the counts, time-outs, and rosters of an operating suite, and the patient is often elderly or cognitively impaired and will not read a Medicare Summary Notice closely enough to notice a procedure that never happened. And the claim carries only codes, modifiers, and units. No note, no wound measurement travels with it, so a clean claim pays before anyone reads a chart.
What a Scrubber Should Stop, and What It Should Only Flag
These are configuration, not judgment. A hard stop blocks the claim and routes it to a coding manager and a physician. A soft stop sends it to an audit queue for a human read. Both run after the provider signs and before the clearinghouse sees it.
| Tier | Rule | What it catches |
|---|
| Hard stop |
For 11042 through 11044, the note must name the tissue by layer: subcutaneous, fascia or muscle, or bone. "Deep tissue" does not clear. |
Depth-based codes generated from a narrative that never states the depth. |
| Hard stop |
Length and width from the flowsheet must reconcile to the area the code requires. A 2 by 3 centimeter wound cannot carry an add-on code for more than 20 square centimeters. |
Units that do not match documented dimensions, on both debridement and graft claims. |
| Hard stop |
Modifier 59 or XU on multi-site debridement, and Modifier 25 on a visit billed with a procedure, hold until a coder confirms distinct sites or a distinct service. Neither appends by default. |
The configuration alleged in the Vohra matter. |
| Soft stop |
Debridement or a graft billed more than twice in fourteen days on one wound; a graft or NPWT started in the first week of an episode with no documented conservative care. |
Frequency that outruns healing, and first-visit high-cost intervention, which OIG named as a pattern in its own data. |
| Soft stop |
A note that closely matches the provider's prior notes; a graft claim for a hospice patient; a graft sheet far larger than the documented wound. |
Template cloning, census mismatches, and wastage billed under the JW modifier. |
Two Wound Care Problems, Not One
September 23, 2026
Three controls sit outside the scrubber. Cross-reference every wound clinician against the Open Payments database for relationships with tissue manufacturers and equipment suppliers, which is what the Apex matter turns on. Require calibrated pre- and post-procedure photographs with a measurement guide before a depth code, a graft, or NPWT initiation can bill. And if a look-back finds systemic problems, decide the disclosure route early: the CMS Self-Referral Disclosure Protocol for Stark issues, the OIG Self-Disclosure Protocol for kickbacks, with the 60-day overpayment clock running regardless of which. For home health, remember that the certification period is 60 days while the payment period is 30, and that the OASIS assessment version in force since April 1, 2026 is E2.
A Third Exposure, Briefly: Negative Pressure Wound Therapy
NPWT (negative pressure wound therapy, a vacuum dressing applied to a wound) sits between durable medical equipment, skilled nursing, and procedure coding, and the boundaries are where the problems are. CPT 97605 and 97606 cover application using a durable pump; 97607 and 97608 cover disposable systems; the pump rental (E2402), canisters (A7000), and dressing sets (A6550) are billed separately as equipment. Four patterns recur, stated here as audit reasoning rather than published findings: billing 11042 when the clinician only cleansed the periwound and changed the foam and drape; billing disposable-system application while the equipment contractor is paid for a durable pump on the same patient; bringing in an outside physician to bill 97605 for dressing changes an agency nurse performs, which the 30-day home health payment already covers; and keeping a patient on a pump for months after the wound has closed or stopped improving.
Where MHMDAA Comes In
MHMDAA (Michael Hill, MD and Associates) is a revenue cycle consulting and payor-provider dispute resolution firm, retained by payors and providers alike, which is why this reads as method rather than argument. Most of what is written about wound care fraud runs the two problems together, cites a settlement as a finding, and offers a benchmark someone made up. Separating them is most of the work.
What follows is unglamorous. For debridement, a chart audit against what the descriptors actually require, starting with the modifier configuration the Vohra matter turned on. For skin substitutes, a look-back at 2023 through 2025 application billing while the 60-day clock on anything found is still yours to control. Neither is improved by a dollar figure nobody can source.
Michael Hill, MD & Associates
Revenue cycle consulting and payor-provider dispute resolution
(877) 464-4556 · info@mhmdaa.com
Neutrality. This brief is educational commentary; it is not legal, coding, or clinical advice, and it is not a determination about any specific claim, payor, provider, or matter. Scenarios described as composites are illustrative of method only. Settlements resolve allegations, denials of liability are stated where made, and figures from a seizure affidavit are allegations. MHMDAA is an independent revenue cycle consulting and payor-provider dispute resolution firm; its principals provide dual-perspective analysis and independent expert services to payors and providers alike, and nothing in this publication constitutes advocacy for either side of any dispute or prejudges any question on which they may serve as independent experts.
Authorship. This document was drafted with human authorship and may include AI-assisted formatting or summarization. All analysis, conclusions, and opinions are solely those of Dr. Michael Hill.
Sources
- HHS-OIG, Medicare Part B Payment Trends for Skin Substitutes, OEI-BL-24-00420, September 2025. CMS, CY2026 Physician Fee Schedule Final Rule (CMS-1832-F), November 5, 2025, with technical correction November 28, 2025; fact sheet on withdrawal of skin substitute LCDs, December 24, 2025; PFS Look-up Tool and CY2026 relative value file.
- DOJ, Vohra Wound Physicians and its Owner Agree to Pay $45M, November 21, 2025; DOJ, Wound Graft Company Owners Sentenced for $1.2B Health Care Fraud and Agree to Pay $309M; U.S. Attorney's Office, C.D. Cal., United States Seizes More Than $2 Million from Pasadena-Based Advanced Wound Care Clinic, April 2026.
- 42 C.F.R. §§424.22(a), 424.22(b), 484.60(a); CMS OASIS-E2 guidance, effective April 1, 2026. MHMDAA, Wound Care Billing and Upcoding Risk, v2.3, September 19, 2026, with its verification register; and internal draft Combating Wound Care Fraud, Waste, and Abuse, v2.14, September 19, 2026, from which the NPWT and scrubber material is drawn, with its unsourced figures removed. CPT and HCPCS code descriptors as published.
