Medicare Reimbursement Changes in Negative Pressure Wound Therapy

CMS Changes How Home Health Agencies Bill for Negative Pressure Wound Therapy Using a Disposable Device

2017 is bringing many changes to how home health care agencies are being reimbursed. As seen in the last article regarding Medicare changes to how outlier payments are calculated, the modifications have a common theme: encourage home health agencies to treat high-complexity cases. This is also the case to the adjustment of claim submission procedures for Negative pressure wound therapy (NPWT) using a disposable device. 

What is Negative Pressure Wound Therapy?

Negative pressure wound therapy is a method of wound care where the wound is sealed and a vacuum is attached that either constantly or intermittently, depending on the MD order, suctions out the discharge. Not all patients are appropriate for NPWT. According to the World Health Organization negative pressure wound therapy is more effective at healing wounds than wet to dry dressings when used on acute and chronic wounds, as well as burn victims. Further, factors like bleeding risk or history of blood clots require that the patient receives this treatment in a facility instead of the home for continuous monitoring.

Medicare Reimbursement for Negative Pressure Wound Therapy

Traditionally, negative wound pressure therapy (the service) has been covered under the home health benefit, while the equipment used to perform the service was classified as follows: (1) The conventional NPWT system was classified as a DME (durable medical equipment) and as such paid for separately; (2) The disposable negative pressure wound device was part of the list of non-routine medical supplies and covered under HH PPS (home health prospective payment system).

Effective January 1, 2017, the Centers for Medicare and Medicaid Services are changing the way negative pressure wound therapy using a disposable device are billed. The coverage of both the service and the device will be shifting from the Home Health Prospective Payment System to the Medicare Hospital Outpatient Prospective Payment System (OPPS).

Type of Bill

Home health care agencies will no longer be able to report the usage of the non-routine supply nor the time it takes for clinicians to perform the service on their regular 032X type of bill. Instead, agencies must use a 34x claim. This means that visits performed for the sole purpose of providing negative pressure wound therapy using a disposable device will not be covered under HH PPS and should not be listed in the 32x claim. When a visit contains other skilled services covered under the home health benefit as well as NPWT with a disposable device, the visit must be billed in two parts. The time spent providing NPWT is billed on the 34x TOB, while the remainder is billed on the 32x. 

Revenue, HCPCS and Disciplines

Negative pressure wound therapy using a disposable device can only be conducted by a registered nurse (revenue code 0559), physical therapist (revenue code 042x) or occupational therapist (revenue code 043x). 

Both the service and the device are covered under one of two HCPCS codes that are defined by the OPPS benefit as follows:

HCPCS 97607 - Negative pressure wound therapy, (for example) 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.

HCPCS 97608 - Negative pressure wound therapy, (for example) 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 or equal to 50 square centimeters.

The above HCPCS codes cover the initial application and the replacement process of NPWT with a disposable device.

Eligibility Requirements

To be eligible for Medicare payment for negative pressure wound therapy with a disposable device, the patient must be enrolled in home health services and must meet all home health eligibility requirements. Specifically, the patient must be under the care of a physician who certifies that the patient is home bound. A valid face-to-face encounter regarding the main reason for home health must be documented in the patient's chart and treatment has to be in accordance with the plan of care, including at least one qualifying discipline performing skilled, intermittent care. Further, the home health agency must have an MD order to perform (and bill for) this service.

The Role Home Health Care Management and Billing Software Plays

It's important for your HHA software to understand the nuances of covered billing practices. Whether for Medicare, Medicaid, managed care or private pay services, TT Medical can recommend several software solutions that provide fast, reliable billing services and enables home health agency billing staff to independently manage their financial processes.

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