Receive Additional Reimbursement from Medicare

Home Health Medicare Billing Outside of HH PPS

Home health billing requires the use of the 32x type of bill (TOB). Using this TOB, home health agencies bill for standard home health services. There is another type of bill, the 34x, which can provide HHA's with reimbursement through OPPS (the Hospital Outpatient Prospective Payment System). CMS implemented OPPS in 2000 to pay for certain Medicare Part B procedures, including designated outpatient and inpatient hospital services, Hepatitis B vaccines and certain medical equipment.

Special circumstances permit home health agencies and hospice agencies to bill OPPS. This type of billing is relatively unused in home health and can add significant income to agencies willing to explore this path. Here are the covered home health services under OPPS:

Outpatient Therapy Billing

Outpatient therapy billing refers to home health services provided to patients who are not currently receiving traditional home health services. Individuals don't necessarily need to be homebound to receive Physical, Occupational or Speech therapy services, as long as they have Medicare Part B. Reimbursement for outpatient therapy billing for home health agencies is calculated based on the Physician's Fee Schedule. HHA's interested in exploring this option must keep in mind that deductibles, co-insurances and therapy caps apply here. Learn more about home health care agencies billing outpatient PT, OT and ST services here.

Negative Pressure Wound Therapy Using a Disposable Device

In addition to billing for regular home health services, HHA's can be reimbursed separately for providing negative pressure wound therapy (NPWT) using a disposable device. NWPT is performed using a sealed vacuum on the wound that removes excess drainage and other liquids that build up inside the wound. While NPWT is not appropriate for all wounds and can be contraindicated for certain medical conditions, patients with acute wounds, chronic wounds and/or burns often see faster healing times than traditional wet to dry dressings. 

Vaccine Reimbursement

Home health agencies can be reimbursed separately for the cost and administration of certain vaccines. Recipients of the vaccination don't need to be under the home health agency's plan of care for the HHA to be reimbursed as long as they have Medicare Part B. Covered immunizations include Pneumococcal, Hepatitis B and seasonal influenza virus vaccines. Learn more about billing OPPS for immunizations here. 

Injectable Osteoporosis Drugs

HH-PPS doesn't cover osteoporosis drugs. But the drugs and their administration are covered separately under OPPS assuming all of the following eligibility criteria are met:

  1. The patient must be eligible for traditional home health services;

  2. A physician must certify that the patient had a fracture as a result of post-menopausal osteoporosis;

  3. A physician must certify that the patient can't administer the injection herself and doesn't have any available caregivers that are able to administer the medication.

While being eligible for home health services is required, the patient doesn't have to be enrolled in home health services for the HHA to be paid for both the drug and its administration. Learn more about billing injectable osteoporosis drugs here.

Diabetes Self-Management and Training Services

Diabetes self-management and training (DSMT) services are covered under Medicare Part B under OPPS if the service is performed outside the home health plan of care. Besides having Medicare Part B, patients must receive an MD order from their physicians to qualify for services. Beneficiaries can receive up to 10 hours of DSMT the first year and may be eligible for up to 2 hours per year after that. The initial 10 hours are split into 2 types of training; The first hour is dedicated to individual training while the remaining 9 hours are designated for group training of 2-20 people. Sessions must be at least 30 minutes each. Training sessions are subject to the Medicare Part B deductible as well as a 20% co-payment. Home health agencies providing diabetes self-management training are reimbursed under the Medicare Physician's Fee Schedule's non-facility rate. Learn more about DSMT home health billing under OPPS here.

Tobacco Cessation Counseling Services

Tobacco cessation counseling services are meant for hospitalized or outpatient patients who have Medicare Part B. Qualification for counseling requires that patients:

  1. Use tobacco;

  2. Are alert and able to comprehend the counseling services;

  3. Receive counseling from a physician or other approved clinical staff, such as an RN. 

Home health agencies are reimbursed based on the Medicare Physician's Fee Schedule. Providers are limited to 8 sessions per year per patient. Learn more about home health billing of tobacco cessation counseling services here. 

Eligibility for Services

Almost all of these services are subject to limitations, caps, deductibles, co-payments and co-insurances. That's why it's important that your home health software vendor provides a complete and comprehensive eligibility report so that providers have a clear idea of where their patients stand. Like all aspects of home health and hospice, without the proper due diligence, income streams can quickly become liabilities.

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