Home Health & Hospice Week

Disposable device visits won’t count.

How much are your time, expertise and other resources worth? Not much, according to a negative pressure wound therapy change in Medicare’s 2017 Home Health Prospective Payment System proposed rule.

Old way: Currently, Medicare pays for durable NPWT devices under the durable medical equipment benefit, noted UnityPoint Health in its comment letter on the rule the Centers for Medicare & Medicaid Services issued in July. For disposable NPWT units, “we code NPWT as a procedural visit and the nursing visit length averages 1.5 to 2 hours depending on the complexity of the wound(s),” said the Iowa-based health system. “The use of a disposable device is a non-covered [nonroutine supply] and consequently we have assumed the cost of the device,” which Unity put at about $500 including the dressing/device change.

New way: Looking to encourage the use of less expensive disposable NPWT units, CMS in the rule proposed that home health agencies bill for them separately using HCPCS codes 97607 and 97608 on Type of Bill 34x. Medicare would pay the Hospital Outpatient PPS rate for the devices. (See Eli’s HCW, Vol. XXV, No. 25-36 for more proposal details.)

Many commenters on the rule expressed support for allowing HHAs to bill for disposable NPWT devices separately. “Furnishing NPWT using a disposable device has the potential to positively impact patients’ quality of life, increasing patients’ autonomy and mobility, and allowing patients to engage in activities of daily living,” cheered Downers Grove, Ill.-based Advocate at Home in its comment letter on the rule.

And facilitating “the use of less expensive disposable devices in place of more costly DME equipment for wound therapy” will lower overall Medicare costs, noted Lafayette, La.-based chain LHC Group Inc. in its comment letter.

The catch: However, the way CMS wants to shape payment has some big problems, agencies and their reps insist. “For instances where the sole purpose for an HHA visit is to furnish NPWT using a disposable device, Medicare will not pay for the visit under the HH PPS,” CMS said in the rule. The HCPCS codes include “payment for both the device and furnishing the service,” the agency maintained. So “visits performed solely for the purposes of furnishing NPWT using a disposable device are not to be reported on the HH PPS claim (type of bill 32x).”

First, the OPPS rate for 97607 and 97608 is too low to cover the device, services, and agency overhead. Using that rate would put agencies “in a predicament where they are required to provide care that is not appropriately reimbursed by Medicare,” warned the American Physical Therapy Association in its comment letter.

The OPPS payment structure is “inaccurate and fails to account for the significant differences between the outpatient setting and the home health setting,” stressed Wound, Ostomy and Continence Nurses Society President Carolyn Watts in the society’s comment letter on the proposed rule. “Not factoring in the actual time, effort and resources that a Home Health Agency (HHA) and their clinical staff will expend in traveling to the home and providing wound care is a major oversight. This is of particular concern in the rural home health setting where a separate visit to a patient for the sole purpose of furnishing a disposable NPWT device could require an hour or more of additional travel time.”

Splitting NPWT, HH Services A Guessing Game

And using a system that prohibits billing under HH PPS is highly burdensome and unnecessary anyway, many of the 86 commenters on the rule argued.

Disallowing nursing visits related to NPWT “will be especially burdensome for HHA clinicians, requiring these services to be separately documented within the clinical and billing records of the HHA,” protested Dignity Health in its comment letter. “Implementation of a separate process for one kind of service will require the development and implementation of new reporting, tracking and billing procedures, updated information systems via IT vendors, and training for clinical and reimbursement staff,” said the California-based health system. “Additional work will also be required for systems to accumulate data for these exceptions for the Medicare cost reporting process,” Dignity added.

For visits that contain both home health skilled nursing and NPWT activities, trying to figure out what counts as what could be challenging, commenters told CMS. “It is unclear how HHAs should divide time and effort between HH PPS and [Outpatient Fee For Service],” criticized UnityPoint.

For example: “A patient is already under a HHA POC and the NPWT related skilled service is provided at the same time as a different skilled service (e.g., catheter change),” an Oklahoma agency offered in its comment letter. “Would it be fraudulent to change the NPWT half-way through the visit and just subtract the time in our documentation and make a communication note for the NPWT? Or, do we do all the HH visit, then do the NPWT treatment? Or do we do another whole new set of vital signs and assessments because that visit will have to stand on its own for auditing? Do we fill out two nurse notes to capture accurate times? Lots of questions.”

Wound Therapy Billing Change Increases Denial Risk

Generally, nearly every visit should include some home health skilled nursing care, some commenters argued. “Inherent in [this] proposal is the assumption that clinicians wouldn’t perform a comprehensive assessment of the patient including the wound, medications, nutrition, etc., and wouldn’t provide the associated comprehensive level of teaching for the patient and family while also furnishing negative wound pressure therapy using a disposable device,” said Eastern Maine HomeCare in its comment letter. “The proposed split of services between Medi-care Part A and Part B eligible services creates a logistical challenge in an already complex billing environment and exposes the home care provider to denied payment for services when Medicare A and Medicare B claims review are in dispute over the comprehensive level of services provided for wound care,” said the agency that includes VNA Home Health Hospice, Visiting Nurses of Aroostook, Bangor Area Visiting Nurses, and Hancock County HomeCare.

Bottom line: “In the context of overall declining reimbursement, the additional expense of developing and implementing these new procedures will place undue hardship on HHAs,” Dignity said.

Instead, CMS should remove the incentive for HHAs to use DME NPWT devices and allow separate billing, commenters urged (see story, this page).

Note: See the proposed rule at www.gpo.gov/fdsys/pkg/FR-2016-07-05/pdf/2016-15448.pdf.