Home Health & Hospice Week

Billing for disposable devices more limited than first appeared.

Brush up on your 34x billing before Jan. 1, or risk losing money — and your compliance status.

Change: In the Home Health Prospective Payment System Proposed Rule for 2017 issued in July, the Centers for Medicare & Medicaid Services proposed a new billing requirement for disposable Negative Pressure Wound Therapy. The rule proposed that home health agencies must bill disposable NPWT devices separately on Type of Bill 34x, and couldn’t bill services related to the device on the usual home health 32x TOB.

Problem: Commenters on the rule blasted CMS with a variety of criticisms, ranging from an inability to bill for usual home health services to administrative burden to underpayment for the device and services to flat-out confusion (see Eli’s HCW, Vol. XXV, No. 36).

Solution: In the 2017 HH PPS final rule issued Oct. 31, CMS puts at least some of those fears to rest. The final rule clarifies that the separate billing policy applies only when the “HHA provider is either initially applying an entirely new disposable NPWT device, or removing a disposable NPWT device and replacing it with an entirely new one. In both cases, all the services associated with NPWT — for example, conducting a wound assessment, changing dressings, and providing instructions for ongoing care — must be reported on TOB 34x with the corresponding CPT® code (that is, CPT code 97607 or 97608); they may not be reported on the home health claim (TOB 32x),” according to the rule published in the Nov. 3 Federal Register.

Good news: “Any follow-up visits for wound assessment, wound management, and dress ing changes where a new disposable NPWT device is not applied must be included on the home health claim (TOB 32x),” CMS further specifies. If an agency furnishes only the separately billable, new NPWT types of visits, then it would submit no 32x bill at all. In those cases, agencies wouldn’t have their overhead reimbursed, commenters had protested. But “we expect that payment for furnishing NPWT using a disposable device will almost always be made in addition to a HH episode payment, which already includes reimbursement for overhead and administrative costs,” CMS clarifies.

HHAs with NPWT-only patients may be at increased risk of Low Utilization Payment Adjustments, however, CMS acknowledges. Visits solely for NPWT, according to the policy, won’t count in calculation to exceed the five-visit LUPA threshold, the rule confirms.

But, non-adjacent LUPA episodes are eligible for LUPA add-on payments, CMS points out. They are designed to help cover administrative costs. Hopefully agencies will be already familiar with 34x billing, since it is available to bill osteoporosis drugs and vaccine administration, CMS comments.

Beneficiaries may not be thrilled with the new policy, notes Anna Doyle with Delta Health Technologies. “In billing this as Part B for home health care services, I am sure that the 20 percent coinsurance liability for furnishing of the NPWT disposable device is not going to be a welcome implication for beneficiaries receiving care at home,” Doyle tells Eli.

Many reasons aside from reimbursement will determine whether HHAs use disposable NPWT units, Doyle expects. “In my experience, NPWT is variable due to the location and size of the wound in addition to the patient’s physical and functional status, presence of comorbidities and of a willing and able caregiver,” she says.

“The disposable type of NPWT is likely a more cost-effective treatment” Doyle allows. “However, one size does not fit all in this case.”

Other NPWT billing tips CMS offers in the final rule:

• HHAs may have an added headache for visits that contain both services that fall under the NPWT policy and those that don’t. “If NPWT using a disposable device is performed during the course of an otherwise covered HHA visit (for example, while also furnishing a catheter change), we proposed that the HHA must not include the time spent furnishing NPWT in their visit charge or in the length of time reported for the visit on the HH PPS claim (TOB 32x),” CMS notes. “In this situation, the HHA bills for NPWT performed using an integrated, disposable device under TOB 34x along with the HCPCS code (97607 or 97608). Additionally, this same visit should also be reported on the HH PPS claim (TOB 32x), but only the time spent furnishing the services unrelated to the provision of NPWT using an integrated, disposable device.”
• Agencies can still get paid when the only non-NPWT services are dependent, CMS reassures. “To ensure appropriate payment for dependent services (for example, home health aide visits, medical social services) dictated by the beneficiary’s plan of care, we will permit TOB 32x home health claims to be used to bill dependent services when the only skilled service (furnishing NPWT using a disposable device) is billed on a 34x claim,” CMS says.

“Specifically, we will permit those TOB 32x home health claims, as long as both (1) the patient qualified for home health on the basis of intermittent skilled nursing care that consisted of furnishing NPWT using a disposable device, and (2) condition code 54 (effective July 1, 2016) is used.”

Reminder: Condition code 54 indicates “that, (1) the HHA provided no skilled services via the TOB 32x during the billing period … but that, (2) the HHA has documentation on file of an allowable circumstance for the provision of non-skilled services.”

Tip: Condition code 54 instructions are online at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3553CP.pdf.

• LPNs can furnish NPWT services, CMS confirms. “Skilled nursing services are those provided by skilled, licensed nursing professionals, which includes both LPNs and RNs,” CMS says in the final rule. “Therefore, LPNs also may furnish NPWT using a disposable device in accordance with State law and agency policies.”
• To help alleviate confusion, CMS provides four NPWT scenarios with their correct billing procedures (see example, p. 310).