1. Schaum, Kathleen D. MS

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In the April 2017 Payment Strategies column, we reviewed the new Medicare billing opportunity for home health agencies (HHAs) that furnish new disposable negative-pressure wound therapy (dNPWT) devices and affiliated professional services to patients under an HHA plan of care. Furnishing dNPWT means the application of a new applicable disposable device, as that term is defined in [S]1834 of the Social Security Act, which includes the professional services (specified by the assigned CPT* code) that are provided. Many clinicians (eg, surgeons, wound care qualified healthcare professionals, wound care nurses, and therapists) throughout the country contacted this author to applaud Congress for enacting Section 504 of the Consolidated Appropriations Act of 2016 and the Centers for Medicare & Medicaid Services (CMS) for releasing a clear regulation that allows HHAs to separately bill for new dNPWT equipment and services.


Prior to January 1, 2017, new dNPWT equipment and associated fluid management systems were considered supplies that HHAs were required to purchase out of their 60-day episode-of-care home health prospective payment system (HH PPS) payment. Having to absorb the cost of the dNPWT equipment seemed unfair because durable medical equipment (DME) suppliers were able to bill separately and prospectively for a month's rental of traditional negative-pressure wound therapy (tNPWT) equipment and accompanying canisters and dressings. This inequity seemed counter to our country's emphasis on using state-of-the-art technology to provide excellent outcomes, at a reduced total cost of care, and with greater patient satisfaction.


Therefore, January 1, 2017 was a great day for patients who need dNPWT and for HHAs that want to accept these referrals. Many surgeons reported to this author that they were ready to refer their postoperative patients who needed dNPWT, and wound care qualified healthcare professionals, nurses, and therapists reported that they identified many patients who could benefit from dNPWT rather than tNPWT.


Like any other new payment program, the dNPWT payment program requires some changes to the HHAs' processes and software programs. However, even though the HHAs and their electronic health record (EHR) vendors knew about this opportunity for more than a year, some did not prepare to handle these new dNPWT equipment referrals and this new separate billing opportunity until after January 1, 2017.


Separate Billing Misperceptions

Throughout 2017, this author has spoken to many HHAs and numerous software vendors. Many of them had misperceptions that caused them to delay their preparations. Here are some of the most common misperceptions that were reported:


* Some HHA administrators did not believe the agency could legally bill separately for furnishing new dNPWT equipment. To prove this billing is legal, this author actually provided the links to (1) Section 504 of the Consolidated Appropriations Act of 2016 and (2) the 2017 HH PPS Final Rule. Both of these documents clearly describe the separate billing process that is permitted when HHAs furnish new dNPWT equipment.


* When some HHA administrators learned that Medicare pays HHAs for furnishing new dNPWT equipment out of the patients' Medicare Part B benefits, they assumed their HHA could not bill for new dNPWT equipment because their agency did not have a DME license. This author educated them that dNPWT is not DME, and a DME license is not required. Instead, the HHA simply submits a separate claim (which includes the new dNPWT device and the professional services specified in the CPT code description), identified as Type of Bill 34x, and Medicare automatically pays for the new dNPWT equipment and affiliated professional services out of the patients' Medicare Part B benefits.


* Because patients do not normally receive bills from the HHA for their skilled visits, some HHA administrators expressed 2 concerns when they learned that Medicare Part B pays for home health visits when new dNPWT equipment is furnished: (1) their nurses and therapists would not know how to explain the 20% coinsurance responsibility to the patients, and (2) their patients would be upset when they received bills for the new dNPWT equipment from the HHA. This author reminded the administrators that Medicare Part B beneficiaries are well aware of their 20% coinsurance responsibility. In fact, many Part B beneficiaries have secondary insurance that picks up most, if not all, of their 20% coinsurance.



If a patient and physician believe that dNPWT (rather than tNPWT) is more appropriate for that patient, the nurses and therapists should simply educate the patient that (1) he/she will receive a Medicare Part B coinsurance bill from the HHA, rather than from the DME supplier, and (2) they will receive a bill only for the number of new pieces of dNPWT equipment that are used, rather than a full month's charges.


* When some HHA administrators learned that they could not comingle the minutes spent assessing the wound, furnishing new dNPWT equipment, and providing education about ongoing care of the new dNPWT equipment with the minutes spent providing other skilled services, they thought the HHA should report 2 visits rather than 1 visit. This author explained that was a misperception and the administrator should review his/her paper or electronic documentation system and make a few adjustments; the minutes spent performing wound care on the days when a new piece of dNPWT equipment is furnished should not be included in the calculation of the administrator's skilled visit minutes for other services performed during the visit. Once those documentation adjustments are made, the HHA should educate their nurses and therapists about how to document and separate the time spent on wound care when new dNPWT equipment is furnished from the time spent on other skilled services. In addition, the nurses and therapists should be educated that time spent replacing the fluid management system on an existing piece of dNPWT equipment should be included in the calculation of their skilled visit minutes for other services performed.


* Some HHA administrators, whose agencies submit electronic bills to Medicare, believed they had to submit paper claims for furnishing new dNPWT equipment. Nothing could be further from the truth. All they have to do is change the Type of Bill on their electronic claims from 32x to 34x. If for some reason their vendor has not yet adjusted their electronic claims to accept 34x in the Type of Bill field, they can use CMS's Fiscal intermediary Standard System Direct Data Entry to submit claims for 97607/97608.


* Some HHA administrators reported that their EHR vendors did not begin to prepare for the documentation and Type of Bill changes until after January 1, 2017. This situation was very surprising to this author. Most software vendors continuously monitor coding and payment system changes that will affect their clients. They usually have the software changes in place by the time the coding/payment changes become effective.



Because this historical separate payment change literally took an act of Congress, one would have expected the EHR vendors to proactively make the required software changes. Although this was the first time that a technology used by patients at home switched from DME to a disposable device, it will probably not be the last. As the EHR vendors adjust their software to handle the new requirements in order for the HHAs to separately bill for furnishing new dNPWT equipment, they are most likely also preparing for documentation and billing for future disposable devices that will be used by patients receiving home healthcare.


* Some HHA administrators reported that if a patient under an HHA plan of care needed dNPWT equipment, they were going to send the patient to the hospital-based outpatient wound care department (HOPD). This author reminded them that furnishing dNPWT (which includes the professional services specified by the assigned CPT code) is included in the HHA's consolidated billing but is not bundled into the HH PPS payment rates. Home health agencies must bill for dNPWT and are paid in addition to their HH PPS payment. Therefore, if an HOPD furnishes new dNPWT equipment to a patient under a home health plan of care, the HOPD must bill the HHA rather than Medicare, ultimately costing the HHA more.





* Celebrate the positive steps that Congress and the CMS took to make it possible for patients under a home health plan of care to use dNPWT equipment if tNPWT DME does not meet their needs.


* Share the clinical, economic, and patient satisfaction attributes of dNPWT with your HHA administration.


* Assure your HHA administration that wound care nurses and therapists can easily educate the patients that they will receive their Medicare Part B 20% coinsurance bills from the HHA rather than from the DME supplier.


* Assure your HHA administration that, on days when the HHA is furnishing new dNPWT equipment to the patient, the wound care nurses and therapists can easily separate the minutes for the wound assessment, application of the dNPWT, and patient education from the calculation of minutes for other skilled services performed during the same visit. All they have to do is educate you about the process they prefer!


* Assure your HHA administration that you can easily learn to document furnishing new dNPWT in whatever print or digital format is necessary.


Your patients, their physicians, and their families will thank you for helping your HHA administration clear up their misperceptions, accept referrals for patients who need dNPWT, and separately bill Medicare for furnishing new dNPWT and affiliated professional services.


*CPT is a registered trademark of the American Medical Association. All rights reserved. [Context Link]