1. Schaum, Kathleen D. MS

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In last month's column, we discussed how the novel coronavirus 2019 (COVID-19) public health emergency caused telehealth to become a "household word" for professionals, providers, patients, and payers. In a matter of a few weeks, providers implemented processes to provide care via telehealth to patients in their homes. Under normal circumstances, this widespread adoption of telehealth may have taken years. In this column, we discuss how COVID-19 has caused many home health agencies (HHAs) that normally only provide Part A services to Medicare beneficiaries to begin providing separately billable services to expand their offerings and increase their revenue.


Let us begin our discussion with some history. For decades, home healthcare has been part of a Medicare beneficiary's Part A benefits. If a beneficiary meets the qualifications for home healthcare, the HHA submits claims for that beneficiary's Part A-covered care to their Medicare Administrative Contractor (MAC). Beneficiaries do not incur a deductible or coinsurance for their Medicare Part A-covered home healthcare.


In addition to providing Medicare Part A-covered home healthcare, HHAs can also provide certain covered separately billable services. Puzzled by HHAs' decision to pass up these opportunities to broaden their offerings and increase their revenue, this author queried several small and large HHAs throughout the country. Following is a review of their responses, which are a bit surprising:


* They cannot count the time toward their nursing visits, although they would be paid separately for the covered service.


* They did not want to have to teach their nurses and therapists how to document for the separately billable services, although the nurses and therapists already document the medical necessity for those exact same services as provided for their patients by other professionals/suppliers.


* They did not want to have to teach their coding and billing staff how to submit claims to their MAC for the separately billable services, although they have adequate staff and the process is not difficult.


* They did not want to have to inform their patients that their agency would be billing the 20% coinsurance for the separately billable service, although the patients' secondary insurance or the patients themselves already pay the 20% coinsurance for those same services to other professionals/suppliers.


* They did not want to add new services and processes while they were getting used to their new Patient-Driven Groupings Model, although they wanted to increase their revenue.


* They reported that their electronic health records were not sophisticated enough to deduct time spent performing separately billable services from the total visit time. (However, now that offering separately billable services is becoming more important to the HHAs' financial success, this author encourages the HHA executives to have their software companies move this software revision higher on their priority list.)


* They thought they had to acquire a durable medical equipment (DME) supplier license to separately bill Medicare for the non-DME services, which is not true.



This year, many HHAs have revisited their business model and are beginning to add separately billable services that can increase their revenue. In many instances, the HHAs provided these services-such as outpatient therapy, Clinical Laboratory Improvement Amendments laboratory services, infusion services, and disposable negative-pressure wound therapy (dNPWT)-but did not charge for them for all the reasons stated above. Now, many agencies are realizing that navigating the claim submission process for separately billable services is worth the effort to bring more services to their patients and increase the HHA's revenue. When this author asked executives from these HHAs that had already added separately billable services if they had words of advice for other HHAs considering a similar expansion, nearly every executive said to "verify your state regulations and review regulatory standards pertaining to the services you wish to perform."


If you are a wound/ulcer management nurse or therapist working in an HHA, you may wonder how this renewed interest in separately billable services pertains to the work you do. Well, this is your opportunity to (re)introduce dNPWT to your HHA. Over the past 4 years, this author has received many calls and emails from nurses and therapists whose patients could benefit from dNPWT but whose HHAs did not want to set up the separate billing and coinsurance collection process for it. This author was always sad to learn that HHAs were not taking advantage of this separate billing opportunity that required an act of Congress to achieve.


Let us reflect on the inequity that existed before the new law was enacted. When patients needed NPWT DME, a DME supplier provided the equipment and supplies to the patients, billed Medicare Part B, and collected the 20% coinsurance from the patients' secondary insurance or from the patients. Prior to 2017, when the patients needed dNPWT (which is not considered DME), the HHA had to purchase the dNPWT equipment and supplies and could not charge Medicare separately. To rectify this inequity, the Consolidate Appropriations Act of 2016 (Pub. L 113-113) requires that MACs pay HHAs separately for dNPWT devices when furnished to an individual who receives home health services which are paid for under the Medicare home health benefit. Payment for the HHAs' acquisition and application of the disposable device is identical to the payment that hospital-owned outpatient wound/ulcer management provider-based departments (PBDs) receive under the Outpatient Prospective Payment System (OPPS). Although this new law was great news for the HHAs and their patients, many of the HHAs still chose not to submit separate bills to Medicare for the reasons outlined above. Now that the HHAs are recognizing the value of expanding their offerings to include separately billable services, this is a wonderful time for nurses and therapists to encourage their HHAs to consider adding dNPWT as a new billable service.


Although HHA nurses and therapists already know the clinical benefits of dNPWT for their patients with wounds/ulcers, they may need some reimbursement talking points to share with their HHA's executives. Following are some pieces of reimbursement information that should interest HHA executives:


* Two codes (97607 and 97608) are available for the HHA to bill when they furnish and the nurses/therapists apply dNPWT devices. When the HHA supplies a new dNPWT device and performs all the services associated with its application, 97607 or 97608 should be reported on the home health claim Type of Bill 34x. Because 97607 and 97608 include the acquisition of the device and the associated work to assess the wound/ulcer, apply the device, and provide instruction for ongoing care, 97607 and 97608 should be reported on the claim with a unit of 1. All follow-up visits for wound assessment, wound management, and dressing changes when a new dNPWT device is not applied should be included on the home health claim (Type of Bill 32x) with the number of minutes spent performing this work.


* Based on the practitioner who provided the service, the HHA should report 97607 or 97608 with one of three revenue codes: 0559 for skilled nurses, 042X for physical therapists, and 043X for occupational therapists. When therapists provide the dNPWT service, the HHA should also report the therapy plan of care modifiers (GO or GP).


* The 2020 national average Medicare allowable payment for the home health visit when a new dNPWT device is furnished and applied is $319.51 for either code. By the time you are reading this article, the 2021 rate should have been released in the 2021 OPPS Final Rule.


* HHAs should conduct insurance benefit verification for 97607 and 97608 from both primary and secondary payers. Medicare requires that HHAs bill for and make a good-faith effort to collect the coinsurance from the patient's secondary insurance. If the patient does not have secondary insurance, Medicare requires HHAs to notify patients of their coinsurance responsibility and to collect the appropriate amount. Medicare will pay the HHA 80% of the OPPS allowable rate, and the HHA will collect the other 20% from either the patient's secondary insurance or from the patient, just like the DME suppliers collect for NPWT DME.


* Both 97607 and 97608 are on the HHA Consolidated Billing list. Therefore, the HHA should be purchasing and billing for dNPWT equipment and services. If HHAs send patients to PBDs or to physicians' offices to receive their dNPWT, the PBDs or physicians' offices are obligated to collect their normal charge from the HHA. This is another good reason for the HHA to provide dNPWT to their patients who need it.


* Two guidance documents should be of interest to HHA executives and their coding and billing staff:


1. The Implementation of Policy Changes for the CY 2017 Home Health Prospective1 was released on November 10, 2016, and explains the new law that allows the provision and separate billing of dNPWT by HHAs.


2. The Clarification of Billing and Payment Policies for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device2 was released on June 11, 2019, and provides excellent dNPWT coding directions and numerous billing scenarios.





1. Centers for Medicare & Medicaid Services. Implementation of Policy Changes for the CY 2017 Home Health Prospective. 2017. Last accessed September 14, 2020. [Context Link]


2. Centers for Medicare & Medicaid Services. Clarification of Billing and Payment Policies for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device. 2019. Last accessed September 14, 2020. [Context Link]