Who Will Medicare Separately Pay for Negative Pressure Wound Therapy?

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Negative pressure wound therapy (NPWT) continues to play a significant role in wound/ulcer management protocols throughout the continuum of care. However, confusion reigns regarding who Medicare will separately pay to provide and apply the equipment and supplies. The confusion begins with the misunderstanding that NPWT durable medical equipment (DME) and disposable NPWT (dNPWT) should be reported on claims with the same codes. The confusion is further compounded with the misunderstanding that NPWT DME and dNPWT receive similar and separate Medicare payment in all places of service. Therefore, this article should clear up some of the confusion.

Inpatient Hospitals

Because the Medicare Severity-Diagnosis Related Groups (MS-DRG) payment system requires inpatient hospitals to purchase or rent medical equipment and supplies ordered for each beneficiary covered by Medicare Part A, inpatient hospitals do not receive separate payment for dNPWT and NPWT DME devices and supplies. The costs for both types of NPWT equipment and supplies must be absorbed by the inpatient hospitals.

Hospital-Owned Outpatient Provider-Based Departments

When a physician or other qualified healthcare professional (QHP) orders NPWT for a Medicare Part B covered patient receiving care in a hospital owned outpatient wound/ulcer management provider-based department (PBD), the PBD and/or the physician/QHP is/are paid differently for dNPWT vs NPWT DME. Their Medicare Part B payment also depends on whether the patient is under a home health agency (HHA) or skilled nursing facility (SNF) plan of care. Let us first consider dNPWT applied in a PBD.

dNPWT. If the patient is not also receiving care by a HHA or SNF, and when the PBD purchases and applies a new dNPWT device, the PBD may report the codes 97607 or 97608, depending on the size of the wound/ulcer. The Medicare Outpatient Prospective Payment System (OPPS) should separately pay the PBD for the application of every new dNPWT device, unless payment for 97607 or 97608 is prohibited by a National Correct Coding Initiative (NCCI) edit because it is considered a component of another procedure that was performed during the same encounter. At encounters when the PBD only changes the dressings and reapplies the same dNPWT device, the PBD should not bill for 97607/97608. Instead, the PBD should bill Medicare for either a clinic visit or any other procedure that was performed during the encounter
 
If the patient is receiving care by a HHA or SNF, the physician/QHP should write an order for the HHA or SNF to purchase and apply the dNPWT device. If the HHA or SNF prefers that the PBD purchase and apply the dNPWT, then the PBD should execute a contract with the HHA or SNF to pay the PBD. The PBD should not bill Medicare. Now let us consider NPWT DME when applied in the PBD.

NPWT DME. If the patient is not receiving care by a SNF or nursing facility (NF), the physician should write an order for the NPWT DME equipment and supplies to be provided, for the patient’s use at home, by a durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) supplier. The DMEPOS supplier delivers the NPWT DME equipment and supplies to the patient’s home and reports the NPWT DME equipment and supplies on their claim to Medicare. If all the coverage criteria are met, Medicare should pay the supplier based on the DMEPOS Fee Schedule.

If the patient is receiving care by a SNF or NF, the physician/QHP should write an order for the SNF or NF to purchase the NPWT DME equipment and supplies.

In either case, when the patient goes to the PBD for a wound assessment, she/he should take the NPWT DME pump, a new canister, and a new dressing kit to the PBD. After the wound assessment, and if the patient still needs the NPWT, either the PBD staff or the physician will reapply the patient’s NPWT DME pump, canister, and dressing. If the PBD staff apply the equipment, the PBD should report 97605 or 97606, depending on the size of the wound/ulcer, on the Medicare claim. If the physician/QHP applies the equipment, both the PBD and the physician/QHP should report 97605 or 97606 on their Medicare claims.

NOTE: The NCCI Edits may prevent separate payment for 97605/97606 and/or 97607/97608 when performed at the same encounter on the same anatomic location as another minor procedure. Therefore, PBDs, physicians, and QHPs should review the NCCI Edit updates at the beginning of each calendar quarter.

Physicians and Other QHPs

As described above for PBDs, physicians and QHPs should determine1) if the Medicare Part B covered beneficiary is also receiving Medicare Part A covered care by a HHA or SNF, and 2) if an NCCI Edit exists that prevents payment for the application of dNPWT or NPWT DME when performed at the same encounter on the same anatomic location as another minor procedure. In addition, the Medicare Physician Fee Schedule (MPFS) has different allowable rates and requirements when physicians/QHPs perform work in places of service (POS) paid as non-facilities versus POS paid as facilities.

Non-facility MPFS Allowable Rates. In non-facility POS (eg, office POS 11, patient’s home POS 12):

• Physicians/QHPs should purchase and report 97607/97608, for the application of every new dNPWT device, and should be paid the MPFS non-facility rates.
• Physicians/QHPs should report 97605/97606, when they apply a NPWT DME pump and supplies that the beneficiary acquired from a DMEPOS supplier or a SNF and should be paid the MPFS non-facility rates.

Facility MPFS Allowable Rates. In facility POS (eg, hospital POS 21, PBD POS 19 or 22, SNF POS 31):

• Physicians /QHPs should not purchase dNPWT devices or NPWT DME devices.
• If physicians/QHPs personally apply NPWT in facilities, they should be paid the MPFS facility allowable rates for the application of NPWT DME (reported with 97605/97606), and for the application of each new dNPWT pump (reported with 97607/97608).

Home Health Agencies

Medicare home health consolidated billing requires HHAs to purchase dNPWT devices which are ordered for their patients. Medicare also expects HHAs to separately report A9272, on their monthly Medicare claims, for each new dNPWT device that they purchase and apply to their patients. Because A9272 only accounts for the dNPWT device and accessories, the HHA should also report a routine registered nurse, licensed practical nurse, physical therapist or occupational therapist visit when one of them applies a new dNPWT system.

Medicare does not expect HHAs to purchase NPWT DME for their patients. Instead that equipment and supplies should be ordered from, provided by, and billed to Medicare Part B by the DMEPOS suppliers.

Skilled Nursing Facilities

The Medicare Patient-Driven Payment Model (PDPM) consolidated billing system requires SNFs to purchase and provide, without separate payment, NPWT DME/supplies and dNPWT, for beneficiaries receiving skilled care in a SNF POS 31. Therefore, Medicare does not separately pay SNFs for this equipment and supplies. If the SNF requests a PBD, physician or QHP to purchase and apply a new dNPWT or to apply a NPWT DME, the PBD, physician, QHP and SNF should execute a contract that allows the PBD, physician, or QHP to bill the SNF rather than the Medicare program.

NOTE: When a physician orders a dNPWT system for a Medicare Part B-covered beneficiary, who is receiving non-skilled care in a nursing facility (NF) POS 32, the NF is not required to purchase the dNPWT system. The PBD, physician, and/or QHP may purchase, apply, and bill the Medicare Part B program for the dNPWT system.

DMEPOS Suppliers

When a physician or QHP submits a complete signed standard written order for a NPWT DME system for a Medicare Part B-covered beneficiary to use at home, the DMEPOS supplier reports E2402 for the equipment, A7000 for the canister, and A6550 for the wound care set. If the coverage criteria are met, the DMEPOS supplier should be paid their state’s allowable rate published on the DMEPOS Supplier Fee Schedule.

NOTE: The Negative Wound Therapy Pumps Local Coverage Determination (LCD) L33821 and the Negative Pressure Wound Therapy Pumps Local Coverage Article (LCA) A52511 contains important documentation requirements and utilization guidelines for the physicians/QHPs who order the NPWT DME and the DMEPOS suppliers who fill the orders. Therefore, the physicians, QHPs, and DMEPOS suppliers should carefully read and implement the LCD and LCA requirements.
 
Because dNPWT is not covered under the DME benefit, DMEPOS suppliers cannot bill Medicare for dNPWT.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.