Healthcare Provider Solutions

The 2017 Final Home Care Rule included clarification that payment for the NPWT device is when a HHA “furnishes NPWT using a disposable device” to mean 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. These visits would be billed on a Type of Bill (TOB) 34x. There are two codes to be used when billing for this service. Currently, CPT codes 97607 and 97608 (APC 5052), with status indicator “T” (Procedure or Service, Multiple Procedure Reduction Applies), include payment for both performing the service and the disposable NPWT device:

  • HCPCS 97607 – Negative pressure wound therapy, (e.g., vacuum-assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.
  • HCPCS 97608 – Negative pressure wound therapy, (e.g., vacuum-assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters. 

Follow up visits related to the wound care where the device is not replaced are to be billed as HH visits on TOB 32x.  In most instances, an HHA providing NPWT will bill both a 34X for the NPWT device along with the professional services and a 32X bill for other HHA professional and dependent services. This will mean a Medicare Part B payment for the NPWT visits and a LUPA or full episode payment for the other services. The NPWT professional services do not count towards the 4 visit LUPA threshold. The NPWT is also subject to a 20% beneficiary coinsurance.

Example:  On Monday, the nurse applies a new disposable NPWT device, and provides instructions for ongoing wound care. During this same visit, per the HH plan of care, the nurse changes the indwelling catheter and provides troubleshooting information and teaching regarding its maintenance. In this scenario, the billing procedures are as follows:

  • The visit included applying a new disposable NPWT device as well as services unrelated to that NPWT service, which means the HHA will submit both a TOB 34x and a TOB 32x.
  • For furnishing NPWT using a disposable device, that is, the application of the new disposable NPWT device and the time spent instructing the beneficiary about ongoing wound care, the HHA would bill using a TOB 34x with CPT® code 97607 or 97608.
  • For services not associated with furnishing NPWT using a disposable device, that is, for the replacement of the indwelling catheter and instructions about troubleshooting and maintenance, the HHA would bill under TOB 32x.

The reimbursement rate for NPWT with a disposable device is the same regardless of the HCPCS code is used.  The rate is $292.49 and this amount must be wage adjusted.

When a claim with HCPCS 97607 and 97608 on TOB 034x is identified as not falling within a HH episode, your MAC will deny lines reporting revenue code 0559 (Skilled Nursing Care, Comprehensive Visit) using the following remittance advice codes:

  • Group Code: CO
  • CARC: 170 (Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.)
  • RARC: N95 (Services subjected to Home Health Initiative medical review/cost report audit.)

This edit is in place to ensure that this patient is in a home health episode when receiving this service.