FAQs

General quesions

Coding

If the physician debrides the wound on the same day he/she applies a disposable NPWT device, should he/she code and bill a debridement code and the NPWT application procedure code?

For patients who are insured by Medicare fee-for-service, the physician should review 2 Medicare guidelines to answer this question:

1. National Correct Coding Initiative (NCCI) Edits

Medicare and most other health plans follow the NCCI Edits when two procedures are performed on the same anatomic location during the same encounter. These edits can change on a quarterly basis. Therefore, physicians should check the NCCI edits on a quarterly basis for the answer to this question. 

2. Local Coverage Determinations (LCDs)

All LCDs, if they exist, can be found either on the specific Medicare Administrative Contractor’s (MAC’s) website or on the Medicare Coverage Database that contains the entire collection of MACs’ LCDs.

For patients who are insured by Medicare Advantage, private payers, Medicaid, Tri-Care, Workers Compensation etc., the physicians should review 2 documents to answer this question:

  1. Their contract with the payer may describe how they pay for multiple procedures performed during the same encounter
  2. The payer’s medical policies which are either found on their public website or on a “provider only” website which may require the physician’s provider number in order to gain access. 
If the physician performs other procedures to the same wound on the same day that he/she applies a disposable NPWT, can the physician code and bill for all of the procedures?

For patients who are insured by Medicare fee-for-service, the physician should review 2 Medicare guidelines to answer this question:

  1. National Correct Coding Initiative (NCCI) Edits

Medicare and most other health plans follow the NCCI Edits when two procedures are performed on the same anatomic location during the same encounter. These edits can change on a quarterly basis. Therefore, physicians should check the NCCI edits on a quarterly basis for the answer to this question. 

  1. Local Coverage Determinations (LCDs)

All LCDs, if they exist, can be found either on the specific Medicare Administrative Contractor’s (MAC’s) website or on the Medicare Coverage Database that contains the entire collection of MACs’ LCDs.

For patients who are insured by Medicare Advantage, private payers, Medicaid, Tri-Care, Workers Compensation etc., the physicians should review 2 documents to answer this question:

  1. Their contract with the payer may describe how they pay for multiple procedures performed during the same encounter.
  2. The payer’s medical policies which are either found on their public website or on a “provider only” website which may require the physician’s provider number in order to gain access.
What do billing units such as "per session" mean?
“Per session” typically means the wound care professional or facility can only bill for that procedure once per encounter.
When should providers use the application of disposable NPWT codes described as "less than 50 sq. cm" and described as "50 sq. cm or greater"?
Providers should select the application of disposable NPWT codes based upon the size of the wound(s) covered under one fluid management component.  The descriptor for CPT® code 97607 specifies a wound surface (length x width) less than or equal to 50 square centimetres.  The descriptor for CPT® code 97608 specifies a surface (length x width) greater than 50 square centimetres. 

Home Health Agencies

Coverage

What services qualify for Medicare covered home health agency care?

Medicare’s Home Health Prospective Payment System (HH PPS) includes payment for all covered home health services when provided to a Medicare patient under a home health plan of care and provided at the patient’s place of residence. These services are paid via a national standardized 60-day episode payment amount with applicable adjustments. Durable Medical Equipment (DME), eg, traditional negative pressure wound therapy (NPWT) pumps, is specifically excluded by Section 1814(k) of the Social Security Act from the national, standardized 60-day episode rate and consolidated billing requirements.

  • Part-time or intermittent nursing care
  • Physical or occupational therapy or speech-language pathology services
  • Medical social services
  • Part-time or intermittent services of a home health aide
  • Medical supplies
  • A covered osteoporosis drug
  • DME
What qualifies a patient for Medicare’s home health benefit?

The physician must certify that the patient meets the following criteria:

  • Is confined to the home
  • Needs skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy
  • Is under the care of a physician
  • Receives services under a plan of care established and reviewed by a physician, and
  • Has had a face-to-face encounter related to the primary reason for home health care with a physician or allowed Non-Physician Practitioner (NPP) within a required timeframe

NOTE: Coverage for disposable negative pressure wound therapy pumps will be determined based upon a physician’s order, as well as patient preference.

Should home health agencies conduct insurance benefit verification before applying the PICO Single Use Negative Pressure Wound Therapy System to each patient?
It is the provider’s responsibility to verify coverage for the PICO Single Use Negative Pressure Wound Therapy System. A home health agency may conduct insurance benefit verification before applying the PICO Single Use Negative Pressure Wound Therapy System. In addition, the home health agency should carefully read the utilization and documentation guidelines in their Medicare Administrative Contractor’s (MAC) pertinent Local Coverage Determination (LCD) (if one exists) or in the pertinent medical policy (if one exists) of the private payer that insures the patient.
Where can home health agencies locate Medicare LCDs and/or private payer medical policies pertinent to the application of PICO Single Use Negative Pressure Wound Therapy System?
All Medicare LCDs, if they exist, can be found either on the specific MAC’s website or on the Medicare Coverage Database that contains all MACs LCDs. Many private payers post their medical policies on their public website or on a “provider only” website that may require your provider number.

Payment

Is it true that effective January 1, 2017, home health agencies are eligible to receive separate Medicare payment for the application of a new PICO Single Use Negative Pressure Wound Therapy System?
Yes, effective January 1, 2017 home health agencies may receive separate Medicare payment for negative pressure wound therapy that uses a new disposable device, such as the PICO Single Use Negative Pressure Wound Therapy System, for Medicare beneficiaries who receive home health agency services under a home health plan of care.
In order for a home health agency to receive separate Medicare payment for the application of a new PICO Single Use Negative Pressure Wound Therapy System, who must do the wound assessment and apply the pump and fluid management system?
The application of a new PICO Single Use Negative Pressure Wound Therapy System may only be performed by licensed nurses (RN or LPN), physical therapists, or occupational therapists in accordance with State law. 
What is the 2017 Medicare national average home health prospective payment system allowable rate for Current Procedural Terminology (CPT®) code 97607 and CPT® code 97608?

The separate payment amount for CPT® code 97607 and CPT® code 97608 is indexed to the Medicare Hospital Outpatient Prospective Payment System (OPPS) payment amount. The payment amount will be subject to the area wage adjustment policies in place under the current year’s OPPS. Each home health agency should check with its administration to learn its specific agency’s Medicare allowable rate. For CY 2017 the national average

Medicare allowable rate is $292.62. The amount paid to the home health agency by Medicare will be equal to 80% of the lesser of the actual charge or the OPPS payment amount for the year. The patient or his/her secondary insurance will pay the Medicare Part B 20% beneficiary coinsurance to the home health agency. 

How can the home health agency learn its exact 2017 Medicare allowable rate for CPT® code 97607 and CPT® code 97608 and the patient’s exact Medicare Part B coinsurance?

The home health agency can learn its exact Medicare allowable rates for CPT® code 97607 and CPT® code 97608 by contacting its billing or finance department. Once the exact allowable rates are identified, the home health agency can calculate 20% of the allowable rate, which will be the patient’s Medicare Part B coinsurance.

For example: If the home health agency’s allowable rate is exactly the same as the national average rate ($292.62), the patient’s coinsurance will be $58.53 and Medicare will pay $234.09 to the home health agency, subject to the sequestration reduction of 2% ($229.41).

Coding

When a home health agency furnishes a new PICO Single Use Negative Pressure Wound Therapy System, what CPT code should the home health agency report on the Medicare Part B claim?

CPT® codes 97607 and 97608 include reimbursement for the disposable device and, therefore, should be reported when a new PICO NPWT Pump with a 7-day battery is furnished to the patient and a wound assessment and instructions for ongoing care is performed by a licensed nurse (RN or LPN), physical therapist, or occupational therapist in accordance with State law. The home health agency should report either 97607 or 97608 using Bill Type 34X.

97607: Negative pressure wound therapy, (eg, 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.

97608: Negative pressure wound therapy, (eg, 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.

Because the PICO Single Use Negative Pressure Wound Therapy System contains two fluid management systems, can the home health agency receive separate Medicare payment when the second fluid management system is attached to a PICO Negative Pressure Wound Therapy Pump (that has a 7-day battery life) which was applied several days ago and which still has several days of active battery life?

No. The time for this visit should be reported on the HH PPS claim using Bill Type 32X unless the visit was performed solely for the purpose of furnishing a new PICO Single Use Negative Pressure Wound Therapy Pump. 

If a patient is under a home health plan of care and the visit includes: 1) the application of a new PICO Single Use Negative Pressure Wound Therapy System by a licensed nurse (RN or LPN), physical therapist, or occupational therapist; and 2) an otherwise covered home health agency visit (eg, furnishing a catheter change), how should the home health agency report this visit?

In the instance where the home health agency furnishes a new PICO NPWT Pump as well as other home health services (eg, furnishing a catheter change), the home health agency 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 using Bill Type 32X. In this situation, the home health agency should submit two claims for this service:

A claim for the new PICO NPWT Pump and related service using Bill Type 34X with the appropriate 97607 or 97608 CPT code as described above; and 

A HH PPS claim using Bill Type 32X, only for the time spent furnishing the services unrelated to the provision of NPWT. 

Hospital-Based Outpatient Wound Care Departments (HOPDs)

Coding

When a physician or other qualified healthcare professional (QHP) assesses the patient’s wound and orders the HOPD staff to apply the PICO Single Use Negative Pressure Wound Therapy System, what code should he/she report on his/her Medicare claim?
If the physician or other QHP did not apply the PICO Single Use Negative Pressure Wound Therapy System, did not perform another procedure, and did document the wound assessment and disposable negative pressure wound therapy system order, the physician or other QHP should report the CPT® code for the appropriate level of evaluation & management service performed. 
When a qualified HOPD staff assesses the wound, furnishes a new PICO Single Use Negative Pressure Wound Therapy System and provides instructions for ongoing care, what CPT® code should the HOPD report on their Medicare claims?

The HOPD may report either CPT® code 97607 or CPT® code 97608, depending on the size of the wound.

97607: Negative pressure wound therapy, (eg, 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.

97608: Negative pressure wound therapy, (eg, 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.

If the physician or other QHP writes an order for the patient to return to the HOPD for wound assessment and replacement of the negative pressure fluid management system several days after a new PICO Single Use Negative Pressure Wound Therapy System (that has a 7-day battery life) was applied, what code should the HOPD report on their Medicare claims?

For a HOPD visit when the wound is assessed and/or another procedure (eg surgical debridement or selective debridement) is performed and a new fluid management system is applied and attached to a PICO Single Use Negative Pressure Wound Therapy System (whose 7-day battery life is not exhausted), the HOPD should report and bill for the actual services furnished during that visit and bill for the work that was performed that visit (eg appropriate level of clinic visit, surgical debridement, selective debridement, etc.).

Payment

What is the 2017 Medicare national average Outpatient Prospective Payment System (OPPS) allowable rate for 97607 and 97608?

For calendar year (CY) 2017, Medicare assigned 97607 and 97608 to Ambulatory Payment Classification (APC) Group 5052 Level II Skin Procedures. The national average 2017 Medicare rate is $292.62. Actual payment to an HOPD will vary based on geographic location. This amount does not account for sequestration.

NOTE: Medicare assigned APC Group 5052 with status indicator “T.” Therefore, the payment for 97607 and 97608 will be reduced by 50% when medically necessary and billed on the same date of service as another procedure with a “T” status indicator.

How can the HOPD learn their exact Medicare allowable rate for 97607 and 97608 and the exact coinsurance the patient will owe?
The HOPD can learn their exact Medicare allowable rates for 97607 and 97608 from their billing or finance departments. Once the exact allowable rates are identified, the HOPD can calculate 20% of the allowable rate, which will be the patient’s coinsurance. For example: If the HOPD’s allowable rate is exactly the same as the national average rate ($292.62), the patient’s coinsurance will be $58.53 and Medicare will pay $234.09, subject to the sequestration reduction of 2% ($229.41).
How can the HOPD determine if/how much the application of the PICO Single Use Negative Pressure Wound Therapy System will be paid by Medicare during the same encounter when another procedure is performed?

To answer this question, the HOPD should refer to three things:

  1. Pertinent Local Coverage Determinations
  2. Status indicator(s)of the APC Groups to which 97607 or 97608 and the other procedure are assigned, and
  3. Current quarter’s National Correct Coding Initiative (NCCI) edits 
How much should the HOPD charge for the application of the PICO Single Use Negative Pressure Wound Therapy System?
Manufacturers cannot advise on specific charge amounts. HOPDs and their finance department should ensure that reported charges associated with CPT® codes 97607 and 97608 reflect both the PICO Single Use Negative Pressure Wound Therapy System and the work to assess the wound, apply it, and provide instructions for ongoing care. The charges associated with CPT® codes 97607 and 97608 should include the disposable NPWT device. Thus the charges for CPT® codes 97607 and 97608 likely will be different from the charges for CPT® codes 97605 and 97606 that describe NPWT using traditional durable medical equipment and do not include the cost of the durable medical equipment itself.

Coverage

Should HOPDs conduct insurance benefit verification before applying the PICO Single Use Negative Pressure Wound Therapy System to each patient?
It is the provider’s responsibility to verify coverage for the PICO Single Use Negative Pressure Wound Therapy System. The HOPD may conduct insurance benefit verification before applying the PICO Single Use Negative Pressure Wound Therapy System. In addition, the HOPD should carefully read the utilization and documentation guidelines in their Medicare Administrative Contractor’s (MAC) pertinent Local Coverage Determination (LCD) [if one exists] or in the pertinent medical policy (if one exists) of the private payer that insures the patient. 
Where can HOPDs locate Medicare LCDs and/or private payer medical policies pertinent to the application of PICO Single Use Negative Pressure Wound Therapy System?

All Medicare LCDs can be found either on the specific MAC’s website or on the Medicare Coverage Database which contains all MACs LCDs.

Many private payers post their medical policies on their public website or on a “provider only” website which may require your provider number.

CPT® is a registered trademark of the American Medical Association.