There are days I feel like I am the only person who did not get the office memo. That’s how I feel about Disposable Negative Pressure Wound Therapy (dNPWT) when the patient has a home health agency. dNPWT has made NPWT more practical and convenient for smaller non-healing wounds which may be just as serious (and just as deep) as large defects. When I started using NPWT in 1997, its primary use was for absolutely huge abdominal surgical dehiscences. The wounds were huge and so was the NPWT device! However, it didn’t take long for all of us to figure out we could save non-healing amputations and even close some diabetic foot and venous leg ulcers. In other words, we all figured out that NPWT was useful and even necessary for smaller wounds. Sometimes the smaller wounds are actually the toughest, although I am not sure that the payers understand this. In any case, dNPWT developed to meet the challenge of refractory small wounds.
However, I felt silly when I was asked how I handled ordering dNPWT through the patient’s Home Health Agency. I had to go to the Federal Register (FR) to get my head around this question. The rest of you probably figured this out, but in case you didn’t, I have pasted some relevant excerpts from the FR below. The FR clearly states that if the patient is currently receiving Home Health services, the Home Health Agency (HHA) is required to provide the dNPWT.
“… The law requires that all medical supplies (routine and nonroutine) be provided by the HHA while the patient is under a home health plan of care. A disposable NPWT device would be considered a non-routine supply for home health.”
—76730 Federal Register / Vol. 81, No. 213 / Thursday, November 3, 2016 / Rules and Regulations
As any wound care practitioner knows, the orders for HHA services require a doctor to sign a “485” form. However, I generally don’t sign the HHA 485 forms. I’d love to, but the HHA won’t send me only the orders that pertain to wound care. They include orders for the patient’s diabetes medications and anticoagulants for their atrial fibrillation, and a lot of other conditions I am not treating. My solution is to send my wound care orders to the primary care physician and have the PCP order home nursing. Then the HHA gets the primary to sign the 485. That means the PCP will be the one to whom questions about the medical necessity of dNPWT will be directed. It’s highly variable as to whether the PCP will be willing or able to answer them. Assuming that the dNPWT actually does get applied by the home health agency, if the patient returns to the wound center with a dNPWT in place, we can’t charge for changing it. When dNPWT are applied in the outpatient center, the charges for the application of dNPWT are included in the APC rate that allows us to bill for the cost of the device. If someone else charged for the application, we can’t use the procedure code for changing traditional NPWT on a disposable. The home health agency has effectively already been paid for that service.
At least in my situation, the HHA will have to fill out an unfamiliar order form and have it signed by the PCP who is not actually caring for the wound. The HHA will have to provide all dNPWT applications because the wound care clinic won’t have the supplies and has no way to be compensated for the service. In case you are still confused about dNPWT and Home Health, a revised MLN Matters article was just posted.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
