Important Changes for 2017

Home Health veterans know that each year new challenges, regulations, and clinical measures will be put into place.  2017 is not going to be any different. With pre-claim review ramping up and a new set of RAC (Recovery Audit Contractors) agreements starting, 2017 is going to be just as busy as 2016.


Let’s not forget we also have the major unknown – what will happen if and when ObamaCare is repealed?  How many of the regulations and compliance measures are going to stay and how many are going to go? How long will the process take?  Estimates range from 12 months to 3 years for a full wind down of current ObamaCare regulations.


Agencies must be ready on January 1st for 3 major new changes.  G Codes for nursing visits are being revamped and added to again.  Outliers are going to be calculated in a new unit method.  Agencies are going to feel some relief for treating wound care by billing for negative pressure wound therapy devices.


G Codes

G Codes G0163 and G0164 will be enjoying retirement as of January 1, 2017.  These two codes are being replaced with four codes, based on RN and LPN services provided to patients.

  • G0493 – Skilled Services by an RN

G0494 – Skilled Services by an LPN

For the observation and assessment of the patient’s condition, each 15 minutes.  The change in the patient’s condition required skilled nursing personnel to identify and evaluate the patients need for possible notification of treatment.

  • G0495 – Skilled Services by an RN

G0496 – Skilled Services by an LPN

For training and/or education of a patient or family member, each 15 minutes.


Quality Assurance and Review staff are going to need to be aware of the type of visit performed and by whom going forward in 2017.  Medicare is using these expanded codes to further calibrate reimbursement in the coming years.


Outlier Calculations

Outlier episodes are sometimes unavoidable and Medicare has realized that certain patients who have a demand for intensive, complex, and costly services sometimes do not receive the care needed in their home.  Therefore, on January 1, 2017, outlier episodes are going to be calculated based on 15 minute increments.  Each 15 minutes of care will be considered 1 unit.


The current per visit rates are now per unit rates.  CMS will be calculating these rates when the claims are submitted based on the units of care provided throughout the episode. However, there is a cap on the total number of units of home health services that can be provided in a single day.  Under this new outlier calculation, the total number of units of care, across all disciplines, will be capped at 32 units (8 hours) of care per day.


Negative Pressure Wound Therapy (NPWT) Devices


A totally new type of payment is coming to home health agencies.  For patients who have a wound and are ordered by their physician to undergo negative pressure wound therapy, the disposable devices are now billable outside of the home health episode. The payment to agencies will be provide through Outpatient PPS (OPPS) under the Part B Medicare Benefit.  Agencies are allowed to bill for certain outpatient treatments using their Part A Medicare number.  There are going to be some nuances that agencies will have to comply with in order to utilize the new reimbursement model.


Agencies who opt for billing separately for the NPWT devices will need to distinguish a nursing visit from a visit whose sole purpose is to change a NPWT dressing.  The visit for changing the NPWT dressing will be billed outside of the normal home health PPS system using bill type (TOB) 034x.


Revenue codes, 0559, 042X, and 043X are to be used in conjunction with HCPCS codes 97607 or 97608.  HCPCS Code 97607 will be used for ongoing wound care that is less than 50 square centimeters.  For wounds greater than 50 square centimeters, HCPCS Code 97608 is to be used.


In order to bill for the NPWT disposable device, visits will need to fall within an active episode and be specifically ordered by the patient’s physician.  Agencies will need to first bill the RAP, prior to billing the NPWT disposable devices in FISS DDE.  Since the payment for NPWT devices falls under the outpatient, Medicare B benefit, services will be subject to the Part B deductible and 20% co-insurance.   If a patient has a Part B supplement insurance plan, you will need to bill this insurance before billing the patient.  Likely, many agencies are not going to be able to bill the Part B supplement insurance plan and will require the agency to pick up the difference.


We are recommending agencies create a separate tracking document with all of the required information necessary to bill for NPWT disposable devices.  Tortolano & Company/Optima Billing is available to bill for NPWT disposable devices to make the process easier on your agency.