(Medicare Benefit Policy Manual)

EXAMPLE:   A patient requires dNPWT  for the treatment of a wound. On Monday, a nurse assesses a patients wound, applies a new disposable NPWT device, and provides wound care education to the patient and family.  The nursing visit is reported on the home health claim as a home health visit using the appropriate G -code, revenue code and units of time on TOB 032x. Payment for these services are included in the overall HH PPS payment rate for the 30-day period of care if the LUPA threshold has been met for the period. The HHA would report the H ealthcare Common Procedure Coding System (HCPCS) code A9272 (for the device only) on the home health type of bill TOB 032x. A separate payment is made for the device only. The nurse returns on Thursday for follow up teaching and assessment of the device. T he nurse does not replace the dNPWT device at this visit. Only the nursing visit is reported on the home health claim using TOB 032x. No separate reporting for the device would be included on the claim since the device was not replaced during this visit.    For instructions  on billing  for NPWT  using a disposable  device,  see Pub. 100-04, Medicare  Claims  Processing Manual, chapter 10, Section 90.3  Billing Instructions for Disposable Negative Pressure Wound Therapy Services.    50.5 - Services of Interns and Residents  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Home health services include the medical services of interns and residents -in-training under an approved hospital teaching program if the services are ordered by the physician or allowed practitioner who is responsible for the plan of care and the HHA is a ffiliated with or is under common control of a hospital furnishing the medical services.  Approved means:    Approved by the Accreditation Council for Graduate Medical Education;   In the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association;   In the case of an intern or resident- in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or   In the case of an intern or resident- in-training in the field of podiatry, approved by the Council on Podiatric Education of the American Podiatric Association.  50.6 - Outpatient Services  (Rev. 1, 10-01-03) A3-3119.6, HHA-206.6  Outpatient services include any of the items or services described above which are provided under arrangements on an outpatient basis at a hospital, skilled nursing facility, rehabilitation center, or outpatient department affiliated with a medical school,  and (1) which require equipment which cannot readily be made available at the patient's place of residence, or (2) which are furnished while the patient is at the facility to receive the services described in (1). The hospital, skilled nursing facility, or outpatient department affiliated with a medical school must all be qualified providers of services.  However, there are special provisions for the use of the facilities of rehabilitation centers.  The cost of transporting an individual to a facility cannot be reimbursed as home health services.   50.7 - Part -Time or Intermittent Home Health Aide and Skilled Nursing Services  (Rev. 1, 10-01-03) A3-3119.7, HHA- 206.7, A3-3119.7A, HHA-206.7A, A3-3119.7.B, HHA-206.7.B  Where a patient is eligible for coverage of home health services, Medicare covers either part-time or intermittent home health aide services or skilled nursing services subject to the limits below.  The law at 1861(m) of the Act  clarified: "the term "part- time or intermittent services" means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by- case basis as to the need for care, less than 8 hours each day and 35 or fewer hours each week).  50.7.1 - Impact on Care Provided in Excess of "Intermittent" or "Part -Time" Care  (Rev.  208, Issued: 04-22-15, Effective: 01 -01-15, Implementation: 05-11-15)  Home health aide and/or skilled nursing care, in excess of the amounts of care that meet the definition of part-time or intermittent, may be provided to a home care patient or purchased by other payers without bearing on whether the home health aide and skilled nursing care meets the Medicare definitions of part -time or intermittent.   EXAMPLE:  A patient needs skilled nursing care monthly for a catheter change and the home health agency also renders needed daily home health aide services 24 hours per day that will be needed for a long and indefinite period of time.  The HHA bills Medicare for the skilled nursing and home health aide services, which were provided before the 35th hour of service each week, and bills the beneficiary (or another payer) for the remainder of the care.  If the Medicare contractor determines that the 35 hours of care are reasonable and necessary, Medicare would cover the 35 hours of skilled nursing and home health aide visits.   50.7.2 - Application of this Policy Revision  (Rev. 1, 10-01-03) A3-3119.7.D, HHA-206.7.D  Additional care covered by other payers discussed in 50.7.1 does not affect Medicare coverage when the conditions listed below apply.  A patient must meet the criteria for Medicare coverage of home health services, before this policy revision becomes applicable to skilled nursing services and/or home health aide services.  The definition of "intermittent" with respect to the need for skilled nursing care where the patient qualifies for coverage based on the need for "skilled nursing care on an intermittent basis" remains unchanged.  Specifically:  1.  This policy revision always applies to home health aide services when the patient qualifies for coverage;   2.  This policy revision applies to skilled nursing care only when the patient needs physical therapy or speech-language pathology services or continued occupational therapy, and also needs skilled nursing care; and  3.  If the patient needs skilled nursing care but does not need physical therapy or speech -language pathology services or occupational therapy, the patient must still meet the longstanding and unchanged definition of "intermittent" skilled nursing care in order to qualify for coverage of any home health services.  60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B)  (Rev. 1, 10-01-03) A3-3122, HHA-212  60.1 - Post-Institutional Home Health Services Furnished During A Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part B (Rev. 1, 10-01-03) A3-3122.1, HHA- 212.1, A3-3122.1, HHA-212.2, PMs A-97-12, A-97- 16, A -98-49   Section 1812(a)(3) of the Act provides post- institutional home health services for individuals enrolled in Part A and Part B and home health services for individuals who are eligible for Part A only.  For beneficiaries who are enrolled in Part A and Part B, Part A finances post- institutional home health services furnished during a home health spell of illness for up to 100 visits during a spell of illness.  Part A finances up to 100 visits furnished during a home health spell of illness if the following criteria are met:   Beneficiaries are enrolled in Part A and  Part B and qualify to receive the Medicare home health benefit;    Beneficiaries must have at least a three consecutive day stay in a hospital or rural primary care hospital; and    Home health services must be initiated and the first covered home health visit must be rendered within 14 days of discharge from a 3 consecutive day stay in a hospital or rural primary care hospital or within 14 days of discharge from a skilled nursing facility in which the individual was provided post-hospital extended care services.  If the first home health visit is not initiated within 14 days of discharge, then home health services are financed under Part B.  After an individual exhausts 100 visits of Part A post- institutional home health services, Part B finances the balance of the home health spell of illness.  A home health spell of illness is a period of consecutive days beginning with the first day not included in a previous home health spell of illness on which the individual is furnished post-institutional home health services which occurs in a month the individual is entitled to Part A.  The home health spell of illness ends with the close of the first period of 60 consecutive days in which the individual is neither an inpatient of a hospital or rural primary care hospital nor an inpatient of a skilled nursing facility (in which the individual was furnished post-hospital extended care services) nor provided home health services.   EXAMPLE 1:   An individual is enrolled in Part A and Part B, qualifies for the Medicare home health benefit, has a three consecutive day stay in a hospital, and is discharged on May 1.  On May 5, the individual receives the first skilled nursing visit under the plan of care.  Therefore, post-institutional home health services have been initiated within 14 days of discharge.  The individual is later hospitalized on June 2.  Prior to the June 2 hospitalization, the individual received 12 home health visits.  The individual stays in the hospital for four consecutive days, is discharged and receives home health services.  That individual continues the May 5 home health spell of illness and would ha ve 88 visits left under that home health spell of illness under Part A.  That individual could not start another home health spell of illness (100 visits under Part A) until a 60- day consecutive period in which the individual was not an inpatient of a hospital, rural primary care hospital, an inpatient of a skilled nursing facility (in which the individual was furnished post-hospital extended care services), or provided home health services had passed.   EXAMPLE 2:   An individual is enrolled in Part A and Part B, qualifies for the Medicare home health benefit, has a three consecutive day stay in a hospital, and home health is initiated within 14 days of discharge.  The individual exhausts the 100 visits under Part A post -institutional home health services, continues to need home health services, and receives home health services under Part B. The individual is then hospitalized for 4 consecutive days.  The individual is again discharged and receives home health service s.  The individual cannot begin a new home health spell of illness because 60 days did not pass in which the individual was not an inpatient of a hospital or rural primary care hospital or an inpatient of a skilled nursing facility in which the individual was furnished post -hospital extended care services.  The individual would be discharged and Part B would continue to finance the home health services.   60.2 - Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet Threshold for Post -Institutional Home Health Services  (Rev. 1, 10- 01-03) A3-3122.1, HHA -212.3   If beneficiaries are enrolled in Part A and Part B and are eligible for the Medicare home health benefit, but do not meet the three consecutive day stay requirement or the 14 day initiation of care requirement, then all of their home health services would be financed under Part B.  For example, this situation would include, but is not limited to, beneficiaries enrolled in Part A and Part B who are coming from the community to a home health agency in need of home health services or who stay less than three consecutive days in a hospital and are discharged.  Any home health services received after discharge would be financed under Part B.   60.3 - Beneficiaries Who Are Part A Only or Part B Only  (Rev. 1, 10- 01-03) A3-3122.1, HHA -212.4   If a beneficiary is enrolled only in Part A and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part A.  The 100- visit limit does not  apply to beneficiaries who are only enrolled in Part A.  If a beneficiary is enrolled only in Part B and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part B.  There is no 100- visit limit under Part B.  The new definition of post -institutional home health services provided during a home health spell of illness only applies to those beneficiaries who are enrolled in both  Part A and Part B and qualify for the Medicare home health benefit.  60.4 - Coinsurance, Copayments, and Deductibles  (Rev.  233, Issued: 02-24-17, Effective: 01-01-17, Implementation: 03-27-17)  There is no coinsurance, copayment, or deductible for home health services and supplies other than the following:   coinsurance required for durable medical equipment (DME) and furnishing NPWT using a disposable device covered as a home health service; and