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Negative Pressure Wound Therapy Billing Reminders

National Government Services recently identified problematic billing while reviewing claims for NPWT. The purpose of this article is to help clarify the various possible billing methods when certain situations occur.

Example 1

How to bill for wound A for the four covered months when the coverage criteria has been met.

  • Month 1 – E2402RRKHKX
  • Month 2 – E2402RRKIKX
  • Month 3 – E2402RRKIKX
  • Month 4 – E2402RRKJKX – Therapy is discontinued for wound A during 4th month

Example 2

Billing for wound A for a fifth month of therapy due to individual circumstances it is believed that an extra month of therapy is necessary (coverage is limited to four months of therapy per wound unless upon individual consideration at the redetermination level it is approved).

  • Month 1 – E2402RRKHKX
  • Month 2 – E2402RRKIKX
  • Month 3 – E2402RRKIKX
  • Month 4 – E2402RRKJKX
  • Month 5 – E2402RRKJGA or E2402RRKJGZ – The KX modifier may not be used.

    The GA modifier is to only be appended if a properly executed ABN has been obtained. If an ABN was not properly executed, append the GZ modifier.

Example 3

Wound A has received its four months of covered therapy during the fourth month wound B (new wound) started receiving therapy. How do you bill for the fifth month?

  • Month 1 – E2402RRKHKX
  • Month 2 – E2402RRKIKX
  • Month 3 – E2402RRKIKX
  • Month 4 – E2402RRKJKX – Wound A 4th month and wound B 1st month
  • Month 5 – E2402RRKJKX – Wound B 2nd covered month

    A new capped rental period does not start in month 4 or 5 because there has been no break in medical necessity of 60+ days for the pump. The presence of a new wound does not, by itself, start a new capped rental period.

Example 4

Wound A received four months of covered therapy, NPWT was discontinued, and 60+ days have passed since the last month of therapy. Now wound B (a new wound) has presented and requires NPWT. This scenario describes a clear break in medical necessity and therefore a new capped rental period begins for wound B. For claims submitted electronically, complete the NTE line level segment (2400 loop) with the following information: The abbreviation “BIS” for break-in-medical need, “pick up” date of the previous equipment (MMDDYY), “delivery” date of the new equipment (MMDDYY), previous diagnosis code (ICD-9), and new diagnosis code (ICD-9).

Format: BIS MMDDYY MMDDYY ICD-9 ICD-9 (Example: BIS 100106 123006 379.31 V43.1)

  • Month 1 – 010110 – E2402RRKHKX
  • Month 2 – 020110 – E2402RRKIKX
  • Month 3 – 030110 – E2402RRKIKX
  • Month 4 – 040110 – E2402RRKJKX – Last month of therapy for wound A

    (60+ days have passed)
     
  • Month 1 – 070110 – E2402RRKHKX – First month for wound B

Example 5

Wound A was treated with NPWT in an inpatient setting for the first two months. The beneficiary went home with continued NPWT for the last two months of covered therapy. The time the patient was treated with the NPWT in the inpatient setting goes toward the cumulative four months of covered therapy even though Medicare Part B did not pay for the therapy.

  • Month 1 – While in an inpatient setting not billed to the DME MAC
  • Month 2 – While in an inpatient setting not billed to DME MAC
  • Month 3 – E2402RRKHKX – 3rd month of therapy but 1st month covered by DME MAC
  • Month 4 – E2402RRKIKX – 4th month of therapy but 2nd month covered by DME MAC
  • Month 5 – E2402RRKIGA or E2402RRKIGZ – 5th month of therapy not covered by DME MAC unless allowed upon individual consideration at the appeals level. KX modifier may not be used. GA modifier is used only if a properly executed ABN has been obtained. If an ABN was not properly executed, append the GZ modifier.

Example 6

Wound A received two months of NPWT while in home setting and then went into inpatient setting for one month with continued NPWT and came back home on NPWT.

  • Month 1 – E2402RRKHKX – 1st month of therapy covered by DME MAC
  • Month 2 – E2402RRKIKX – 2nd month of therapy covered by DME MAC
  • Month 3 – While in an inpatient setting not billed to DME MAC
  • Month 4 – E2402RRKIKX – 4th month of therapy but 3rd month covered by DME MAC
  • Month 5 – E2402RRKJGA or E2402RRKIGZ – 5th month of therapy but not covered by DME MAC unless allowed upon individual consideration at the appeals level. KX modifier may not be used. GA modifier is used only if a properly executed ABN has been obtained. If an ABN was not properly executed, append the GZ modifier.

Example 7

Wound A received two months of NPWT while in home setting and then went into an inpatient setting for one month not receiving therapy and came back home on NPWT.

  • Month 1 – E2402RRKHKX
  • Month 2 – E2402RRKIKX

    (1 month in an inpatient setting in between with no therapy)
     
  • Month 3 – E2402RRKIKX – No new capped rental period would begin because there was not a 60+ day break in medical necessity
  • Month 4 – E2402RRKJKX

For more information regarding capped rental billing and the local coverage determination and policy article, please refer to the National Government Services Web site under Medical Policy Center.

Negative Pressure Wound Therapy Billing Reminders
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