11/02/2021

You Asked... We Answered

You Asked:

Is it possible for a physician overseeing the care of a home health or hospice patient to bill for care plan oversight for their patients and if so, what all does that process entail?

We Answered:

Yes, it is possible for physicians to bill for care plan oversight of their home health or hospice patients. Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for patients of skilled nursing facilities (SNFs), nursing home facilities, or hospitals.

Per CMS:

Criteria for Coverage

The beneficiary requires complex or multi-disciplinary care modalities requiring the physician's ongoing involvement in the beneficiary's plan of care.
CPO services are furnished during the period in which the beneficiary was receiving Medicare-covered home health agency (HHA) or hospice services.
The physician who submits the claim for CPO must be the same physician that signed the home health or hospice plan of care.
The physician furnished at least 30 minutes of CPO within the calendar month. Time counted toward CPO may not include time spent by a nurse or time spent consulting with a nurse.
Time counted toward hospital discharge management (CPT codes 99238-99239) or discharge from observation (CPT code 99217) may not also be counted toward CPO. Services that are separately documented and that are provided after the patient is physically discharged may be counted toward CPO.
The physician provided a covered service that required a face-to-face encounter (i.e., Evaluation & Management (E/M) service) with the beneficiary within the 6 months immediately preceding the CPO service. EKG, lab, and surgical services do not meet this face-to-face encounter requirement.
The CPO service may not be routine post-operative care provided during the global surgery period by the surgeon.
For home health CPO, the physician may not have a "significant financial or contractual interest in the home health agency." For hospice CPO, the physician may not be employed by or volunteer as medical director of the hospice.
CPO services must be submitted by the same physician that provided the services.
Services provided "incident to" a physician's service may not be counted toward the 30-minute requirement for CPO.
The same physician may not submit a claim for both CPO and end stage renal disease (ESRD) capitation payment for the same beneficiary during the same month.
The physician must document, in the patient's medical record, the services furnished to the patient and date and length of time associated with these services.

CPO Codes

Note: Refer to a HCPCS manual for additional information. The types of services that are included in CPO are noted in the narrative descriptions for each HCPCS code.

CPO Documentation:

Medical records for these services must indicate:
- For HCPCS codes G0181 and G0182, the physician spent 30 minutes or more for countable care planning activities
- The specific service furnished, including the date and length of time

CPO Claim Submission

The patient does not have to be present for CPO services to be provided and claims submitted to Medicare.
The HHA or Hospice Provider Number is required on claims for CPO (HCPCS codes G0181 and G0182).
- Electronic claims: submit the HHA's or hospice's NPI, as appropriate, in loop 2300, ref segment, with qualifier 1J.
- Paper claims: submit the HHA's or hospice's NPI, as appropriate, in Item 23.
Date of service for HCPCS codes G0181 and G0182 are to be submitted with the first and last dates care planning services were provided during the calendar month.
- Do not submit the first and last calendar date of the month unless services were provided on those dates
- Submit the claim after the end of the month in which the service is performed
- Report care planning only once per calendar month
- Report only one month of services per line item
Place of service submitted corresponds with where the CPO services were provided.
Submit CPT codes 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter.

Certification / Recertification

Physician certification/recertification claims are Part B claims paid for under the Physician Fee Schedule.

HOME HEALTH:

No payment can be made for covered home health services that a home health agency (HHA) provides unless a physician certifies that:
- Home health services are needed because the individual is confined to his/her home
- The individual needs intermittent skilled nursing care, or physical therapy, or speech-language pathology services, or continues to need occupational therapy.
- A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician
- The services are or were furnished while the individual was under the care of a physician; and
- The individual had a face-to-face encounter with an allowed provider type no more than 90 days prior to or within 30 days after the start of home health care and the encounter
Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.
When services are continued past an initial 60-day episode of care, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services
Recertifications must be signed by the physician who reviews the plan of care.

HOSPICE:

The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course.
Recertification for subsequent periods only requires the written certification by the hospice medical director or the physician member of the hospice interdisciplinary group.
Certifications and recertifications must be dated and signed by the physician and must include the benefit periods to which they apply.
Certifications and recertifications must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less.

Applicable Codes

HHHN Codes

Note: Refer to a HCPCS manual for additional information. The types of services that are included are noted in the narrative descriptions for each HCPCS code.

Claim Submission

Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be submitted for the same date of service as the supervision service HCPCS code (G0181).
Submit HCPCS code G0179 for recertification after a patient has received services for at least 60 days (or one certification period).
- Except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.
Date of service for HCPCS codes G0179 and G0180 must be submitted as the date physician/NPP saw the patient, not the date the physician/NPP signed the certification or recertification.

Reference:

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11/02/2021

You Asked... We Answered