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Gastroenterology Coding Alert

CMS,CPT Differences Hinder Use of Care Plan Oversight Codes

Published on Sat Jun 01, 2002

Significant differences between the HCPCS and CPT codes for care plan oversight (CPO) are causing many gastroenterologists to put off billing for supervisory services provided to clinical nutrition patients under the care of a home health agency. While the differences between the two sets of codes can be confusing, recent clarifications issued by CMS may make it easier for gastroenterologists to rightfully claim their reimbursement dollars.

Although patients can be under the care of a home health agency for many reasons, clinical nutrition services may be the most common one in gastroen-terology. Clinical nutrition services include either parenteral (PEN, also referred to as total parental nutrition or TPN) or enteral (EN) nutrition. Many patients who are being administered PEN/EN in a home setting have long-term gastrointestinal conditions such as Crohn's disease or pancreatitis.

Not every PEN/EN patient who is at home qualifies for CPO, says Carolyn Viall, RN, MSN, associate professor of nursing at the University of North Carolina at Chapel Hill Hospital, and a member of the American Society for Parenteral and Enteral Nutrition's public policy committee. "Many patients on clinical nutrition may be at home but do not have home healthcare," she explains. "CPO is for patients with complex problems that require home health services. The clinical nutrition is only one prescribed therapy; the home health service is a separate order."

The gastroenterologist must be acting as the patient's primary care physician and have direct contact with the home health agency in order to bill these codes. "An internist or oncologist may ask a gastroenterologist for an opinion on a patient who needs enteral or parenteral nutrition," says Pat Stout, CMC, CPT, an independent gastroenterology coding consultant in Knoxville, Tenn. "But because the other physician takes over after the opinion has been rendered, the gastroenterologist cannot bill for any type of CPO service."

Physician Certification Billable Only to Medicare

The two billable services that a gastroenterologist may provide in this home health situation are physician certification of a home healthcare plan and care plan oversight. Physician certification includes the creation of a home healthcare plan by the gastroenterologist. The plan is dictated by the gastroenterologist to the home health agency, which transcribes the information (for Medicare patients) on CMS Form 485 and returns the form to the gastroenterologist for a signature.

In a typical home healthcare plan, the gastroenterologist may order the nurse to administer PEN/EN, monitor the patient's weight and vital signs, take lab specimens and add supplements to the PEN/EN mixture if needed, Stout explains. The gastroenterologist may also order physical therapy, bathing and light housekeeping duties. In addition to these orders, physician certification also requires establishing goals and expectations for the patient's progress.

Physician certification of a home healthcare plan is a separately billable service for Medicare patients only CPT does not have a code that can be reported to private payers. To report physician certification services for Medicare patients, you should use HCPCS code G0180 (Physician certification services for Medicare-covered services provided by a participating home health agency [patient not present], including review of initial or subsequent reports of patient status, review of patient's responses to the Oasis assessment instrument, contact with the home health agency to ascertain the initial implementation plan of care, and documentation in the patient's office record, per certification period).

Code G0180 can only be used when a patient has not received Medicare-covered home health services for at least 60 days. Reimbursement for the code is about $71.

If the home healthcare services for a Medicare patient extend beyond 60 days, the recertification of the plan can be billed with G0179 (MD recertification, HHA patient). This can be the same plan that was previously certified with G0180 or a modification of it, but the patient has to have received home health services for at least the past 60 days. Payment from Medicare is about $60.

CMS and CPT Have Separate CPO Codes

In addition to developing the plan, the gastroenterologist can bill for CPO if he or she assumes responsibility for the monitoring of the patient's condition and the supervision of the home healthcare plan. "Patients can get into trouble due to lack of monitoring," Viall says. "There are fluid issues and diarrhea to contend with. If the patient gets dehydrated, then you could have an electrolyte imbalance."

CPO activities do not require a face-to-face encounter with the patient,Viall says, and can include the following:

  • The review of patient lab reports, other diagnostic studies, and records of patient status including those kept by the home healthcare nurse.
  • Communication with other healthcare professionals not employed in the same practice who are involved in the patient's care. This communication also includes telephone calls (with some exceptions), which is another unusual feature of the CPO codes. "Telephone calls are usually not a reimbursable service even though there are separate CPT codes (99371-99373) that can be used to report them," Stout says.

  • Integration of new information into the new medical treatment plan or the adjustment of medical therapy.

    CMS and CPT have codes to cover these supervisory services. CPO for Medicare beneficiaries should be reported with HCPCS code G0181 (Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency [patient not present] requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication [including telephone calls] with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more).

    G0181 is the only CPO code that CMS recognizes. Reimbursement will be about $121.

    For patients with private payers, two CPT codes may be billed for CPO depending on the amount of time spent on those activities within the past month. For CPO services of 15-29 minutes, you should report 99374 (Physician supervision of a patient under care of home health agency [patient not present] in home, domiciliary or equivalent environment [e.g., Alzheimer's facility] requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication [including telephone calls] for purposes of assessment or care decisions with health care profes-sional[s], family member[s], surrogate decision makers[s] [e.g., legal guardian] and/or key caregiver[s] involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes). Code 99375 ( 30 minutes or more) should be reported for services of more than 30 minutes. Reimbursement for these codes depends on the payer.

    CMS and CPT Differ on Countable Activities

    Significant differences exist between the requirements for CMS' CPO codes, which were created in 2001, and CPT's, which were revised for 2001 and again for 2002. An "all-state" coverage bulletin that was published by most Medicare carriers in the latter half of 2001 clarified the main requirements for CMS coverage:

  • The gastroenterologist must provide a reimbursable service that requires a face-to-face encounter with the patient within the six months prior to the first billing of CPO. A face-to-face encounter, CMS says, usually means an E/M service. CPT does not specify that any face-to-face encounter is required.

  • If a gastroenterologist bills for CPO, he or she must be the same physician who signed the patient's home healthcare plan. In addition, CMS and CPT require that only one physician report CPO services for a given period of time, Viall says. "If you have two doctors submitting bills, then one of those will be denied," she says.

  • Though no time value is given in the HCPCS code definition, CMS' recent policy clarification states that the gastroenterologist must spend a minimum of 30 minutes providing CPO services within the calendar month for which payment is claimed to bill G0181.


    CPT's codes have a stated time component and are broken down into two categories: 15-29 minutes of service within a 30-day period for 99374, and more than 30 minutes for 99375.

  • The biggest difference between the two sets of CPO codes is the activities that can be counted toward those time minimums. Although the previously mentioned activities (review of lab studies, communication with other healthcare providers, etc.) are considered countable activities by CMS and CPT, CMS specifies that the time spent on the following services is NOT countable toward the 30-minute minimum for Medicare beneficiaries:
  • activities by members of the gastroenterologist's staff

  • discussions with the patient or his or her family regarding the adjustment of medications or treatment

  • telephone calls for prescriptions to the patient's pharmacist, unless the conversation involves a discussion of pharmaceutical therapies. This is a noteworthy exclusion for PEN/EN patients because the gastroenterologist will probably spend some time on the phone with the pharmacist adjusting the nutrition formula, Viall says.

    CPT revised its CPO codes this year to include communication with family members, surrogate decision-makers and other key caregivers as a countable CPO activity. CPT does not restrict the nature of the communications with other healthcare providers as CMS does. And although CPT does not have a separate code for physician certification of the home health plan, it allows time spent developing and revising the care plan to be counted as a CPO activity.

    Problems With Generic Documentation

    Documentation of CPO services was another issue that was covered in the CMS policy clarification. Gastroenterol-ogists must document in the patient's record what services were furnished and the date and length of time associated with those services. Blanket statements that 30 minutes were spent in the past month are considered insufficient.

    "The amount of effort it takes to jot down what was done is another thing that has detracted from gastroen-terologists billing these codes more often," Viall says. "But it can be something as brief as '2-13-02 spent 10 minutes reviewing lab report on blood workup.'"

     

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