Gastroenterology Coding Alert

Effective Jan. 1, 2001, HCFA began reimbursing gastroenterologists for doing something they may have already been doing certifying and recertifying plans of care for home healthcare patients. Many gastroenterologists have put off billing for these services because they just didnt believe that HCFA would offer them a new source of revenue.

HCFA has established the following HCPCS codes for reporting certification and recertification services after the Jan. 1, 2001, effective date:

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 patients responses to the Oasis assessment instrument, contact with the home health agency to ascertain the initial implementation plan of care, and documentation in the patients office record, per certification period.

G0179 MD recertification, HHA patient

The ordering of home health services is nothing new, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group in Stuart, Fla. Most physicians ask me if Im sure this is legal. It sounds too good to be true, but it is.

HCFA is using the HCPCS codes to entice gastroenterologists and other physicians to give more time and thought to home healthcare plans, according to Brett Baker, third party relations specialist at the American Society of Internal Medicine in Washington, D.C.

Because there are lots of time constraints and paperwork involved in the prescribing of these services, HCFA believes that some physicians have only been giving the plans cursory attention.

Another reason why gastroenterologists have been reluctant to bill these codes is because there has been a lack of information on how they should be used. The problem is that there has been very little information in the Federal Register about how to use these codes, Baker says. The carriers have been slow on getting information out because they are waiting for instructions from HCFA, and information from HCFA is just trickling out.

Use G0180 for Certification of Plan

The initial certification code, G0180, which has a transitioned nonfacility relative value unit (RVU) of 1.91, should be reported when a patient has not received Medicare-covered home health services for at least 60 days. This certification only applies when the services of a Medicare covered home health agency are prescribed, Pride explains. These agencies provide nursing, as well as some housekeeping to homebound patients. These services literally have to be in the patients private residence, she says. Also, the patient has to be truly homebound. He or she cannot be able drive to the physicians office for a visit.

An example of a patient for whom home health service might be prescribed is someone with a severe and chronic digestive disease such as Crohns Disease or pancreatitis, according to Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn. People with severe Crohns Disease may need total parenteral nutrition (TPN), and may have other complications resulting from the disease or from a recent surgery to remove the inflamed intestine, she explains. A physician may order a home health-care nurse to administer TPN intravenously, monitor the patients weight and vital signs, take lab specimens and add supplements to the TPN mixture if necessary.

In addition, the gastroenterologist may want the nurse to assess the effect of the medications being given, the patients hydration status and the healing of any incisions that might have been made if the patient underwent surgery. Under some circumstances, physical therapy, bathing and light housekeeping may be ordered from the agency. The physician dictates these orders to the agency via the telephone. He or she also creates goals for the patient and expectations of what progress should occur.

This would be a typical initial certification for a plan of home healthcare, says Pride, who emphasizes that the patient does not have to be present when the gastroenterologist develops this plan. This certification is for a 60-day period.

Use G0179 for Recertification of Plan

If the plan must be extended beyond 60 days, G1079, with a transitioned nonfacility RVU of 1.60, should be used to report the recertification of the care plan. This can be the same plan that was previously certified or a modification of it.

Stout stresses, however, that to bill these codes, the gastroenterologist must be acting as the patients primary care physician and have direct contact with the home healthcare agency. Due to the complex nature of conditions, such as Crohns Disease or chronic pancreatitis, there is a need for a physician to provide ongoing monitoring, she explains. At times, internists or family practice physicians may not be comfortable managing the complexities of certain illnesses and will have a gastroenterologist manage this aspect of the patients care.

Many times a GI physician will be asked by an internist for his or her opinion regarding a patient with a disease such as multiple sclerosis or amyotrophic lateral sclerosis (ALS) who needs enteral or parenteral nutrition, Stout continues. Because the internist or other primary care physician takes over after the recommendation is made, it is not considered home healthcare plan certification on the part of the gastroenterologist.

Form HCFA 485 Can Be Used for Documentation

HCFA has not directly addressed what documentation is required for these services. Baker contends that physicians need to document the certification or recertification of the patient home healthcare plan in the medical record. The note should describe activities involved in making the decision, and explain why the plan is appropriate or why the recertified plan had to be revised.

On the other hand, Pride recommends using Form HCFA 485 (Home Health Certification and Plan of Care) for documentation. When the gastroenterologist dictates the plan of care to the home health agency, the agency should transcribe that information to the Form HCFA 485 and return it to the physician for his or her signature. The agency keeps the original form on file and gives a copy to the gastroenterologist. Pride suggests the home healthcare agency make a copy of the signed copy and keeps it with the claim for certification.

A diagnosis code must also be included in the claim. In the previously cited example of a patient with Crohns Disease, a diagnosis code such as 555.0 (regional enteritis, small intestine) should be used for the primary diagnosis. Other conditions such as intestinal mal-absorption (579.9) may be reported secondary.

Some coders question what site of service should be reported with these codes: home or office. Pride says that Medicare representatives have indicated to her that all sites of service are valid for G0180 and G0179, but she uses office on her claims.

Coordination of Care Billed Separately

Once the plan of care has been certified, any coordination of care done with the home health nurse should be billed by the gastroenterologist as plan oversight care. The gastroenterologist may decide after a week to change the patients medications and increase the number of nurse visits, explains Pride. This modification is part of the plan care oversight and can be billed with 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 patients care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more). As noted in the definition, the plan oversight requires a minimum of 30 minutes be spent on the patients care over a 30-day period.

However, the time spent creating the certification or recertification plan cannot be counted toward the 30-minute minimum for the plan care oversight, Baker says. Its been confirmed in conversations with HCFA that there is to be no double-dipping, which may make it a little harder for gastroenterologists to meet the care plan oversight time requirements, he explains.