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HELP DOCS BILL CPO WITH THESE 12 RULES

Published on Thu Jul 28, 2005

Know what counts and what doesn't for the 30-minute requirement.

You can strengthen your relationship with physicians by helping them avoid fraud and abuse worries and earn their rightful reimbursement all at the same time.

The HHS Office of Inspector General has its eye on physician care plan oversight. You can help docs claim bulletproof CPO services by heeding these 12 coverage rules set out by the Centers for Medicare & Medicaid Services:

1. The beneficiary must require complex or multi-disciplinary care modalities requiring ongoing physician involvement in the patient's plan of care;

2. The CPO services should be furnished during the period in which the beneficiary was receiving Medicare-covered HHA or hospice services;

3. The physician who bills CPO must be the same one who signed the home health or hospice plan of care;

4. The physician furnished at least 30 minutes of care plan oversight within the calendar month for which payment is claimed. Time spent by a physician's nurse or the time spent consulting with one's nurse is not countable toward the 30-minute threshold. Low-intensity services included as part of other evaluation and management services don't count either;

5. The work included in hospital discharge day management (codes 99238-99239) and discharge from observation (code 99217) is not countable toward the 30 minutes. On the same day as discharge, only those services separately documented as occurring after the patient is actually physically discharged from the hospital count;

6. The physician provided a covered physician service that required a face-to-face encounter with the beneficiary within the six months immediately preceding the first CPO service. Only E/M services are an acceptable prerequisite for face-to-face encounters for CPO. EKG, lab and surgical services are not sufficient for CPO;

7. The CPO billed by the physician was not routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician;

8. If the beneficiary is receiving home health agency services, the physician did not have a significant financial or contractual interest in the HHA. A physician who is an employee of a hospice, including a volunteer medical director, should not bill CPO services;

9. The physician who bills the CPO services is the physician who furnished them;

10. Services provided incident to a physician's service don't qualify as CPO;

11. The physician is not billing for the Medicare end stage renal disease (ESRD) capitation payment for the same beneficiary during the same month; and

12. The physician billing for CPO must document in the patient's record the services furnished and the date and length of time associated with those services. "Documentation supplied by HHA or hospices may not be used in lieu of a physician's documentation," the OIG added in an October 2003 report on CPO (A-02-02-01019).

Note: The coverage criteria are on pp. 14-15 of the Medicare Benefit Policy Manual, Chapter 15, at www.cms.hhs.gov/manuals/102_policy/bp102c15.pdf. Physician billing instructions and requirements are on pp. 162-164 of the Medicare Claims Processing Manual, Chapter 12, at www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf.

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