Internal Medicine Coding Alert

Effective Jan. 1, 2001, HCFA will reimburse internists for doing something they were already doing certifying and recertifying plans of care for home healthcare patients. Although they prescribe home healthcare services frequently, many internists have not billed for these services because they didnt believe HCFA would offer them this new stream of revenue.

The ordering of home health services is nothing new, says Kathy Pride, CPC, an internal medicine coder and coding supervisor for Martin Memorial Medical Group in Stuart, Fla. Most internists ask me if Im sure this is legal. It sounds too good to be true, but it is [true]. HCFA is using these codes to entice internists to give more time and thought to these home healthcare plans, according to Brett Baker, third-party-relations specialist at the American Society of Internal Medicine (ASIM) in Washington, D.C. HCFA is now paying internists so that they will pay closer attention to the creation and review of the care plan and to make sure that the patient is getting appropriate care, he explains. Because there are time constraints and paperwork involved in the prescribing of these services, HCFA believes that some internists have only been giving the plans cursory attention.

Another reason internists have been reluctant to bill these codes is a lack of information on how they should be reported. 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.

New HCPCS Codes for Home Healthcare Services

HCFA has established the following HCPCS codes for reporting certification and recertification services after the January 1 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; and

G0179 MD recertification, HAA patient.

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 services as well as some housekeeping services to homebound patients. These services literally have to be in the patients private residence, she says. Also the patient has to be truly home-bound he or she cannot be able to drive to the internists office for a visit.

For example, an 80-year-old man who has recently had surgery to remove his gallbladder also has chronic obstructive pulmonary disease and cancer of the lung. Because of the potential for complications with this patient, the internist who is monitoring the patients recovery feels it is appropriate to send a nurse from a home health agency to see the patient twice a week for the first four weeks, and once a week thereafter.

The internist wants the nurse to assess the effect of the medications, the patients gastrointestinal status, nutrition, hydration status and the healing of the incision. Physical therapy, bathing and light housekeeping are also ordered from the agency. The internist dictates these orders to the agency via telephone. He or she also creates goals for the patient and expectations of what the patients progress should be.

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 internist develops this plan. This certification is for a 60-day period. If the plan must be extended beyond 60 days, code G0179, with a transitioned nonfacility RVU of 1.60, should be used to report the recertification of the care plan, which can be the same plan that was previously certified or a modification of it.

HCFA Form 485 Can Be Used for Documentation

HCFA has not directly addressed what an internist needs to do to document these services. Baker contends that physicians need to document the certification or re-certification of the patient home healthcare plan in the medical record. The note should describe activities involved in 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 HCFA form 485 (Home Health Certification and Plan of Care) for documentation. When the internist dictates the plan of care to the home health agency, the agency should transcribe that information to form 485 and then return it to the internist for his or her signature. The agency keeps the original form on file and gives a copy to the internist. Pride suggests the home health agency make a copy of the internists signed copy and keep it with the claim for certification.

A diagnosis code must also be included on the claim. In the previous example, Pride recommends reporting cholecystitis (575.0, acute cholecystitis) as the primary diagnosis. Lung cancer could be used as a secondary diagnosis (162.8, malignant neoplasm of trachea, bronchus, and lung, other parts of bronchus or lung).

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

Coding for Oversight Services

Once the plan of care has been certified, any coordination of care with the home healthcare nurse should be billed by the internist as a plan oversight care service. The internist 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 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 by ASIM, in conversations with HCFA, that there is to be no double-dipping, which may make it a little harder for internists to met the care plan oversight time requirements, he explains.