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Orthopedic Coding Alert

Stop Giving Away Your CPO Services for Free

Published on Thu Nov 06, 2003

Documentation is key for care plan oversight reimbursement

Don't let carriers undervalue your physician's care plan oversight (CPO) services: Start getting paid for CPO with a solid understanding of how and when to report 99374-99380 and G0179-G0180.
 
Suppose your orthopedist spends 40 minutes setting up a home-health plan of care for an elderly diabetic patient who falls outside of her home and sprains her right wrist and right ankle with multiple abrasions of the right lower leg. Due to her wrist injury, she cannot ambulate with crutches or a walker, so she is confined to a wheelchair while her injuries heal. She requires home care for assistance with activities of daily living, hygiene, and wound care. You write off the 40 minutes as nonbillable time - and in the process, you forfeit about $80 in care plan oversight services.
 
Physicians supervising home healthcare can often recoup payment for their time by accessing CPO codes 99374-99380 for private payers, and G0179-G0180 for Medicare. Reimbursement for these codes is on par with some of the higher-level E/M codes, so if your documentation supports it, you should charge for CPO. But because the OIG intends to scrutinize CPO services in 2004, it's more important than ever to ensure that your CPO documentation is airtight.

Face-to-Face Time Not Required

CPO services are time-based, non-face-to-face E/M services that include many tasks that orthopedists regularly perform for the long-term management of home-health agency, hospice or nursing-facility patients under their care. Orthopedists might provide such services for spinal injury patients who are wheelchair-bound or accident victims recovering from multiple traumatic injuries.
 
Although preauthorization is sometimes required, many payers will recognize these codes. Remember that Medicare only accepts G0179-G0180 for CPO, while private payers usually require the 99374 series. The CPO codes include:
 

  • G0179 - Physician recertification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per recertification period
     
  • G0180 - Physician certification ... including review of reports of patient status ... to affirm the initial implementation of the plan of care ...
     
  • G0181 - Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency ...
     
  • G0182 - Physician supervision of a patient under a Medicare-approved hospice (patient not present)
     requiring complex and multidisciplinary care modalities...
     
  •   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 multidisci-
     plinary 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 healthcare professional(s), family
     member(s), surrogate decision maker(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
     
  •   99375 - ... 30 minutes or more
     
  •   99377 - Physician supervision of a hospice patient ...; 15-29 minutes
     
  •   99378 - ... 30 minutes or more
     
  •   99379 - Physician supervision of a nursing facility patient ...; 15-29 minutes
     
  •   99380 - ... 30 minutes or more.

    Other activities that you may count toward CPO but that are not specifically mentioned in the CPT descriptors include time devoted to medical decision-making and coordination of physician services.

    When You Can Report CPO During Global

    Suppose Dr. Jones performs surgery on a patient and decides that the patient requires a month of home healthcare during recovery. To determine whether you can report Dr. Jones' services with a CPO code, you first have to decide whether the patient requires healthcare because of the surgery.
      
    "If the patient only requires home healthcare because he's recovering from surgery, then the CPO is included in the global surgical package," says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants, a healthcare reimbursement consulting firm in Cumberland, Wis. For example, if you perform a hip replacement and you request that a home-health practitioner visit the patient weekly to check for infection and help the patient perform range-of-motion exercises, you cannot report the CPO codes.
     
    Section 15513 of the Medicare Carriers Manual states that CPO services are only payable if the service was "not routine postoperative care provided in the global surgical period of a surgical procedure billed by the physician." Some carriers, such as Utah Medicare, echo this policy word-for-word, leaving some practices to believe that non-routine services, such as postoperative complications, are therefore billable.
     
    Other carriers, such as Empire Medicare (New York and New Jersey's carrier), more explicitly prohibit surgeons from reporting CPO that is at all related to a surgical procedure. Empire's policy states, "Payment is made for CPO to a physician providing postsurgical care during the postoperative period only if the care plan oversight is documented to be unrelated to the surgery."
     
    If your carrier's policy isn't as specific as Empire Medicare's, don't simply interpret the policy on your own to select when you feel that the postoperative care is "routine." Contact your carrier for a carrier-specific vignette offering an example of when CPO services are separately billable during a global period.

    Spend At Least 30 Minutes for Medicare

    The orthopedist must spend at least 30 minutes performing CPO for you to be able to report G0181 or G0182 to Medicare. If your practice frequently reports these services, you should consider stapling a "cheat sheet" to the forms that your home-health agencies send to you. This works well for Jerri Freeman, coder at High Point Orthopedic in Thomasville, NC. The form allows the physician to document the time that he or she spends on the patient's CPO.
     
    Although Medicare will deny CPO services that you report with the 99374 series, these carriers do offer second chances, Buechner says. "If the practice doesn't do a lot of Medicare business, they probably don't know that Medicare carriers recommend the HCPCS Level III codes," he says. "If Medicare denies your claim because you've reported the CPT codes instead of the G codes, you can file a corrected claim with the correct codes."

    Travel Time Isn't Included in CPO

    You cannot report all of your physician's home-health certification services as CPO, even if they involve much time and effort. You can only count the activities requiring a physician's skill, and anything that does not meaningfully contribute to the treatment of the illness or the injury does not count.
     
    According to the Medicare Carriers Manual, section 15513, you should never report the following services as CPO:
     

  •   physician phone calls to the patient or family
     
  •   travel time
     
  •   time spent preparing claims for processing. 
      
    A physician billing CPO must have had a face-to-face encounter with the patient for whom the services are reported within the six months immediately preceding the first reported CPO claim. Qualifying E/M services include 99221-99263 and 99281-99357.

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