Primary Care Coding Alert

Understanding and justifying the use of care plan oversight codes (99374-99380) has always been a challenge for family practice coders. This category of evaluation and management (E/M) service became even more complex when CPT 2001 announced preliminary language changes late last year. Care plan oversight codes were revised to reflect more clearly the range of settings in which physician services may be provided and to include involvement by other caregivers such as nonphysician practitioners (e.g., visiting nurses, physical therapists, occupational therapists).

These changes provided a higher degree of specificity, which we havent had in the past, explains Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City.

However, HCFA did not agree with the revised definitions and implemented new temporary HCPCS codes (G0181 and G0182) to be used with Medicare beneficiaries. As a result, explains Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., family practice coders will now have two sets of codes CPT and HCPCS to consider when reporting these services.

CPT Language Broadens Definitions

Fick notes that the six CPT 2001 codes are organized into code pairs:

99374 and 99375 describe care plan oversight with patients under the care of a home health agency delivered in a home, domiciliary or equivalent environment (e.g., Alzheimers facility); 99374 reports 15-29 minutes of services, while 99375 is assigned for 30 or more minutes;

99377 and 99378 reflect the same time breakdown, but describe services provided to hospice patients; and

99379 and 99380 likewise reflect the same time increments, but represent care plan oversight with patients in a nursing facility.

The 2001 revisions include language allowing physicians to count time spent in ... communication (including telephone calls) for purposes of assessment or care decisions with other healthcare professionals and other nonphysician professionals [emphasis added] involved in patients care ... toward the minutes outlined in the code description, Fick adds.

Preliminary Language Revisions Raise Concern

HCFA began implementing the two alternate G codes when CPT initially announced its proposed changes to care plan oversight language in late 2000, Callaway explains. At that time, CPT considered revising the previous code definition to include non-professional caretakers or non-health professionals [emphasis added] in its coverage. HCFA did not agree with these descriptions and determined it did not want to include them in service descriptions used with the Medicare program.

As a result, HCFA implemented G0181 and G0182, which maintain the language found in the CPT 2000 version of the codes:

G0181 physician supervision of a patient receiving Medicare-covered services from 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 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.

G0182 ... Medicare-covered services from a Medicare-participating hospice (patient not present) ...

HCFA explained its stance in the Nov. 1, 2000, final rule, published in the Federal Register: Although we agree that interactions with non-health care professionals are important to the overall care of patients ... such communication is included in the pre-visit and post-visit work of evaluation and management codes. The two G codes will be paid at the same levels as the corresponding 2000 CPT codes.

Ultimately (and ironically), CPT did not include language about nonprofessional caretakers or nonhealth professionals in its revised definitions. Instead, the final version referenced nonphysician professionals [emphasis added]. However, this decision was made after HCFA announced its policy to institute the temporary HCPCS codes for use with Medicare patients.

The end result is that we have these codes for 2001 that coders and their physicians will need to deal with, Callaway explains. HCFA was concerned about who would be qualified to be included in these services and, rather than wrestle with it, decided to keep the definitions the way they were.

Recoup the Costs of Care Plan Oversight Services

Coders argue that this additional variable complicates an already confusing situation. A lot of practices tell me that reporting care plan oversight is a real hassle, Callaway says. The codes exist to help physicians report the time they spent fielding telephone calls and responding to problems with patients being cared for in these facilities. But their involvement usually occurs just a few minutes at a time. The practice has to have a good tracking system in place to take advantage of these codes.

Fick agrees, noting, Its difficult to document a physicians time well enough to use these codes. Many view the care plan oversight codes as a nice attempt, but feel the time and effort needed to document the service makes reporting the code prohibitive.

Example: A physician provides care plan oversight services to a patient under hospice care. During the final weeks of the patients life, hospice caregivers call the doctor regularly about such issues as adjustments to pain medication, the need to start intravenous fluids and requests for a variety of other prescriptions and orders. Each phone call must be logged, and the physician must document the duration of time as well as the issues discussed and action taken.

Callaway says a number of practices she works with have developed a successful system for logging time spent on care plan oversight services. Payment for care plan oversight can represent a significant amount of revenue for a practice, she says. Practices that put a tracking system in place have discovered it really pays off.

For example, Callaway notes that Palmetto GBA, the South Carolina Medicare carrier, reimburses 99378 at $96.50.

How to Log Physician Time

The system for documenting physician time spent on care plan oversight services involves using a log sheet (see insert). Most practices who use this grid or one similar photocopy it onto colored paper so it is easy to spot, Callaway says. Then, they attach it to the left-hand side of each patients chart for whom the physician provides care plan oversight. The doctor simply jots down the date and duration of every call in the proper box of the grid, while making a note on the right-hand side of the chart detailing the work. At the end of the month, the coding or billing department goes through the charts and reviews the colored grids. They tally up the minutes to see if the physician has documented 30 or more minutes for each patient and, if so, report the proper corresponding code. They replace the previous months grid with a new one, and the process begins again.

This logging system allows several practices that Callaway works with to recoup the costs of providing these services. Medicare audited a practice I am working with and saw the grid, she says. The auditor thought it was great and that it was a very effective documentation tool.