Pulmonology Coding Alert

Pulmonologists often provide care plan oversight (CPO) services to patients with lung diseases who are admitted to home healthcare. For example, patients with chronic obstructive lung disease (COPD) (496) and emphysema (ICD-9 492.0 -492.8 -) are treated effectively at home or in hospice. Patients with COPD often require multiple medications, such as diuretics to decrease edema. Pulmonary physicians also review lab test results, and they must communicate those results to home health caregivers.

Although you can bill under the CPO Services Procedures Codes, pulmonologists must document that those patients had some active, ongoing problem that required close monitoring by home health workers. They must also show that the home health workers had to consult with the pulmonologist frequently.

Susan Callaway-Stradley, CPC, CCS-P, a coding consultant and educator in North Augusta, S.C., stresses that CPO services call for impeccable documentation. You must prove that you spent 30 minutes on things you can bill for. You must also bill in the month following the service you provided, according to Medicare guidelines. If you send your bill out on Sept. 30 for services you provided in September, you wont get paid, she says.

Although there is no standard, government-approved form for tracking and reporting these cases, pulmonary practices can create their own form that is easy to use.

Billing Requirements

To bill for CPO, you obtain and submit the Medicare provider number of the beneficiarys home health agency (HHA) or hospice. Report the number in item 23 of the HCFA 1500 form. Submit the dates that the services were provided, not the calendar period the claim is being submitted for.

Callaway-Stradley emphasizes that the pulmonologist who orders home healthcare and then sees the patient at home within the same month cant use these codes. Neither can you use the codes for patients in nursing homes. When you go through the instructions from any of the Medicare carriers on these codes, these are the things that need especially careful, focused attention, she says. Care plan oversight codes provide a real opportunity to be audited.

According to Callaway-Stradley, only one-fourth of the money the government set aside for CPO was paid out last year. The probable reason is that the documentation requirements were so cumbersome that most physicians didnt complete them. I have one client who got audited for using these codes, she says. The reason for the audit was that the clients office was the only one in the area using these codes. Luckily, the clients documentation was first-rate.

HCFA Announces New Codes HCFA has announced that effective Jan. 1, 2001, new codes will be in effect for providing supervision of home health (G0181) and hospice patients (G0182). These codes will replace 99375 and 99378 as described in the article Care Plan Oversite: Billing for Home Healthcare in this issue on page 82. Until that time, use 99375 and 99378 to report these services. In addition, a new code, G0180 will be added for physician services to prepare home health certification forms. 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.

Payment for Care Plan Oversight

Medicare allows separate payment for these CPO services furnished on or after Jan. 1, 1997:

1. The beneficiary must require complex or multi-disciplinary care and ongoing physician involvement.

2. The beneficiary must be receiving Medicare-covered home health or hospice services. Use 99375 for physician supervision under care of home health agencies (HHA) for 30 minutes or more. For a hospice patient, use 99378 for 30 minutes or more.

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

4. The physician must furnish at least 30 minutes of CPO (see countable services below) within the calendar month he or she claims payment for. Make sure no other physician has been paid for CPO within that month.

5. The physician must have provided services that required a face-to-face encounter with the beneficiary with the six months before the first CPO (that means an evaluation and management service, but not EKG, lab services or diagnostic services).

6. The CPO must not be routine postoperative care for a surgical procedure billed by the physician.

7. For beneficiaries of Medicare-covered home health services, the physician must not have a significant financial or contractual interest in the home health agency.

8. For beneficiaries of Medicare-covered hospice services, the physician must not be the medical director or employee of the hospice or providing services under arrangements with the hospice.

9. The physician who bills for CPO services must have furnished them personally.

10. Services provided by ancillary staff incident to a physicians service do not qualify as CPO.

11. The physician may not bill CPO during the same calendar month he or she bills the Medicare monthly capitation payment (end stage renal disease benefit) for the same beneficiary. Susan Callaway-Stradley, CPC, CCS-P, a coding consultant and educator in North Augusta, S.C explains, Theres a flat fee for everything for dialysis patients.

12. The physician must document in the patients record which services were furnished, and the date and length of time associated with them.

Countable and Non-countable Services

You may count these services toward the 30-minute minimum requirement for CPO:

1. Review of charts, reports, treatment plans, or lab or study results, except for the initial interpretation or review of lab or study results ordered during or associated with a face-to-face encounter.

2. Telephone calls with other healthcare professionals (not employed by the same practice).

3. Team conferences (document the time spent per patient).

4. Telephone or face-to-face discussions with a pharmacist about pharmaceutical therapies.

5. Medical decision-making.

6. Activities to coordinate services if those activities require the skills of a physician.

You may not count these services:

1. Services furnished by nurse practitioners, physician assistants and other non-physicians. Examples are time staff spends getting or filing charts, calling the HHA or patients.

2. The physicians telephone call to patient or family even to adjust medication or treatment.

3. Travel time spent preparing or processing claims.

4. Initial interpretation of lab or study results that were ordered because of a face-to-face encounter.

5. Low-intensity services included as part of other evaluation and management services.

6. Informal consults with health professionals not involved in the patients care.

7. Time the physician spent discussing the patients care with his or her nurse, or conversations the nurse had with the HHA. (But you can count the time the physician spends working on the care plan after the nurse has conveyed information to the physician.)

8. A second physician working with the one who signed the plan for care. (Only one physician per month will be paid for CPO for a patient.)

9. The work included in hospital discharge day management (99238-99239) and discharge from observation (99217). (Physicians may bill for work on the same day as discharge, but only for services after the patient is discharged.)

Medicare does not pay for a physician to sign plans of care, and physicians may not accept payment from an agency for signing plans of care.