Pulmonology Coding Alert

Pulmonologists may be responsible for the care plan oversight (CPO) of patients with lung diseases who are treated in a hospice or through home healthcare. For example, patients with emphysema (492.0-492.8) or chronic obstructive lung disease (COPD, 496) can be treated effectively in either setting. In these cases, pulmonology physicians would review lab results of these patients and discuss appropriate medication and treatment with the hospice or home health staff. Coding for these services is even more difficult in 2001 because Medicare no longer recognizes CPT codes 99375 and 99378 (see below for definitions). This year, HCPCS instituted temporary G codes G0181 and G0182 for billing CPO for 30 minutes or more in a calendar month. As a result, coders have two sets of codes to consider, the CPT codes to be used with private carriers and the G codes to be used with Medicare.

CPT Revisions Include Nonphysician Professionals

CPO includes the development and revision of the patients care plan, explains Mary Jean Sage, CMA-AC, president of Sage Associates, a practice management-consulting firm, and program director for Certified Medical Billing Associates (CMBA), Amoyo Grande, Calif.

The supervising physician needs to communicate with healthcare professionals such as nurses, pharmacists, and therapists. CPT broadened the scope of its codes in the 2001 manual to include these nonphysician professionals.

Code 99375 specifies the physician care of a patient in a home health agency (patient not present), in home, domiciliary, or equivalent environment (e.g., Alzheimers facility) requiring:

complex multidisciplinary 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 other healthcare professionals and nonphysician professionals involved in the care, integration of new information in the medical treatment plan and/or adjustment of medical therapy, within a calendar month, of 30 minutes or more.

Code 99378 covers the same areas as 99375, but for a hospice patient.

New HCPCS Codes

Medicare, under the impression that the new CPT language would include communication with non-health- care professionals, began implementing the G codes in response to this intended revision. In clarifying its reasoning, HCFA explained in its Final Rule published in the Nov. 1, 2000, Federal Register that although the CPT Committee had not released its final definition, the revised codes make a significant change.

Specifically, the new definitions include the time the physician spends communicating with nonprofessional caretakers involved in delivering the home health or hospice services. While HCFA recognizes that nonhealth professionals contribute to the care of both home health and hospice patients, its long-standing policy has been that payment for these services is included in the E/M.

HCFA changed the code definitions because they were concerned for the well-being of the patient, stating that the goal in care plan management is to be certain that the home health or hospice professional staff communicate with the patients physician to allow the beneficiary to receive appropriate care.

Therefore, to be consistent with Medicare policy, they established the following temporary G codes:

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 healthcare 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; and

G0182 Medicare-approved hospice (patient not present), 30 minutes or more.

Ironically, the phrases that HCFA was worried about non-healthcare and non-professional caregivers were not included in the final wording of the CPT codes but were instead replaced by the words non-physician professionals. However, since Medicare had already initiated the change, coders must deal with the confusion of two sets of codes, at least for this year, until HCFA reviews the wording for next years manuals.

CPO Coding Scenarios

Scenario #1:
A 53-year-old textile worker in the final stages of brown lung disease is being cared for at a hospice. During the last month of her life, the pulmonologist providing CPO discusses her medication, respiration therapy, and other treatments with the professional staff. Each conversation is logged, including the date, the amount of time spent, and the issues discussed and actions taken. At the end of the month, the billing staff totals the number of minutes, determining that the pulmonologist spent 45 minutes on CPO. If Medicare covers the patient, these services would be billed using G0182, while if she uses a private carrier, 99378 would be used. Coders using the G codes must also remember that HCFA maintains that these discussions cannot take place between professionals employed in the same practice.

Scenario #2:
A 45-year-old smoker is being treated at home for the early stages of emphysema. His wife, who provides his basic care, talks to the pulmonologist providing CPO about his medication and oxygen treatments for 15 minutes once a week. This service is not billable, either for Medicare or for a private carrier, because the wife does not meet the definition of a healthcare professional, using Medicares language, or a nonphysician professional involved in patient care as defined by the CPT codes.

Medicare versus Third-Party Carriers

There are two other areas where private carriers and Medicare differ:

1. Private carriers, unlike Medicare, reimburse for CPO time involving patients in nursing facilities with 99379 (... 15-29 minutes) and 99380 (... 30 minutes or more).

2. Private carriers allow for the billing of CPO time between 15-29 minutes in a calendar month with 99374 for home healthcare, 99377 for hospice patients, and 99380 for nursing facilities. For Medicare, any time under 30 minutes is nonbillable.

For example, a certified respiration therapist (CRT) provides therapy through a home health agency to a 75-year-old emphysema patient. The pulmonologist providing the CPO routinely updates the treatment every month, spending 15 minutes discussing the patient with the CRT. At the end of the month, a private carrier would be billed using 99374. However, for Medicare these minutes would not be billable because the total did not meet the minimum time requirement (30 minutes).

In addition, in the Final Rule explaining the rationale for these two temporary CPO codes, HCFA also clarified its policy concerning physicians assistants, nurse practitioners and clinical nurse practitioners. They state that these healthcare professionals can bill for CPO if they have been providing ongoing care for a patient through E/M services; however, they cannot bill if they are involved only in the delivery of home health or hospice services. They cannot bill for the certification or recertification of a patients plan of care because this is strictly a physician service.

According to Carol Pohlig, RN, CPC, a reimburse-ment analyst for the office of clinical documentation in the department of medicine at the University of Pennsylvania in Philadelphia, this is welcome news as it clarifies the role of these nonphysician practitioners (NPPs). While it was assumed that NPPs who practice as independent billing practitioners could provide and bill for CPO service, having it in writing is helpful.

Develop an Easy Documentation System

While revenue from CPO can be significant for a practice, careful documentation is essential in order to receive reimbursement from either Medicare or a private carrier. The date, the amount of time, the issues and concerns discussed, and the treatment prescribed must be carefully logged for each patient. Since only a few minutes is spent on each, the resulting but necessary paperwork can be time-consuming and cumbersome.

Developing an easy-to-use procedure is the key to translating CPO time into dollars.

One system that has proven to be effective is the use of a grid attached to a patients chart. The pulmonologist can fill in the necessary information in the appropriate places when he speaks to healthcare professionals in a hospice or home health agency. At the end of the month, the coding staff can tally the amount of time to determine if the minimum of 15 minutes required by a private carrier or the 30 minutes required by Medicare has been met. For Medicare, the bill must be sent the month following the dates of the services provided to ensure reimbursement. Thus, a bill itemizing CPO provided during April must be dated no earlier than May 1.

Pulmonologists should also be aware of the specific guidelines for logging time towards CPO. It should:

be reported separately from codes for office/outpatient, hospital, home, nursing facility, and domiciliary services

reflect the time and services that occur during one calendar month

be reported only once by a physician in a given month

be reported only by the physician who signs off on the HHA or hospice plan of care

not be used to report supervision of patient care unless recurring supervision of therapy is needed.