This is just example:
Cert. period is 6/15/2013 - 8/14/2012.
Dr. spent over 35 minutes during 6/28/2013-7/4/2013 and then
another 32 minutes 7/15/2013 - 7/19/2013 and then
another 38 minutes 7/29/2013-8/4/2013.
May I bill three G0181 ?
If yes what would be DOS ?
If no - what I can bill ?
Thank you.
This is from the Novitas Medicare website. The services have to be within the
calender month, not every 30 days.
Physician Care Plan Oversight Services
Care Plan Oversight is supervision of patients under care of home health agencies or hospices that require 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 with other health professionals not employed in the same practice who are involved in the patient's care, integration of new information into the care plan, and/or adjustment of medical therapy.
HCPCS 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 health care professionals involved in the patient's 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 Physician supervision of a patient under a Medicare-approved hospice (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 patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more.
Care Plan Oversight (CPO) modalities include:
Regular physician development and/or revision of care plans;
Review of subsequent reports of patient status;
Review of related laboratory and other studies;
Communication with other health professionals not employed in the same practice who are involved in the patient's care;
Integration of new information into the medical treatment plan, and/or
Adjustment of medical therapy.
Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:
Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;
Time spent by staff getting or filing charts;
Travel time; and/or
Physician's time spent telephoning prescriptions in to the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.
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Indications
These services are covered only if all the following requirements are met:
The beneficiary must require complex or multi-disciplinary care modalities requiring ongoing physician involvement in the patient's plan of care;
The care plan oversight (CPO) services should be furnished during the period in which the beneficiary was receiving Medicare covered Home Health Agency (HHA) or hospice services;
The physician who bills CPO must be the same physician who developed and signed the home health or hospice plan of care;
The physician furnished at least 30 minutes of care plan oversight within the calendar month for which payment is claimed. Time spent by a physician's nurse or the time spent consulting with one's nurse is not countable toward the 30-minute threshold. Low-intensity services included as part of other evaluation and management services are not included as part of the 30 minutes required for coverage;
The work included in hospital discharge day management (codes 99238-99239) and discharge from observation (code 99217) is not countable toward the 30 minutes per month required for work on the same day as discharge but only for those services separately documented as occurring after the patient is actually physically discharged from the hospital;
The physician provided a covered physician service that required a face-to-face encounter with the beneficiary within the six months immediately preceding the first care plan oversight service. Only evaluation and management services are acceptable prerequisite face-to-face encounters for CPO. EKG, lab, and surgical services are not sufficient face-to-face services for CPO;
The care plan oversight billed by the physician was not routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician;
If the beneficiary is receiving home health agency services, the physician did not have a significant financial or contractual interest in the home health agency. A physician who is an employee of a hospice, including a volunteer medical director, should not bill CPO services. Payment for the services of a physician employed by the hospice is included in the payment to the hospice;
The physician who bills the care plan oversight services is the physician who furnished them;
Services provided incident to a physician's service do not qualify as CPO and do not count toward the 30-minute requirement;
The physician is not billing for the Medicare end stage renal disease (ESRD) capitation payment for the same beneficiary during the same month; and
The physician billing for CPO must document in the patient's record the services furnished and the date and length of time associated with those services.
The place of service code should represent the place where the preponderance of the oversight work was performed. Appropriate place of service codes are limited to: 11 (office), 12 (home), 49 (independent clinic), and 71 (state/local public health clinic).
Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient's care with the home health agency or hospice during the month for which CPO services were billed.
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Limitations
CPO services are covered for home health and hospice patients, but are not covered for patients of skilled nursing facilities (SNFs), nursing home facilities, or hospitals.
Communication with nonprofessionals is part of the pre/post service work of other evaluation and management services and is not attributable to CPO.
Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must be providing ongoing care for the beneficiary through evaluation and management services (but not if they are involved only in the delivery of the Medicare covered home health or hospice service).
Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered. CPO services may not be billed across calendar months and should be submitted (and paid) only for one unit of service. There must be at least 30 or more minutes in one calendar month to be able to report CPO services.
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Plan of Care
The plan of care must contain all pertinent diagnoses, including:
The patient's mental status;
The types of services, supplies, and equipment required;
The frequency of the visits to be made;
Prognosis;
Rehabilitation potential;
Functional limitations;
Activities permitted;
Nutritional requirements;
All medications and treatments;
Safety measures to protect against injury;
Instructions for timely discharge or referral; and
Any additional items the HHA or physician chooses to include.
The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.
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Documentation Requirements
When reporting physician supervision of a patient receiving Medicare covered services provided by a participating home health agency, the medical record must clearly support that the following elements of the service have been met:
Complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans are reasonable and necessary; and
review of subsequent reports of patient status (when performed); and
review of laboratory and other studies; and
communication (including telephone calls) with other health care providers involved in the patient's care (when performed); and
integration of new information into the medical treatment plan and/or adjustment of medical therapy.
Care plan oversight codes are time based with very specific activities that may be counted towards the 30-minute minimum per calendar month. It is imperative that the medical record documentation documents the accurate date, the total time and clearly reflects the services provided to the patient as part of the CPO activity.
The medical record documentation must provide accurate, detailed information specific to the services that were performed and counted towards the 30 minutes of CPO services. Therefore, the medical record must adequately demonstrate that all of the requirements for billing CPO were met (e.g., duration of applicable telephone calls, time spent reviewing charts, time spent involved in team conferences).
Medical record documentation supplied by the health agency or hospice facility may not be substituted in lieu of the physician's documentation.
The medical record must support that the physician provided a covered face-to-face encounter (evaluation and management service) with the patient within six months immediately preceding the first care plan oversight service.
The documentation must support that the physician who bills the care plan oversight service was the physician who provided the service.
Physicians must enter on the Medicare claim form the 6-character Medicare provider number of the HHA or hospice providing Medicare covered services to the beneficiary for the period during which CPO services were furnished and for which the physician signed the plan of care. Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers.
All medical record documentation must be maintained by the physician supervising a patient receiving Medicare covered services provided by a participating home health agency and must be made available to the Medicare contractor upon request.
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Physician Certification and Recertification of Home Health Services
Physician's services involved in physician certification (and recertification) of Medicare-covered home health services may be separately coded and reimbursed. These services include creation and review of a plan of care and verification that the home health agency initially complies with the physician's plan of care. The physician's work in reviewing data collected in the home health agency's patient assessment would be included in these services. This policy defines the coverage for physician services. For information concerning coverage of home health services, please refer to the Home Health Manual and to the appropriate Home Health Intermediary.
HCPCs
G0179 Physician re-certification 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 re-certification period
G0180 Physician certification 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 certification period
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Indications
Physician certification and recertification will be considered medically reasonable and necessary for a patient receiving Medicare-covered home health services requiring the development of a plan of care by the physician when the following conditions are met:
A plan for furnishing the services has been established and periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function.
The physician services for initial certification of Medicare-covered home health services are billable once for a certification period. This may be billed when the patient has not received Medicare-covered home health services for at least 60 days
Physician services for recertification of Medicare-covered home health services may be billed after a patient has received services for at least 60 days when the physician signs the certification after the initial certification period. This recertification may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.
The physician billing for physician certification must be the provider supervising the patient's care. Physicians in specialties other than those commonly providing primary or comprehensive medical care to patients under the care of home health agencies may be subject to review for medical necessity.
A physician may perform other evaluation and management services during the same month for which he/she is billing the physician's services for certification/recertification. However, time counted towards the services for certification/recertification should not be included in the work or time counted towards the pre, post, and intraservice work of the evaluation and management service.
Discharge planning for a hospitalized patient is included in the E&M codes 99217, 99238 and 99239, and is not part of the physician certification.
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Limitations
Physician's services for certification/recertification are covered for reimbursement only when performed by physicians (e.g., MD's, DO's and DPM's with respect to those functions which he/she is legally authorized to perform per State regulations). Services provided by other practitioners (including, but not limited to, chiropractors, dentists, optometrists, clinical psychologists, clinical social workers, physical therapists, occupational therapists, speech therapists, physician assistants, nurse practitioners and certified clinical nurse specialists) are not Medicare covered services.
Claims for services will be denied if the physician submitting the claim is not the physician signing the HHA plan of care (the primary physician).
Only one physician may bill for services for certification of Medicare-covered HHA services for a beneficiary, in a 60-day period. All other claims will be denied.
Recertification services reported in excess of one per 60 days when a new plan of care is not required (e.g., patient condition worsens requiring new care plan) will be denied.
Since HHA services are usually intermittent, continued physician services to recertify Medicare-covered HHA services occurring for multiple certification periods may be subject to review for medical necessity.
Physicians in specialties other than those commonly providing primary or comprehensive medical care to patients under the care of home health agencies (HHAs) may be subject to review for medical necessity.
Discharge planning for a hospitalized patient is included in the E&M codes 99217, 99238 and 99239, and is not part of the physician certification.
The place of service code should represent the place where the preponderance of the plan development and review was performed.
Enter the provider number of the home health agency (HHA) from which the beneficiary is receiving Medicare-covered services in Item 23 of the HCFA –1500, or in the electronic equivalent.
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Documentation Requirements
When reporting physician certification for Medicare covered home health services, the medical record must clearly support that the following elements of the service have been met:
Contacts with the home health agency; and
Review of reports of patient status (required to affirm the initial implementation of the plan).
When reporting physician re-certification for Medicare covered home health services, the medical record must clearly support that the following elements of the service have been met, including the following:
Contacts with the home health agency; and
Review of subsequent reports of patient status.
Documentation supporting the development of a plan of care and or certification/recertification must be maintained by the physician and be included in the patient's medical records. If the written plan was not prepared by the physician (i.e., it was prepared by the HHA), the medical record must document the physician's contribution to the development of the plan, or document review of the specific items entered into the plan.
Since the certification and recertification of Medicare-covered home health services include either the creation of a new or review of an existing plan of care, the following elements should be evident in the medical record:
The patient's mental status;
The types of services, supplies, and equipment required;
The frequency of the visits to be made;
Prognosis;
Rehabilitation potential;
Functional limitations;
Activities permitted;
Nutritional requirements;
All medications and treatments;
Safety measures to protect against injury;
Instructions for timely discharge or referral; and
Any additional items the HHA or physician chooses to include.
It is not sufficient that the HHA maintain documentation in their records for the physician. The physician must maintain his/her own records, including periodic summary reports provided by the home health agency.
Documentation of all face-to-face E&M visits and any phone communications with the patient or immediate caretakers must be present in the patient's chart. This documentation must indicate an ongoing knowledge of any changes in the patient's condition, drugs, or other needs, and how they are being met.
All medical record documentation must be maintained by the physician certifying/recertifying the home health services and must be made available to the Medicare contractor upon request.
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Questions and Answers
Some physicians have raised the following questions concerning care plan oversight services.
Q1. What physician activities are considered care plan oversight services for which separate payment is allowed?
A1. Care plan oversight includes the following physician activities: development or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan, and/or adjustment of medical therapy. Care plan oversight does not include the routine pre-and post-service work associated with visits and procedures. Also, telephone calls with patients and/or their families are not included.
Q2. What documentation is required?
A2. Physicians claiming payment for care plan oversight services must document in their records the care plan oversight services they furnish, including the dates and exact duration of time spent on the services for which payment is claimed. Care plan oversight is recognized by Medicare as a physician service and must be provided and documented only by the responsible physician.
Q3. How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight services?
A3. Since care plan oversight services do not typically involve a face-to-face encounter between the patient and the physician, the patient may not be aware that the services were provided. Physicians can help by informing their patients that Medicare will pay for these services when the specified conditions are met. Beneficiaries will also be notified regarding allowed care plan oversight services in their Explanation of Your Medicare Part B Benefits messages.
