Understanding Care Plan Oversight Reimbursement

Referring to Home Health, Resources for Physicians
Care Plan Oversight

CPO reimbursement covers a physician’s involvement in: (1) Initial certification (2) Any recertifications, and (3) Care plan supervision.

You oversee the care plan of countless home health patients and those numbers are rapidly growing. Shouldn’t you get paid for the services you already provide? It’s not as complicated or time-consuming as you may think. These quick and easy tips will ensure an increase in your revenue.

Care Plan Oversight (CPO) is a way for Medicare to reimburse physicians for their role in managing the care of the home health patient. CPO reimbursement covers a physician’s involvement in: (1) Initial certification (2) Any recertifications, and (3) Care plan supervision.

Many physicians are missing out on extra revenue for their practice because they aren’t tracking and billing for CPO reimbursement.

2012 CPO Billable Rates (national average)

  • Certification (G0180) ……………………………… $53.48
  • Recertification (G0179) ……………………………. $41.40
  • Home Health Care Plan Supervision (G0181) …………… $106.24

 

Say, for example, you average 10 home health patients every month for one year. By providing 30 minutes or more of CPO each month, you could receive more than $12,000 in Medicare reimbursements.

Types of CPO

Certification (G0180)

This is the code used when the patient has not received Medicare-covered home health care for at least 60 days. A physician must first certify a patient before they can receive home health services covered by Medicare.

Includes:

  • Ordering the plan of care
  • Signing the 485
  • Documenting the face-to-face encounter

 

Recertification (G0179)

This is the code used when patients have received Medicare-covered home health services over the past 60 days. The billing for recertification should be reported only once every 60 days, unless the patient starts a new episode before 60 days have elapsed and requires a new plan of care to start a new episode.

Home Health Care Plan Supervision (G0181)

This is the code used to document care plan supervision totaling 30 minutes or more during a calendar month.

Get Paid for What You Already Do

Physician services that count toward the 30-minute minimum requirement for care plan supervision:

  • Review of charts, reports, treatment plans, or lab and study results outside the initial patient review
  • Communication with other health care professionals involved with the patient’s care
  • Discussions with a pharmacist about a patient’s pharmacological needs
  • Coordination of services that require your skills as a physician
  • Documenting the services provided (includes time to write a note about service provided, decision making performed, amount of time spent on countable services)
  • Time spent on activities undertaken on day of hospital discharge separately documented as occurring after physical discharge from hospital.

 

Services that don’t count:

  • Time spent by staff getting or filing charts, calling HHAs, or patients/families
  • Physician telephone calls to patient/family, even to adjust medication or treatment
  • Physician time spent telephoning prescriptions to pharmacist
  • Travel time
  • Time spent preparing/processing claims
  • Initial time spent reviewing results of tests ordered during face-to-face encounter
  • Time spent on day of hospital discharge to manage the discharge plan

 

Conditions of Coverage

  • Patients must receive home health services that are covered by Medicare and require complex or multi-disciplinary modalities requiring physician involvement.
  • Physician must document 30 minutes or more of time to supervision of patient’s care plan and include documentation in the patient record.
  • The physician who bills CPO must be the same as the physician who signs the treatment plan and personally provides the service.
  • A nurse practitioner, nurse clinical specialist or a physician assistant may bill for CPO if they have been providing patient evaluation and management as a “physician service” while acting within the scope of state laws.
  • Only one physician per month can bill.
  • The physician must have furnished a service requiring a face-to-face encounter with the patient in the six-month period before CPO is billed.
  • You cannot bill for CPO if billing for Medicare ESRD capitation payment in the same month.
  • Any work included in hospital stay discharge management or discharge from hospital observation is not countable toward CPO.
  • To bill separately for CPO in the post-operative period, the physician must document that CPO services are unrelated to the surgery.

 

Billing Tips

  • Only physicians are allowed to bill for initial Certification and Recertification.
  • Care plan supervision claims can only include one month’s services per line item and cannot include any other services.
  • Certification and Recertification claims cannot be included on the care plan supervision bill.
  • The claim form (HCFA-1500) must include the home health agency’s six-digit Medicare provider number in Block 23. The provider number is located in Locator #5 of the HCFA-485 (top right corner).
  • The place of service (Locator 24B of the 1500 Form) is typically the physician’s office (not the home).
  • For care plan supervision billing, dates of service are the first and last date during which documented care planning services were actually provided during the calendar month.
  • For Certification and Recertification billing, the date of service will depend on the rules that apply in your particular area: Either (1) the date the physician signs the plan of care; or (2) the starting date of the home health episode.

 

To expedite the handling of paper claims

  • Some claim forms come with an attachment on the bottom of the form. If the form is perforated on the bottom, please remove the attachment in your office prior to mailing.
  • Many providers use HCFA-1500 forms that are attached as they run through a printer. To speed the handling of these claims, please burst them prior to mailing.
  • If you have an attachment to a claim, please staple the attachment behind the claim. This will ensure the right attachment is kept with the right claim.
  • If you have a multiple-page claim, do not put the total on each page. Put the total on the last or final page of the multiple-page claim.
  • Send nonassigned claims in a separate envelope from your assigned claims.
  • Do not print any information on the top portion of the HCFA-1500. This space is needed for Medicare to place the Internal Control Number (ICN).
  • There are some exemptions to Care Plan Oversight, including rural health clinics and federally funded health clinics.

Non-Countable Services

The following activities are services not countable toward the 30-minute minimum requirement for care plan supervision:

  1. Services furnished by physician assistants and other non-physicians cannot be billed under the care plan supervision service. This includes the time spent by staff getting or filing charts, calling HHAs, patients, etc.
  2. The physician’s telephone call to patient or family, even to adjust medication or treatment.
  3. The physician’s time spent telephoning prescriptions in to the pharmacist is not countable since these activities do not require physician work or meaningfully contribute to the treatment of the illness or injury.
  4. Travel time and time spent preparing claims and for claims processing.
  5. Initial interpretation or review of lab or study results that were ordered during or associated with a face-to-face encounter.
  6. Low-intensity services included as part of the Evaluation and Management services.
  7. Informal consults with health professionals not involved in the patient’s care.
  8. The physician’s time spent discussing with his or her nurse and conversations the nurse had with the HHA do not count toward this 30-minute requirement. However, the time spent by the physician working on the care plan after the nurse has conveyed the pertinent information to the physician is countable toward the 30 minutes.
  9. Only one physician per month will be paid for care plan supervision for a patient. Other physicians working with the physician who signed the plan of care are not permitted to bill for these services.
  10. The work included in hospital discharge day management (99238-99239) and discharge from observation (99217) is not countable toward the 30 minutes per month required for the billing of care plan supervision.
  11. Physicians may bill 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.

 

 

 

 

 

 

 

 

Certification and Recertification Billing Overview

1. Home health certification, under Medicare Part B, allows the physician to be reimbursed for certifying a patient’s need for home health care and to set up specific treatment/plan of care. Codes G0180 (initial Certification) and G0179 (Recertification) are the codes used to identify these services.

2. The home health agency Certification code (G0180) can be billed only when the patient has not received Medicare-covered home health services for at least 60 days.

3. The home health agency Recertification code (G0179) is used after the patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.

4. Only physicians are allowed to bill for initial Certification and Recertification billing.

5. Surgeons who refer patients for Medicare-covered home health care and who are certifying (or recertifying) the plan of care are able to report codes G0179 and G0180.

6. The claim should include the home health agency’s Medicare provider number in Block 23 of the HCFA-1500 form. The six-digit home health agency Medicare provider number is located in Locator #5 of the HCFA-485 (top right corner).

7. Depending on your Medicare region’s interpretation, the correct date of service to use is either: (a) the date that the physician signs the HCFA form 485; or (b) the start date of the current home health Certification period. At a minimum, the physician should maintain a copy of the 485, as this is their documentation. The physician should also maintain supporting information in his or her chart detailing the development of the plan of care.

 

Care Plan Supervision (G0181 and G0182)

Because many home health and hospice patients are not under direct, immediate medical care, they need physicians to take an active role in overseeing their treatment. Many times it’s a simple phone call to the pharmacy or quickly looking over a lab report. But over time these tasks can add up. If a physician spends just 30 minutes in a month supervising a home health or hospice patient, they could be eligible for a Medicare reimbursement as part of care plan supervision.

 

 

 

Conditions of Coverage

1. The patient must require complex multidisciplinary care modalities requiring ongoing physician involvement in the patient’s plan of care.

2. The patient must be receiving Medicare-covered home health or hospice services during the period in which the Care Plan Oversight services are furnished.

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

4. The physician must furnish at least 30 minutes of care plan supervision within the calendar month for which payment is claimed and no other physician has been paid for Care Plan Oversight within that calendar month.

5. The physician must have provided a covered physician service that required a face-to-face encounter with the patient within the six months immediately preceding the provision of the first Care Plan

Oversight service (a face-to-face encounter does not include EKG, lab services, or surgery).

6. The care plan supervision billed must not be routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician.

7. For patients receiving Medicare covered home health services, the physician must not have a significant financial or contractual interest in the home health agency as defined in 42 CFR 424.22 (d). In the event the physician is a Medical Director or an employee of the provider and this relationship satisfies applicable Stark safe harbors, this relationship would not preclude CPO eligibility for the physician.

8. The Care Plan Oversight services must be personally furnished by the physician who bills them.

9. Services provided “incident to a physician’s services do not qualify as care plan supervision and do not count toward the 30-minute requirement.”

10. The physician may not bill care plan supervision during the same calendar month in which he or she bills the Medicare monthly capitation payment (ESRD benefit) for the same patient.

11. The physician billing for care plan supervision must document in the patient’s record which services were furnished and the date and length of time associated with those services.

 

 

Care Plan Supervision (CPS) Billing Overview

1. The physician must furnish 30 minutes or more of care plan supervision within the calendar month for which payment is claimed.

2. The claim cannot be submitted until after the end of the month in which care plan supervision was provided.

3. Care plan supervision can only be billed once per calendar month.

4. The claim must include the home health agency or hospice Medicare provider number in Block 23 of the HCFA-1500 form. The six-digit home health agency Medicare provider number is located in Locator #5 of the HCFA-485 (top right corner).

5. Neither a physician who is billing for the end-stage renal disease services under a capitation arrangement nor a physician who is providing surgical follow-up in the global surgical period may bill for care plan oversight.

6.

 

 

 

8. Medicare will return claims submitted for CPS services where the Medicare Home Health Agency or hospice provider number is missing as unprocessable. Claims submitted for CPS services submitted with an invalid HHA or hospice Medicare provider number will be denied.

9. Claims for care plan supervision services will be denied when review of beneficiary claims history files fails to identify a covered physician service requiring a face-to-face encounter by the physician during the six months preceding the provision of the first care plan supervision service. The face-to-face encounter is defined as an Evaluation and Management Code in the ranges 99201-99263 or 99281-99357.

10. Dates of service on the HCFA-1500 form should include the first and last date during which documented care planning services were actually provided during the calendar month on the claim. This may not always be the first and last day of the calendar month for which the claim is being submitted. Medical records for those dates must also document that 30 minutes or more of time have been spent by the physician for countable care planning activities as well as which services were furnished, and the date and length of time associated with those services.

11. The physician who bills CPS must be the same physician who signed the home health or hospice plan of care. A physician who is a Medical Director or employee of the hospice agency may not bill for care plan supervision services. For patients receiving Medicare covered hospice services and residing in a SNF, the physician must not be the Medical director or an employee of the SNF.

12. In order to facilitate care plan supervision tracking, we provide a Care Plan Oversight Tracker (Page 20). This tracker should not be relied on as the doctor’s exclusive means of documenting the CPS services. Rather, specific documentation of services provided should be separately maintained in the patient charts.

 

Non-Physician Practitioners and Care Plan Supervision Services

Nurse Practitioners (NPs), Physician Assistants (PAs) and Clinical Nurse

Specialists may provide care plan supervision (G0181/G0182) services if:

• They are practicing within the scope of their state practice act.

• They are part of the same group practice as the physician who signed

the plan of care.

• If a CNS/NP, they must have a collaborative agreement with the

physician who signed the plan of care.

• If a PA, the physician who signed the plan of care must also

provide general supervision over the PA.

• They are providing on-going care for the beneficiary through

evaluation and management services.

• They provide 30+ minutes of services; the 30+ minutes cannot be

divided between multiple people.

• They have their own Medicare billing number.

Note that non-physician practitioners may not bill for certification (G0180) or

recertification (G0179) because the physician must sign the plan of care.

Co-Pay Disclosure

• Because both care plan supervision and Certification/Recertification

of home health services are considered Medicare Part B physician

services, there is a requirement of a 20% co-pay by beneficiaries.

• There is a Medicare requirement that providers make a “reasonable

collection effort,” which means an effort similar to what the provider

puts forth to collect from non-Medicare patients.

• Routine waivers of Medicare co-payments are strictly prohibited by

federal law.

 

Care Plan Oversight Rates (refer to graph on page 12, 13 and 14)—pull out just the rates in our 5 states.

 

Billing Tips

The claim form (HCFA-1500) must include the six-digit Medicare provider number of the home health or hospice agency in Locator 23 of the form. (Please reference the Plan of Care for the appropriate Medicare provider number.) Place of Service (Locator 24B of the 1500

Form) is typically the physician’s office.

Dates of Service:

• For care plan supervision billing, the first and last date during which documented care planning services were actually provided during the calendar month.

• For Certification and Recertification billing, the date of service will depend on the rules applicable to your particular area. Two interpretations are currently utilized: either (1) the date the physician signs the plan of care; or (2) the starting date of the applicable home health episode.

To expedite the handling of paper claims, we offer these suggestions:

• Some claim forms come with an attachment on the bottom of the form.

If the form is perforated on the bottom, please remove the attachment in your office prior to mailing.

• Many providers use HCFA-1500 forms that are attached as they run through a printer. To speed the handling of these claims, please burst them prior to mailing.

• If you have an attachment to a claim, please staple the attachment behind the claim. This will ensure the right attachment is kept with the right claim.

• One vs. multiple-page claims: If you have a multiple-page claim, do not put the total on each page. You must place the total on the last or final page of the multiple-page claim. If you put a total on each page,

Medicare will consider the page a standalone page of the claim. Also, if you have attachments (e.g., operative notes) for a multiple-page claim, it is especially important not to total each page of the claim and then attach the operative notes. The claim will be separated in the Medicare office and, most likely, the operative notes will be attached to the wrong part of the claim.

• If you file both non-assigned and assigned claims, please send your nonassigned claims in a separate envelope than your assigned claims.

• Do not print any information on the top portion of the HCFA-1500. This space is needed for Medicare to place the Internal Control Number (ICN).