Do’s and don’ts of oversight codes
When a patient is referred to hospice, that doesn’t mean the physician no longer has a say in treatment, nor does it mean there are no more billing opportunities. There are several case management-related services that are billable by a physician whose patient is being cared for in a home health or hospice setting, including G0181 and G0182 for care plan oversight.
Physicians often take an active role in monitoring their patients’ progress following a referral to home health or hospice. They may take part in interdisciplinary team meetings, hold telephone conversations with other health care professionals, and recertify patients for continued care under home health.
All these services may represent a significant portion of a physician’s time and may be deserving of payment. The problem is that there are a number of case management codes to choose from, most of which are not covered under Medicare or are no longer being used, says Cindy C. Parman, CPC, CPC-H, RCC, president of Coding Strategies, Inc., a coding consulting firm in Dallas, GA.
Coding Strategies provides its clients, which include physicians, with reimbursement advice to help physicians get paid for their home health and hospice-related services.
At first blush, code 99361 (medical conference) seems an accurate and appropriate code to report a meeting with home health workers or hospice interdisciplinary team members. In CPT 2003, the code is described as a "medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care."
Code 99361 is not a separately payable item and is always considered part of evaluation and management services, the document advises.
Similarly, 99371-99373, telephone conferences for the purpose of coordinating care, seem appropriate. According to the CPT, 99371-99373 describes a telephone call by a physician to a patient or health care professional for medical management or coordinating medical management. But Medicare policy excludes payment of these codes.
While it seems that the codes that best describe the case management efforts of physicians lead to no reimbursement, care plan oversight codes encompass the services described in 99361 and 99371-99373. More importantly, they may be reimbursable.
It is important to note that the Center for Medicare & Medicaid Services (CMS) does not recognize codes 99374-99375 (physician supervision). Rather than using 99374-99375 for home health and 99377 (physician supervision) for hospice, the correct care plan oversight codes are listed in HCPCS:
- 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 revisions of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communications (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 revisions of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communications (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.
While Medicare requires G codes and commercial payers likely require CPT codes, the way to determine time spent performing care plan oversight (CPO) is the same. Using Medicare as an example, practices must painstakingly document each minute the physician spends performing CPO services in a 30-day period. Because these codes state "30 minutes or more," they are generally reported only once each month, typically at the end of each month where CPO services were provided, says Parman.
The definitions for both home health and hospice CPO point to seven services that can be used to tally CPO: review of charts, reports, treatment plans, and other test results; telephone calls (excluding time spent on hold) to hospice or home health representatives; team conferences; discussions with pharmacist about pharmaceutical therapies; medical decision-making; coordination of services; documenting the services provided in the patient chart.
CPO services must be provided by physician
Care plan oversight provided by a nurse, nurse practitioner, physician assistant, clinical nurse specialist, or other staff is not separately reimbursable and cannot be counted toward the total CPO time for the month. CPO codes are reserved for services provided directly by the physician. Telephone calls to the patient or family made by someone other than the physician are not eligible for reimbursement. Aside from the previously mentioned non-countable services, Medicare’s list of non-covered CPO services include:
- travel time and time spent preparing claims and for claims processing;
- initial interpretation or review of lab or study results that were ordered during or associated with a face-to-face encounter;
- low-intensity services included as part of the evaluation and management services;
- informal consults with health professionals not involved in the patient’s care.
The physician’s time spent discussing, with his or her nurse, conversations the nurse had with the hospice does 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. Only one physician per month will be paid for CPO for a patient. Other physicians working with the physician who signed the plan of care are not permitted to bill for these services.
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 billing of care plan oversight. 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.
Physician time spent calling in prescriptions to a pharmacy, retrieving a chart, or traveling is not considered eligible and cannot be counted toward time spent performing CPO.
Practices also can bill for certifying and recertifying patients for home health services. Oncology physicians, for instance, who refer patients to home care should bill Medicare for certifying and recertifying services provided to a home health agency. The codes are meant to encourage greater physician involvement in their patients’ care.
Use G0179 (MD recertification, home health agency patient) to recertify a patient who has received home health services for at least 60 days, or one certification period. Code G0180 is for 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 patient responses to OASIS assessment instrument, contact with the home health agency to ascertain the initial implementation plan of care, and documentation in the patient’s office record, per certification period. It applies to patients who have not received Medicare-covered home health services for at least 60 days.
The national reimbursement average for G0180 is $73, and the national reimbursement average for G0180 is $53.These amounts will vary by region.