Medicare guidelines on physician billing

Medicare has established the following rules to guide physicians in billing for care plan oversight (CPO):

  • The beneficiary must require complex or multidisciplinary care modalities requiring ongoing physician involvement in the patient’s plan of care.
  • CPO must be billed during the period in which the beneficiary is receiving home health or hospice services.
  • The beneficiary must be receiving Medicare-covered home health or hospice services during the period in which the CPO services are furnished.
  • The physician who bills CPO must be the same physician who signed the home health or hospice plan of care.
  • The physician must furnish at least 30 minutes of CPO within the calendar month for which payment is claimed, and no other physician can be paid for CPO within that calendar month.
  • The physician or non-physician practitioner must have provided a covered physician service that required a face-to-face encounter (codes 99201-99263, 99281-99357) with the beneficiary 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).
  • The CPO billed must not be routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician.
  • For beneficiaries receiving Medicare-covered home health services, the physician must not have a significant financial or contractual interest in the home health agency.
  • For beneficiaries receiving Medicare-covered hospice services, the physician must not be the medical director or an employee of the hospice or providing services under arrangements with the hospice.
  • The CPO services must be personally furnished by the physician who bills 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 may not bill CPO during the same calendar month in which (s)he bills the Medicare monthly capitation payment (90918-90925) (ESRD benefit) for the same beneficiary.
  • The physician billing for CPO must document in the patient’s record which services were furnished and the date and length of time associated with those services.