Full-time medical director offers fringe benefits

Salaried MDs upgrade care

While virtually every hospice has a medical director, a surprising number of hospices are employing full-time medical directors, suggesting that hospices are placing a greater emphasis on the role of their top physicians. According to the National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, full-time medical directors do not drain the budget. Instead, an in-house physician brings value-added services to patients, attending physicians, and the community. In addition, hospices can charge Medicare Part A for the billable services provided by the hospice medical director.

"Physicians can contribute to cost-effectiveness through appropriate, evidence-based decisions about palliative drugs and treatments," wrote health care journalist Larry Beresford in an NHPCO monograph titled Providing Direct, Billable Physician Services to Hospice Patients. "Hospices can also generate physician billing income from hospice patient visits, as well as from palliative care consultations for non-hospice patients, which can be used to offset the cost of the physician’s salary."

The purpose of the report, which was released in June, is to provide guidance on how to add a full-time medical director and use the position effectively. The motivation to bring in a salaried medical director should not be the revenue from direct, billable physician services, but from the greater connection an in-house physician will bring to the larger physician community and the increased accessibility to medical expertise, says Stephen Connor, PhD, vice president for research, development, and finance at the NHPCO.

Employing a full-time medical director allows a hospice to expand the medical director’s role and responsibilities beyond those of a volunteer physician. According to the monograph, the top five areas of hospice medical director responsibility are:

  • acting as a medical resource for the interdisciplinary team;
  • participating in admission and recertification decisions;
  • participating in interdisciplinary team meetings;
  • reviewing patient eligibility for hospice services;
  • consulting with attending physicians regarding pain and symptom control.

In addition, a majority of hospices reported that hospice physicians provided home visits, and nearly half said they were available to teach medical students, residents, and fellows about palliative care. In general, services delivered by physicians, whether employed or not, fall under the following categories:

Professional services. This describes services provided directly to the patient by the physician.

Administrative services. This refers to tasks related to the workings of the hospice, such as certifications of terminal illness, care plan development, team conferences, and supervising and management activities.

Technical services. This refers to services that may involve the physician, such as lab and other non-professional services.

Employment status determines how the physician bills for services. For example, an employed hospice physician bills the facility, which, in turn, bills the payer. A physician who is not employed by a hospice, such as a patient’s attending physician, bills the payer directly. In the case of Medicare, services of employed physicians are billed by the hospice to Medicare Part A, while non-employed physicians bill Medicare Part B.

The salaried doctor

Employed hospice physicians, including volunteer physicians, provide a number of billing opportunities for hospices, including evaluation and management services. Hospices are bound by very specific billing rules outlined in the American Medical Association Current Procedural Terminology (CPT) manual. In addition, an appropriate ICD-9 code must accompany the billing code found in the CPT.

General billing guidelines for the hospice-employed physician are as follows:

  • The physician bills hospice for medical services.
  • Hospice verifies dates and services prior to billing Medicare Part A.
  • Hospice is paid 100% of the allowable fee schedule.
  • Hospice pays physicians per contractual agreement.
  • Hospice obtains a physician billing number from Medicare.
  • The payment for physician services is not part of the per diem payment, but it does count against aggregate cap.

Office visits and consultations are some of the more common professional services performed by physicians. At first glance, the codes associated with those services seem straightforward. But office visits and consultations are some of the most highly scrutinized codes because of the potential for fraud and abuse. Hospices should compare the reported code to the patient chart to ensure the proper level is assigned to the office visit or consultation.

A consult can be requested by an attending physician who seeks an opinion for a specific problem. Consults can take place in either an inpatient or outpatient setting. In order to bill for a consult, a written or verbal request must be made by an attending physician. The request must be documented in the patient record. Upon completion of the consultation, the consulting physician must document his or her findings in the patient record and submit a written report to the physician who requested the consult.

The level of the service equates to the level of payment, which depends in large part on the depth of the examination and the complexity of medical decision-making. The CPT manual has highly detailed guidelines for how to determine which of the three levels should be billed. Once the level is determined and the appropriate CPT code and ICD-9 code are chosen, the hospice bills for the salaried physician’s consultation services.

The non-employed physician

Billing for hospice-related services by a physician not employed by the hospice is generally set aside for the patient’s attending physician. An attending physician providing care to a hospice patent should be billed under Medicare Part B using CPT and ICD-9 codes. The most common hospice-related service provided by an attending physician is care plan oversight (CPO). The problem is that there are a number of codes that can be used to describe this service. The correct CPO codes for Medicare are listed in HCPCS as follows (commercial payers may require CPT 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 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.

Code 99361 (medical conference) seems an accurate and appropriate code to report a meeting with home health workers or hospice interdisciplinary team members, but Medicare considers 99361 to be inclusive evaluation and management services.

In the same vein, 99371-99373, telephone conferences for the purpose of coordinating care, seems 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, CPO codes encompass the services described in 99361 and 99371-99373. More important, they may be reimbursable. The organization provides its referring physicians with reimbursement advice to help them get paid for their home health and hospice-related services.

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; and documenting the services provided in the patient chart.

CPO 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 includes:

  • travel time and time spent preparing and processing claims;
  • 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 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 home health agency or hospice (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).

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.

Also, physician time spent calling in prescriptions to a pharmacy or retrieving a chart are not considered eligible and cannot be counted toward time spent performing CPO.

Attending physicians or hospice-employed physicians may encounter medical conditions unrelated to the terminal diagnosis. This is the one instance where the hospice physician may bill Part B rather than billing the hospice. The attending physician also should bill Part B.

Some codes refer to services that have technical and professional components, such as laboratory and radiation treatment services. The technical component of medical services is considered part of the hospice per diem and must be billed directly to the hospice by the physician who performed the service.