Teach physicians how to use CPO codes

Overlooked codes represent increased income

As hospices try to encourage physicians to refer patients to their care, one of the hurdles standing between physicians and a timely referral is reimbursement. While not the most significant problem, physicians’ loss of reimbursement as a result of referring patients outside their care is an obstacle that affects hospice referral.

Hospices can remind their referring physicians that Medicare allows some reimbursement for physicians’ involvement in their patients’ care in hospices. Medical directors and administrators should instruct physicians to bill for care plan oversight each time they call to follow up on patient care.

Documenting each call is a tedious process, one that leaves physicians unwilling to go through the trouble. Two oncology practices that work with hospice and home care use a tracking system that makes it easier to keep track of care plan oversight and garner reimbursement. Their advice is one that hospices can pass along to referring physicians.

Log systems that track the time physicians spend on care plan oversight provided to patients admitted to home health or hospices (CPT 99374-99375) can help make the paperwork hurdle more manageable for physicians who refer patients to hospices, advises Sharon Grimes, CPC, insurance and billing manager for West Clinic in Memphis, TN.

All too often, physicians are unwilling to take time away from their patients in hospices care to gather the documentation necessary for care plan oversight (CPO) billing, she says. Many end up providing their services for free, Grimes says. The CPO codes are among the least used by oncology practices, adds Nancy Cothern, business manager at Baptist Regional Cancer Institute in Jacksonville, FL.

Tracking how physicians spend their time

At the heart of the problem is the time it takes to keep track of each three-minute to five-minute phone call in 30-minute increments, to locate corresponding notations in the patient record, and to gather them up every 30 days to submit a bill. Setting up a log system that tracks how physicians are spending their time can help, Grimes advises.

CPT 2000 uses the clinical example of a 58-year-old woman with advanced intra-abdominal ovarian cancer. The care plan includes home oxygen, intravenous diuretics for edema and ascites, and pain control management through the use of intravenous morphine. As part of CPO, the physician contacts the nurse, family, and social worker by phone to discuss care, and the social worker indicates the patient wants to withdraw from supportive measures. In order for the physician to be able to properly bill for this care, he or she must document review and modification and certifications from nurses, social workers, pharmacists, and durable medical equipment suppliers.

The first step to tracking CPO services is understanding the billable components to the service, says Reynolds. CPO must be accrued in 30-minute increments. The CPT 2000 provides minimal direction in this area. Payers will provide better detail as to their requirements. For example, Palmetto Government Benefits Administrator, a fiscal intermediary, offers the following directives to its Medicare providers:

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

• The beneficiary must be receiving Medicare-covered home health agency (HHA), hospice, or nursing facility 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 (see details of services that may be included below) within the calendar month for which payment is claimed, and no other physician has been paid for care plan oversight within that calendar month.

• The physician must have provided a covered physician service that required a face-to-face encounter with the beneficiary within the six months immediately preceding the provision of the first CPO 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 HHA.

• 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.

• 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 he or she bills the Medicare monthly capitation payment 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.

Services that can be counted as part of CPO include:

• Review of charts, reports, treatment plans, or lab or study results, except for the initial interpretation or review of lab or study results that were ordered during or associated with a face-to-face encounter.

• Telephone calls with other health care professionals (not employed in the same practice) involved in the care of the patient.

• Team conferences (time spent per individual patient must be documented).

• Telephone or face-to-face discussions with a pharmacist about pharmaceutical therapies.

• Medical decision making.

• Activities to coordinate services may be counted toward CPO time if the coordination activities require the skills of a physician.

Services not included

Services that physicians may not include in CPO billing include:

• Services furnished by nurse practitioners, physician assistants, and other nonphysicians cannot be billed under the CPO service. This includes the time spent by staff getting or filing charts, calling HHAs or patients.

• The physician’s telephone call to a patient or family, even to adjust medication or treatment. The physician’s time spent telephoning prescriptions into the pharmacist may not be counted, since those activities do not require physician work or meaningfully contribute to the treatment of the illness or injury.

• Travel time, 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 other evaluation and management services.

• Informal consults with health professionals not involved in the patient’s care.

• The physician’s time spent discussing the patient with his/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 may be counted 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 those services.

• The work included in hospital discharge day management (99238-99239) and discharge from observation (99217) may not be counted toward the 30 minutes per month of CPO. 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.

While Reynolds’ current practice has yet to implement a log system, she shares how a previous employer handled CPO billing. Physicians there used their hospital cards as a way of documenting CPO while out of the office and as a phone log while in the office.

The hospital card, which the physicians carried with them to keep track of the patients they need to see at each facility, allowed them to jot down the time they spent on CPO and other services. Each physician was assigned a billing staff person who was responsible for collecting the card at the end of the day, she says.

In the office, physicians noted the length of call, the patient being discussed, the facility or agency that was caring for the patient, and made brief notes describing the nature of the CPO.

The billing staff assigned to that physician were responsible for reviewing the cards and phone log and counting the minutes each physician spent on CPO. The physician was notified when he or she had spent 30 or more minutes doing CPO for any patient, clearing the way for a billing.

Remind physicians not to make the mistake of thinking a log system can replace patient chart notes. Physicians still have to make the proper notations in the patient chart, she stresses. It does, however, eliminate the time physicians have to spend pouring over the chart to recall each instance they performed CPO, Reynolds adds.