May 2005 Table of Contents

GETTING PAID

How to Document and Bill Care Plan Oversight



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You're probably already doing the work. Here's how to get paid for it, too.

Fam Pract Manag. 2005 May;12(5):23-25.

If you're like most family physicians, you probably spend a lot of time on the phone following up with patients, family and other caregivers to coordinate the care of your patients. Unfortunately, most insurance companies do not reimburse phone time, and physicians are specifically prohibited from billing Medicare patients for phone calls. Medicare considers this pre- and post-visit work a bundled component of evaluation and management (E/M) services.

However, there is one non-face-to-face service you can bill and be reimbursed for by Medicare: care plan oversight (CPO). Physicians often provide this service but do not bill for it because the rules are both complicated and extremely specific. They specify which provider can bill the service, which beneficiaries are eligible to receive the service and which components make up CPO. However, the reimbursement for the service justifies taking some time to learn the rules, document the time spent and bill for the service.

Apparently, growing numbers of physicians have been sorting through CPO's complexities. The Centers for Medicare & Medicaid Services (CMS) has noted a significant increase in the payments to physicians for CPO, from $15 million in 2000 to $41 million in 2001. As a result, billing for CPO is an area that the Department of Health and Human Services Office of the Inspector General (OIG) has announced it will be scrutinizing more carefully this year for evidence of fraud. Don't let this scare you. If you meet the requirements, you should bill for these services.

To figure out if you have a situation that meets the physician and beneficiary requirements for CPO, see “Checklist of care plan oversight requirements.” If you are eligible, then consult “Adding up your care plan oversight time” to determine which CPO service components can count toward the total time you bill each month.

CHECKLIST OF CARE PLAN OVERSIGHT REQUIREMENTS

If your situation meets all the requirements listed below, you are eligible to bill for your services:

  • The physician cannot have a significant financial arrangement with the home health agency or hospice that is providing care to the patient.

  • The physician may not be an employee or medical director of the home health agency or hospice.

  • Only one physician per month may bill CPO.

  • 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 period may bill for CPO.

  • The physician who bills for the CPO must be the same physician who signed the certification for the home health agency or hospice in the first place.

  • The physician must have had a face-to-face service with the patient within six months of billing for the CPO.

  • The physician must have personally provided at least 30 minutes of service in one calendar month.

  • The beneficiary must be receiving Medicare covered home health or hospice services during the period in which CPO is billed.

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

CPO by the numbers

The CPT manual defines CPO using six CPT codes, 99374 through 99380. Specifically, 99374 is used for 15 to 29 minutes and 99375 for 30 minutes or more. For services relating to hospice care, 99377 is used for 15 to 29 minutes and 99378 is used for 30 minutes or more. For ser vices relating to nursing facility care, 99379 is used for 15 to 29 minutes and 99380 for 30 minutes or more. Check with your health plans to find out whether they pay for these ser vices; many don't.

Medicare, however, uses two HCPCS codes, G0181 and G0182, to define and pay for CPO. The definition of G0181 is “physician supervision of a patient receiving Medicare-covered services pro vided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (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 describes the same service for a patient in a Medicare-approved hospice.

HCPCS code G0181 has 3.28 relative value units (RVUs), and G0182 has 3.46 RVUs. By comparison, a patient visit coded as 99213 has 1.39 RVUs. (These are the national non-geographically adjusted values.)

ADDING UP YOUR CARE PLAN OVERSIGHT TIME

Use this list to help you sort out the activities that can and cannot count toward your care plan oversight:

Yes, you can bill for the time you spend:

  • Reviewing charts, reports and treatment plans;

  • Reviewing diagnostic studies if the review is not part of an E/M service;

  • Talking on the phone with other health care professionals who are not employees of the practice and are involved in the patient's care;

  • Conducting team conferences;

  • Discussing drug treatment and interactions (not routine prescription renewals) with a pharmacist;

  • Coordinating care if physician or nonphysician practitioner time is required;

  • Making and implementing changes to the treatment plan.

No, you may not bill for the time you spend:

  • Renewing prescriptions;

  • Talking with fellow employees at the practice;

  • Traveling;

  • Preparing or submitting claims;

  • Talking to the patient's family, even if discussing treatment plan changes;

  • Holding informal consults with physicians who are not treating the patient;

  • Working on discharge services (99217 for observation care discharge; 99238 or 99239 for hospital discharge);

  • Interpreting test results at an E/M visit.

In addition, you may not bill for care plan oversight work performed by staff who are neither physicians nor nonphysician practitioners (defined by Medicare as a nurse practitioner, a clinical nurse specialist or a physician assistant who has a collaborative relationship with the physician who signed the initial hospice or home health agency plan of care).

Yes, you can bill for the time you spend:

  • Reviewing charts, reports and treatment plans;

  • Reviewing diagnostic studies if the review is not part of an E/M service;

  • Talking on the phone with other health care professionals who are not employees of the practice and are involved in the patient's care;

  • Conducting team conferences;

  • Discussing drug treatment and interactions (not routine prescription renewals) with a pharmacist;

  • Coordinating care if physician or nonphysician practitioner time is required;

  • Making and implementing changes to the treatment plan.

No, you may not bill for the time you spend:

  • Renewing prescriptions;

  • Talking with fellow employees at the practice;

  • Traveling;

  • Preparing or submitting claims;

  • Talking to the patient's family, even if discussing treatment plan changes;

  • Holding informal consults with physicians who are not treating the patient;

  • Working on discharge services (99217 for observation care discharge; 99238 or 99239 for hospital discharge);

  • Interpreting test results at an E/M visit.

In addition, you may not bill for care plan oversight work performed by staff who are neither physicians nor nonphysician practitioners (defined by Medicare as a nurse practitioner, a clinical nurse specialist or a physician assistant who has a collaborative relationship with the physician who signed the initial hospice or home health agency plan of care).

Who can furnish CPO?

CPO services must be personally furnished by a physician or nonphysician practitioner. CMS recently clarified that a nonphysician practitioner may bill for CPO1. CMS defines nonphysician practitioner as a nurse practitioner, a clinical nurse specialist or a physician assistant and requires that the nonphysician practitioner have a collaborative relationship with the physician who signed the initial hospice or home health agency plan of care.

The CPO services must take at least 30 minutes in a calendar month to be billable. The services do not need to be provided on the same day, but the total services over the course of a month must add up to at least 30 minutes.

The physician or nonphysician practitioner must personally document the date, the time spent and a brief description of the activities provided in the patient's record. The services should be billed to Medicare with a start date of the first of the month and an end date of the month's final day.

Who can receive CPO?

Patients are eligible to receive CPO services if they require complex treatment, are being cared for by multidisciplinary teams and are under the care of a Medicare-approved home health agency or hospice.

For example, a family physician sees an elderly patient with diabetes who lives alone and has nonhealing skin ulcers. The patient is enrolled in and receiving services from a home health agency, and the physician signs the initial plan of care. Over the course of the month, the physician coordinates care with the agency's nursing staff, arranges for treatment at a wound clinic and talks to the treating physician there, reviews multiple lab results not related to an office visit or another E/M service, and adjusts the patient's medications. The physician spends more than 30 minutes during the month doing these activities, documents the dates, times and services, and bills G0181.

Another example is medical care for a patient undergoing chemotherapy for colon cancer. The family physician signs the plan of care, certifying the patient for home health services, and provides an E/M service. During the course of the month, the physician discusses the patient's care with the oncologist, manages the patient's pain, arranges for nutrition services and interacts with the home health agency staff. Over the course of the calendar month, if the physician spends more than 30 minutes in these activities and documents the services, dates and times, then G0181 can be billed.

Billing for CPO

Establishing a monthly routine is the best way to ensure you are paid for your CPO services. Here's one approach: First, log all patients for whom CPO is provided each month. This list will remind you which charts to pull at the end of the month when it's time to submit claims. Second, keep a CPO log in each patient chart and document the date, total time and a brief description of the services each time you provide them. Be sure to sign the CPO documentation.

At the end of the month, have a staff person collect the logs from the patients' charts, total the time and bill CPO for those patients for whom you provided more than 30 minutes of CPO during the calendar month. Use the start and end dates of the month as the service dates, and put the provider number of the home health agency/hospice on the claim form. Finally, return the logs to the charts for use in future months.

Carefully consult the sidebars with this article. Then go ahead: Bill and be paid for these services you are already providing.

Betsy Nicoletti is the author of the 2005 Physician Auditing Workbook. She is a consultant in Springfield, Vt.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

1. Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2005. Federal Register. Nov. 15, 2004:66360.

Copyright © 2005 by the American Academy of Family Physicians.
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