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Here's how to get paid for certifying and recertifying home health care for your Medicare patients.

Fam Pract Manag. 2001;8(5):16

Recent developments have made certifying Medicare home health services both easier and more financially rewarding for family physicians. Here's what you need to know.


As we've explained before (see “Certifying Home Health Care Services Requires Extra Caution,” FPM, July/August 1997, page 20), certifying a Medicare patient's need for home health care includes certifying that the patient is “confined to the home” (i.e., homebound). Unfortunately, this requirement has historically been one of the most difficult for physicians to understand.

The Benefits Improvement and Protection Act of 2000 (BIPA) clarified the definition of “homebound” by expanding the list of circumstances under which a patient may be considered homebound. Specifically, BIPA says the following:

  • Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day care program that is licensed or certified by a state, or accredited, to furnish adult day care services in the state shall not negate the individual's homebound status.

  • Any absence for religious services is deemed to be an absence of infrequent or short duration and thus does not negate the homebound status of the individual.

Note that BIPA does not change the existing homebound guidelines beyond the two specific circumstances cited above, nor does it imply that Medicare coverage has been expanded to include adult day care services. Also note that home health agencies, not physicians, are responsible for demonstrating an adult day care center is licensed or accredited.

More rewarding

As we told you in January (see “New Year, New Codes: Highlights From CPT and HCPCS 2001,” FPM, page 14;, the Health Care Financing Administration (HCFA) has established two new HCPCS codes to describe the services involved in physician certification and recertification and the development of a care plan for patients who've been prescribed Medicare-covered home health services.

The certification code, G0180, is reimbursable only if the patient has not received Medicare-covered home health services for at least 60 days. The Medicare allowed amount for this service (unadjusted geographically) is $73.07. The service includes the following:

  • Review of initial or subsequent reports of patient status,

  • Review of the patient's responses to the Oasis assessment instrument,

  • Contact with the home health agency to ascertain the initial implementation plan of care, Documentation in the patient's record.

The recertification code, G0179, may be submitted when the physician signs the certification (i.e., recertifies the patient's need for home health care) after a patient has received services for at least 60 days (or one certification period). Code G0179 should be reported only once every 60 days, except in the rare situation when a patient starts a new episode before 60 days elapses and requires a new plan of care. The Medicare allowed amount for this service (unadjusted geographically) is $61.21.

Note that G0179 does not appear to apply to “change orders” or other documents that a home health agency sends you for your signature throughout the care process. You should consider that paperwork to be part of care plan oversight and count it toward the time billed as care plan oversight under HCPCS code G0181. Likewise, do not count the work of G0180 or G0179 toward care plan oversight if it has already been billed separately, since that would, in effect, amount to billing twice for the same service.

Questions about G0180 and G0179 remain, and HCFA has indicated that it intends to further define the services through detailed instructions to its Medicare carriers, so stay tuned. In the meantime, if you are providing these services and have not started billing for them yet, you should start now.

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