Getting to Know CPO. A Guide to Care Plan Oversight

Transcription

1 Getting to Know CPO A Guide to Care Plan Oversight

2 Table of Contents The Basics...2 Types of CPO...3 Certification & Recertification...4 Care Plan Supervision CPO Market Rates...12 Billing Tips...16 Limitations on Rural Health Clinics...17 Federally Qualified Health Clinics...17 Resources & Legal About Amedisys...19 Care Plan Oversight Tracker...20 The following materials are solely for general informational purposes, and are not and should not be considered legal advice. The information originates from the Centers for Medicare and Medicaid Services, and is subject to revision and limitations from time to time at the sole discretion of CMS, their fiscal intermediaries, and other governmental oversight agencies. Amedisys, Inc., does not expressly or implicitly warrant the accuracy, completeness, or fitness for a particular purpose of the information provided herein, and the recipient makes use of such information at his/her/its own risk. This information should not substitute for a provider s own due diligence, and any questions or clarification are best addressed by the Medicare Part B provider relations representative for your area. While a home health care provider may provide information, education, and limited resources regarding such matters, it cannot perform free billing services, even for the home health- and/or hospice-related codes discussed in these materials, and cannot bill these codes for a physician Rev Getting to Know CPO 1

3 The Basics 60% of doctors don t know CPO coverage or how it s billed. 80% of doctors choose not to bill CPO because they believe it s too complex. Care Plan Oversight (CPO) reimbursement was created in 1995 by Medicare as an incentive for physicians to take a more active role in the care of home health patients. While many doctors have been providing care, they haven t been taking advantage of the reimbursement. The perceived complexity and confusion of CPO billing has led many to believe it s not worth the hassle. But once you know the particulars of CPO reimbursement, the extra bit of work can be worth quite a bit. Knowing CPO Can Pay Off Let s say you average 10 home health patients every month for one year. By providing 30 minutes or more of Care Plan Oversight each month, you could receive more than $12,000 in Medicare reimbursements. The Value of CPO 10 patients X $ (G0181 National Average) = $1, (month) X 12 months = $12,748 per year Annualized income for 16 Patients = $20,398 Annualized income for 24 Patients = $30,597 Have You: Reviewed charts, reports, treatment plans, or lab and study results outside the initial patient review? Communicated with other health care professionals involved with the patient s care? Had discussions with a pharmacist about a patient s pharmacological needs? Coordinated services that required your skills as a physician? If you answered yes to any of these then you may have been providing CPO, and you may be eligible for Medicare reimbursement. Getting to Know CPO 2

4 Types of CPO Certification (G0180) The initial certification of a patient for Medicare-covered home health services. This code is used when the patient has not received Medicarecovered home health care for at least 60 days. Recertification (G0179) Recertification for patients who have received Medicare-covered home health services over the past 60 days. Care Plan Supervision (G0181 & G0182) This broad category of patient oversight involves many forms of care including revision of care plans, review of lab reports and other studies, communication with other health care professionals involved in the patient s care and more (see page 6 for a full list of countable services). This care must total 30 minutes or more during a calendar month. Home Health Care Plan Supervision is billed under code G0181; Hospice Care Plan Supervision uses G CPO Billable Rates (national average, varies by location) Certification (G0180)... $53.48 Recertification (G0179)... $41.40 Home Health Care Plan Supervision (G0181)... $ Hospice Care Plan Supervision (G0182)... $ Getting to Know CPO 3

5 Certification and Recertification $53.48 G0180 Billable Rate (national average, varies by location) Certification (G0180) A physician must first certify a patient before they can receive home health services covered by Medicare. The work this certification process requires is eligible for reimbursement under Medicare code G0180. This includes: ordering the plan of care signing the 485 documenting the face-to-face encounter $41.40 G0179 Billable Rate (national average, varies by location) Recertification (G0179) Physicians are eligible for reimbursement when recertifying a patient for home health services. The billing for recertification should be reported only once every 60 days, unless the patient starts a new episode before 60 days have elapsed and requires a new plan of care to start a new episode. Getting to Know CPO 4

6 Certification and Recertification Billing Overview 1. Home health certification, under Medicare Part B, allows the physician to be reimbursed for certifying a patient s need for home health care and to set up specific treatment/plan of care. Codes G0180 (initial Certification) and G0179 (Recertification) are the codes used to identify these services. 2. The home health agency Certification code (G0180) can be billed only when the patient has not received Medicare-covered home health services for at least 60 days. 3. The home health agency Recertification code (G0179) is used after the patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period. 4. Only physicians are allowed to bill for initial Certification and Recertification billing. 5. Surgeons who refer patients for Medicare-covered home health care and who are certifying (or recertifying) the plan of care are able to report codes G0179 and G The claim should include the home health agency s Medicare provider number in Block 23 of the HCFA-1500 form. The six-digit home health agency Medicare provider number is located in Locator #5 of the HCFA-485 (top right corner). 7. Depending on your Medicare region s interpretation, the correct date of service to use is either: (a) the date that the physician signs the HCFA form 485; or (b) the start date of the current home health Certification period. At a minimum, the physician should maintain a copy of the 485, as this is their documentation. The physician should also maintain supporting information in his or her chart detailing the development of the plan of care. Getting to Know CPO 5

7 Care Plan Supervision (G0181 and G0182) $ G0181: Billable Rate $ G0182: Billable Rate (national averages, vary by location) Because many home health and hospice patients are not under direct, immediate medical care, they need physicians to take an active role in overseeing their treatment. Many times it s a simple phone call to the pharmacy or quickly looking over a lab report. But over time these tasks can add up. If a physician spends just 30 minutes in a month supervising a home health or hospice patient, they could be eligible for a Medicare reimbursement as part of care plan supervision. Countable Services The following activities are countable services toward the 30-minute minimum requirement for care plan supervision: 1. Review of charts, reports, treatment plans, or lab or study results, except for initial interpretation, or review of lab or study results that were ordered during or associated with a face-to-face encounter. 2. Telephone calls with other health care professionals (not employed in the same practice) involved in the care of the patient. 3. Team conferences (time spent per individual patient must be documented). 4. Telephone or face-to-face discussions with a pharmacist about pharmaceutical therapies. 5. Medical decision making. 6. Activities to coordinate services are countable if the coordination activities require the skills of a physician. Getting to Know CPO 6

8 Non-Countable Services The following activities are services not countable toward the 30-minute minimum requirement for care plan supervision: 1. Services furnished by physician assistants and other non-physicians cannot be billed under the care plan supervision service. This includes the time spent by staff getting or filing charts, calling HHAs, patients, etc. 2. The physician s telephone call to patient or family, even to adjust medication or treatment. The physician s time spent telephoning prescriptions in to the pharmacist is not countable since these activities do not require physician work or meaningfully contribute to the treatment of the illness or injury. 3. Travel time and time spent preparing claims and for claims processing. 4. Initial interpretation or review of lab or study results that were ordered during or associated with a face-to-face encounter. 5. Low-intensity services included as part of the Evaluation and Management services. 6. Informal consults with health professionals not involved in the patient s care. 7. The physician s time spent discussing with his or 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 is countable toward the 30 minutes. 8. Only one physician per month will be paid for care plan supervision for a patient. Other physicians working with the physician who signed the plan of care are not permitted to bill for these services. 9. The work included in hospital discharge day management ( ) and discharge from observation (99217) is not countable toward the 30 minutes per month required for the billing of care plan supervision. 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. Getting to Know CPO 7

9 Conditions of Coverage 1. The patient must require complex multidisciplinary care modalities requiring ongoing physician involvement in the patient s plan of care. 2. The patient must be receiving Medicare-covered home health or hospice services during the period in which the Care Plan Oversight services are furnished. 3. The physician who bills care plan supervision must be the same physician who signed the home health or hospice plan of care. 4. The physician must furnish at least 30 minutes of care plan supervision (see details of countable services on page 6) within the calendar month for which payment is claimed and no other physician has been paid for Care Plan Oversight within that calendar month. 5. The physician must have provided a covered physician service that required a face-to-face encounter with the patient 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). 6. The care plan supervision billed must not be routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician. 7. For patients receiving Medicare covered home health services, the physician must not have a significant financial or contractual interest in the home health agency as defined in 42 CFR (d). In the event the physician is a Medical Director or an employee of the provider and this relationship satisfies applicable Stark safe harbors, this relationship would not preclude CPO eligibility for the physician. 8. The Care Plan Oversight services must be personally furnished by the physician who bills them. 9. Services provided incident to a physician s services do not qualify as care plan supervision and do not count toward the 30-minute requirement. 10. The physician may not bill care plan supervision during the same calendar month in which he or she bills the Medicare monthly capitation payment (ESRD benefit) for the same patient. 11. The physician billing for care plan supervision must document in the patient s record which services were furnished and the date and length of time associated with those services. Getting to Know CPO 8

10 Additional Hospice Conditions of Coverage 1. For patients 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. 2. For patients receiving Medicare covered hospice services and residing in a SNF, the physician must not be the Medical Director or an employee of the SNF. Care Plan Supervision (CPS) Billing Overview 1. The physician must furnish 30 minutes or more of care plan supervision within the calendar month for which payment is claimed. 2. The claim cannot be submitted until after the end of the month in which care plan supervision was provided. 3. Care plan supervision can only be billed once per calendar month. 4. The claim must include the home health agency or hospice Medicare provider number in Block 23 of the HCFA-1500 form. The six-digit home health agency Medicare provider number is located in Locator #5 of the HCFA-485 (top right corner). 5. 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 surgical period may bill for care plan oversight. 6. The physician must have had a face-to-face service with the patient within six months of billing for the care plan oversight. 7. Care plan supervision claims can only include one month s services per line item and cannot include any other services. Certification and Recertification claims cannot be included on the care plan supervision bill. 8. Medicare will return claims submitted for CPS services where the Medicare Home Health Agency or hospice provider number is missing as unprocessable. Claims submitted for CPS services submitted with an invalid HHA or hospice Medicare provider number will be denied. 9. Claims for care plan supervision services will be denied when review of beneficiary claims history files fails to identify a covered physician service requiring a face-to-face encounter by the physician during the six months preceding the provision of the first care plan supervision service. The face-to-face encounter is defined as an Evaluation and Management Code in the ranges or Getting to Know CPO 9

11 10. Dates of service on the HCFA-1500 form should include the first and last date during which documented care planning services were actually provided during the calendar month on the claim. This may not always be the first and last day of the calendar month for which the claim is being submitted. Medical records for those dates must also document that 30 minutes or more of time have been spent by the physician for countable care planning activities as well as which services were furnished, and the date and length of time associated with those services. 11. The physician who bills CPS must be the same physician who signed the home health or hospice plan of care. A physician who is a Medical Director or employee of the hospice agency may not bill for care plan supervision services. For patients receiving Medicare covered hospice services and residing in a SNF, the physician must not be the Medical director or an employee of the SNF. 12. In order to facilitate care plan supervision tracking, we provide a Care Plan Oversight Tracker (Page 20). This tracker should not be relied on as the doctor s exclusive means of documenting the CPS services. Rather, specific documentation of services provided should be separately maintained in the patient charts. Getting to Know CPO 10

12 The reimbursement rate for NPs/PAs is 85% of the physician rate. Only the physician who signs the plan of care may bill for the care plan supervision services. Non-Physician Practitioners and Care Plan Supervision Services Nurse Practitioners (NPs), Physician Assistants (PAs) and Clinical Nurse Specialists may provide care plan supervision (G0181/G0182) services if: They are practicing within the scope of their state practice act. They are part of the same group practice as the physician who signed the plan of care. If a CNS/NP, they must have a collaborative agreement with the physician who signed the plan of care. The Non-Physician Practitioner must have seen and examined the patient and cannot simply be functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care. If a PA, the physician who signed the plan of care must also provide general supervision over the PA. They are providing on-going care for the beneficiary through evaluation and management services. They provide 30+ minutes of services; the 30+ minutes cannot be divided between multiple people. They have their own Medicare billing number. Note that non-physician practitioners may not bill for certification (G0180) or recertification (G0179) because the physician must sign the plan of care. Co-Pay Disclosure Because both care plan supervision and Certification/Recertification of home health services are considered Medicare Part B physician services, there is a requirement of a 20% co-pay by beneficiaries. There is a Medicare requirement that providers make a reasonable collection effort, which means an effort similar to what the provider puts forth to collect from non-medicare patients. Routine waivers of Medicare co-payments are strictly prohibited by federal law. Getting to Know CPO 11

13 2012 CPO Market Rates CPS (Home Health) CPS (Hospice) Certification Recertification G0181 G0182 G0180 G0179 Alabama $97.85 $99.05 $48.55 $37.32 Alaska $ $ $65.62 $49.80 Arizona $ $ $52.15 $40.32 Arkansas $97.22 $98.40 $48.15 $36.98 California: Anaheim/Santa Ana $ $ $59.55 $46.53 California: Los Angeles, CA $ $ $57.50 $44.81 California: Marin/Napa/Solano $ $ $60.27 $47.15 California: Oakland/Berkeley $ $ $60.68 $47.46 California: San Francisco $ $ $64.03 $50.28 California: San Mateo $ $ $63.86 $50.13 California: Santa Clara $ $ $63.49 $49.79 California: Ventura $ $ $58.51 $45.69 California: Rest of the state $ $ $55.12 $42.83 Colorado $ $ $52.70 $40.81 Connecticut $ $ $56.77 $44.15 Delaware $ $ $53.84 $41.77 DC & MD/VA Suburbs $ $ $59.71 $46.58 Florida: Ft. Lauderdale $ $ $55.55 $43.10 Florida: Miami $ $ $56.77 $44.02 Florida: Rest of the state $ $ $52.60 $40.63 Georiga: Atlanta $ $ $53.16 $41.19 Georgia: Rest of the state $ $ $49.74 $38.27 Hawaii/Guam $ $ $56.75 $44.31 Idaho $98.97 $ $49.19 $37.84 Illinois: Chicago $ $ $56.37 $43.65 Illinois: East St. Louis $ $ $52.20 $40.23 Illinois: Suburban Chicago $ $ $56.35 $43.71 Illinois: Rest of the state $ $ $50.61 $38.96 Indiana $ $ $50.03 $38.56 Iowa $98.18 $99.38 $48.79 $37.52 Getting to Know CPO 12

14 CPS (Home Health) CPS (Hospice) Certification Recertification Kansas $ $ $49.67 $38.20 Kentucky $98.50 $99.69 $48.73 $37.43 Louisiana: New Orleans $ $ $51.96 $40.18 Louisiana: Rest of the state $98.73 $99.93 $48.89 $37.57 Maine: Southern $ $ $53.00 $41.10 Maine: Rest of the state $99.65 $ $49.57 $38.16 Maryland: Baltimore/Surrounding Cntys $ $ $56.43 $43.85 Maryland: Rest of the state $ $ $53.99 $41.86 Massachusetts: Metropolitan Boston $ $ $57.05 $44.50 Massachusetts : Rest of the state $ $ $54.54 $42.35 Michigan: Detroit $ $ $55.03 $42.58 Michigan: Rest of the state $ $ $50.65 $39.03 Minnesota $ $ $52.12 $40.41 Mississippi $98.32 $99.50 $48.60 $37.32 Missouri: Metro Kansas City $ $ $51.73 $39.93 Missouri: Metro St. Louis $ $ $51.82 $40.03 Missouri: Rest of the state $98.58 $99.73 $48.53 $37.22 Montana $ $ $52.90 $40.95 Nebraska $98.44 $99.68 $49.09 $37.80 Nevada $ $ $54.73 $42.50 New Hampshire $ $ $53.83 $41.78 New Jersey: Northern $ $ $59.14 $46.12 New Jersey: Rest of the state $ $ $56.90 $44.30 New Mexico $ $ $50.35 $38.78 New York: Manhattan $ $ $59.17 $46.04 New York: NYC Suburbs/Long Island $ $ $60.54 $47.24 New York: Poughkeepsie/N. NYC Suburbs $ $ $54.98 $42.69 New York: Queens $ $ $60.42 $47.08 New York: Rest of the state $ $ $50.42 $38.90 North Carolina $ $ $50.26 $38.75 North Dakota $ $ $52.10 $40.35 Ohio $ $ $51.00 $39.30 Oklahoma $97.80 $98.97 $48.28 $37.04 Getting to Know CPO 13

15 CPS (Home Health) CPS (Hospice) Certification Recertification Oregon: Portland $ $ $53.62 $41.62 Oregon: Rest of the state $ $ $51.16 $39.53 Pennsylvannia: Metro Philadelphia $ $ $55.61 $43.14 Pennsylvannia: Rest of the state $ $ $50.44 $38.84 Puerto Rico $88.58 $89.50 $42.53 $32.19 Rhode Island $ $ $54.89 $42.57 South Carolina $99.33 $ $49.50 $38.12 South Dakota $ $ $51.99 $40.27 Tennessee $98.87 $ $49.19 $37.86 Texas: Austin $ $ $52.68 $40.81 Texas: Beaumont $ $ $49.68 $38.22 Texas: Brazoria $ $ $52.49 $40.59 Texas: Dallas $ $ $53.22 $41.23 Texas: Fort Worth $ $ $51.92 $40.15 Texas: Galveston $ $ $52.83 $40.87 Texas: Houston $ $ $52.92 $40.95 Texas: Rest of the state $ $ $49.98 $38.49 Utah $ $ $50.50 $38.89 Vermont $ $ $52.38 $40.59 Virgin Islands $ $ $52.83 $40.90 Virginia $ $ $51.73 $40.01 Washington: Seattle (King County) $ $ $57.28 $44.64 Washington: Rest of the state $ $ $52.91 $41.00 West Virginia $98.30 $99.42 $48.15 $36.86 Wisconsin $ $ $51.00 $39.40 Wyoming $ $ $53.08 $41.08 Getting to Know CPO 14

16 Sample HCFA 1500 NEED FORM HERE Getting to Know CPO 15

17 Billing Tips Because Medicare billing requirements change, please consult your Billing Advisor or your Medicare Part B representative for proper billing procedures. The claim form (HCFA-1500) must include the six-digit Medicare provider number of the home health or hospice agency in Locator 23 of the form. (Please reference the Plan of Care for the appropriate Medicare provider number.) Place of Service (Locator 24B of the 1500 Form) is typically the physician s office. Dates of Service: For care plan supervision billing, the first and last date during which documented care planning services were actually provided during the calendar month. For Certification and Recertification billing, the date of service will depend on the rules applicable to your particular area. Two interpretations are currently utilized: either (1) the date the physician signs the plan of care; or (2) the starting date of the applicable home health episode. To expedite the handling of paper claims, we offer these suggestions: Some claim forms come with an attachment on the bottom of the form. If the form is perforated on the bottom, please remove the attachment in your office prior to mailing. Many providers use HCFA-1500 forms that are attached as they run through a printer. To speed the handling of these claims, please burst them prior to mailing. If you have an attachment to a claim, please staple the attachment behind the claim. This will ensure the right attachment is kept with the right claim. One vs. multiple-page claims: If you have a multiple-page claim, do not put the total on each page. You must place the total on the last or final page of the multiple-page claim. If you put a total on each page, Medicare will consider the page a standalone page of the claim. Also, if you have attachments (e.g., operative notes) for a multiple-page claim, it is especially important not to total each page of the claim and then attach the operative notes. The claim will be separated in the Medicare office and, most likely, the operative notes will be attached to the wrong part of the claim. If you file both non-assigned and assigned claims, please send your nonassigned claims in a separate envelope than your assigned claims. Do not print any information on the top portion of the HCFA This space is needed for Medicare to place the Internal Control Number (ICN). Getting to Know CPO 16

18 Limitations on Rural Health Clinics The Rural Health Clinic Services Act of 1977 amended the Social Security Act to extend Medicare and Medicaid entitlement and payment for primary and emergency care services furnished at a Rural Health Clinic (RHC) by physicians and certain non-physician practitioners, and for services and supplies incidental to their services. With respect to physicians who are being paid under the Rural Health Clinic program, the reimbursement they receive from the government as part of the RHC payment is already adjusted to include reimbursement for the same Care Plan Oversight activities that CMS reimburses via G0179, G0180, and G0181. In other words, they are not entitled to receive separate payments for services provided to Rural Health Clinic patients at the rural health clinic or at other facilities. Accordingly, they are not permitted to bill separately for these codes. The public policy at play here is that the government would consider such billings to be double dipping, because they are presumably getting a higher reimbursement rate via the rural health clinic payment. The physician s recourse would be to include any non-covered costs in their cost reports, which are determinative of their all-inclusive payment rate. Federally Qualified Health Clinics Similarly, a Federally Qualified Health Center (FQHC) is another federally funded program for rural areas that is specifically excluded from eligibility for Care Plan Oversight. The G0179, G0180, G0181, and G0182 billing codes expressly reimburse for physician services, which is inconsistent with the nature of the FQHC. Additionally, FQHC billing regulations require a face-to-face encounter, which is not generally provided with Care Plan Oversight services that occur outside the presence of the patient. For these reasons, Medicare intermediaries have traditionally excluded FQHCs from participation in Care Plan Oversight billing. Getting to Know CPO 17

19 MercuryDoc Can Help MercuryDoc is Amedisys web-based patient management portal for physicians, enabling real-time communication and collaboration between you and our clinicians. MercuryDoc makes it easier to stay informed on your patients progress, providing: secure access to your patients home health records graphed trends and vital signs online management of Plans of Care (485s), supplemental orders and patient referrals With MercuryDoc, you can easily track time spent signing orders, reviewing plans of care and other related activities. At the end of the month, you have the ability to print one concise report of time spent on these activities. This report may make is easier for you to track services and determine time spent on care plan supervision. For more information, Getting to Know CPO 18

20 Amedisys Home Health and Hospice Care Seventy-five percent of Americans over age 65 suffer from multiple chronic conditions. Their complex co-morbidities require frequent monitoring, adjustments to their care plans and extended education. Amedisys can help you manage and care for these patients in a way that fits your practice and assists your staff. With special training in home health care for heart disease, COPD, diabetes, dementia and other conditions, Amedisys clinicans work with your orders and treatment plan to help care for your patients at home. We focus on delivering the home-based nursing, therapy and specialty care that s best for our patients, whether that is: recovery and rehabilitation after an operation/injury treatment and education on managing chronic diseases palliative care for those with a terminal illness compassionate hospice care at the end of life A Reliable Partner With 24/7 on-call availability, care centers nationwide, weekend intake in many areas and a growing network of managed care providers, Amedisys helps you and your staff easily access home health and hospice care. Learn more: /partners Additional Resources CMS HIPPA National Association for Home Care and Hospice (NAHC) Palmetto GBA Getting to Know CPO 19

21 Print out and affix this form inside your patients charts to help keep track of care plan supervision. Care Plan Oversight Tracker Home Health and Hospice Care Patient: DOB: Account Number: Physician: Care Center: Care Center Medicare Provider Number: Activity CPO Code Date Diagnosis Home Health Certification Home Health Recertification G0180 G0179 Activities to coordinate services (DO, FR, HHNC, WU, 60DS, DS)* Documentation Care Plan Supervision (Home Health: G0180 Hospice: G0182) Date Minutes Date Minutes Date Minutes Medical decision making Review (charts, treatment plans, lab or other test results) Telephone calls with other healthcare professionals Team conferences Discussions with pharmacist (re: pharmaceutical therapies) Minute totals: Total monthly care plan supervision minutes**: * DO: Doctor s Orders FR: Faxed Reports HHNC: Home Health Nurse Contract WU: Wound Updates 60DS: 60-day Summary DS: Discharge Summary ** CPS time must equal at least 30 minutes in a calendar month to bill Medicare. Physician Signature DATE This form can help you keep track of care plan oversight services, but should not be relied on as your exclusive means of documenting care plan supervision services. Specific documentation of services provided should be separately maintained in your patient charts. Getting to Know CPO 20