Care Plan Oversight Policy

Transcription

1 Care Plan Oversight Policy Policy Number 2018R0033A Annual Approval Date 7/13/2018 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System known as ices Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies. *CPT is a registered trademark of the American Medical Association. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Policy Overview Care Plan Oversight (CPO) Services refer to physician and other health care professional supervision of patients under the care of home health agencies, hospice, or nursing facilities. Care Plan Oversight services are reported separately from codes for office/outpatient, hospital, home, nursing facility, or domiciliary services. Code selection for Care Plan Oversight Services is determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period. Reimbursement Guidelines UnitedHealthcare Community Plan considers Care Plan Oversight Services to be reimbursable services when submitted with the following codes only:

2 CPT codes 94005, 99340, 99375, 99378, 99380, 0405T HCPCS codes G0179, G0180, G0181, G0182 CPO services are reimbursed for 30 minutes or more per Centers for Medicare & Medicaid Services (CMS) guidelines. The following codes are not reimbursable for Care Plan Oversight Services: CPT codes 99339, 99374, 99377, HCPCS codes S0220, S0221, S0250, S0270, S0271, S0272 State Exceptions Arizona Arizona Medicaid is exempt from this policy based on state requirements Iowa Effective 1/1/16 the Iowa Qualified Health Plan (IAQHP) product (excluding HAWKi Product ID IAHI and IAHIC) allows code S0220 to be billed for Care Plan Oversight services. New Mexico Texas Virginia Wisconsin Questions and Answers Codes G0179, G0180, G0181, and G0182 are not covered for Medicaid Non-Dual members. TX Star Kids allows codes 99399, 99374, 99377, and to be reimbursed for Non- Face-to-Face Clinician Supervision of a Home Health Client. Virginia Medicaid and CCC Plus are exempt from this policy based on State requirements. Wisconsin Medicaid does not cover Care Plan Oversight services. Q: Does UnitedHealthcare Community Plan reimburse Care Plan Oversight Services codes for less than 30 minutes? 1 A: UnitedHealthcare Community Plan follows CMS payment methodology for reimbursement of Care Plan Oversight Services. According to the CMS Medicare Benefit Policy Manual, Covered Medical and Other Health Services, Chapter 15, Section 30, these services are covered only if the physician furnished at least 30 minutes of Care Plan Oversight within the calendar month for which payment is claimed. Codes CPT code section Home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) 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 related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; minutes

3 99340 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living facility) 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 related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in 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 Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and Supervision of a hospice patient (patient not present) requiring complex and Supervision of a hospice patient (patient not present) requiring complex and Supervision of a nursing facility patient (patient not present) requiring complex and Supervision of a nursing facility patient (patient not present) requiring complex and

4 0405T HCPCS code section G0179 G0180 G0181 G0182 S0220 S0221 S0250 S0270 S0271 Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-toface time Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per re-certification period Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per certification period 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 review 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 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 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 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 30 minutes Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 60 minutes Comprehensive geriatric assessment and treatment planning performed by assessment team Physician management of patient home care, standard monthly case rate (per 30 days) Physician management of patient home care, hospice monthly case rate (per 30 days) S0272 Physician management of patient home care, episodic care monthly case rate (per 30 days) Resources Individual state Medicaid contracts, regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and services

5 Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets History 9/15/2018 Application section update per legal update 6/17/2018 Annual Policy Version Change State Exception Section: Exception added for Virginia History prior to 1/1/2016 archived. 7/15/2017 Application Section: Removed UnitedHealthcare Community Plan Medicare products as applying to this policy. Added location for UnitedHealthcare Community Plan Medicare reimbursement policies. 1/1/2017 Annual Policy Version Change History prior to 1/1/2015 archived. 10/17/2016 State Exceptions Section: Exception added for Texas 7/13/2016 Policy Approval Date Change (no new version) 5/23/2016 State Exceptions Section: Exception added for Wisconsin 3/7/2016 State Exceptions Section: Exception added for Pennsylvania 1/1/2016 Annual Policy Version Change Policy Change: Reimbursement Guidelines and CPT Codes section updated History prior to 1/1/2014 archived. 1/30/2006 Policy implemented by UnitedHealthcare Community & State