Don’t Overlook Care Plan Oversight

Home health and monthly care services deserve reimbursement, but will require you to report care plan oversight correctly.

By Kristine Cuddy, CPC, CIMC

Coding for care plan oversight (CPO) often is overlooked. This is a mistake: CPO services deserve reimbursement, and coding and documentation requirements, although exacting, are worth the effort. Here are the guidelines you need to make the most of CPO billing.

Evaluation and Management – CEMC

Be Aware of CPO Types

There are two types of CPO services: 1.) certification and recertification of home health agency (HHA) services; and 2.) monthly CPO.

Certification and recertification of HHA services are reported with:

G0179                  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

G0180                  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

These codes are reported when the physician receives the Centers for Medicare & Medicaid Services’ (CMS’) 485 form from the HHA, requesting approval for services to be provided over a 60-day period. The physician reviews the HHA 485 form, makes any necessary changes, additions, and deletions, and signs off on the form. The completed 485 form is typically faxed back to the HHA by the physician’s office. Remember to keep the 485 form on file (the best place to keep it is in the patient’s medical record).

Know CMS 485 Form Requirements

The Medicare Claims Processing Manual, chapter 12, section 180, provides the following specific requirements regarding the CMS 485 form:

  • Physician must sign CMS 485 form and do all of the following:

Review initial or subsequent reports of patient status

Review the patient’s responses to the OASIS assessment instrument

Contact the HHA to ascertain the initial implementation plan of care (faxing the signed 485 form suffices)

Document in the patient’s record (keeping the 485 form in the record supports this)

The initial certification of HHA services for the first 60 days of home health care is reported with G0180. Subsequent certification of HHA services for each additional 60 days of home health care is reported using G0179.

For example, Mrs. Smith has gone home after knee surgery. Dr. John is her primary care provider. Dr. John has seen Mrs. Smith for a face-to-face evaluation and management (E/M) during the last six months. Dr. John received a fax from a HHA requesting review and authorization of home health services for the first 60 days during Mrs. Smith’s recovery time. Dr. John reviews the hospital discharge records from the surgeon and any other relevant medical records; reviews the CMS 485 HHA form that contains the modes of care, services, medications, etc.; makes any changes necessary; fills out any designated areas; signs the form; faxes it back to the HHA; and, files the form in Mrs. Smith’s medical record. Dr. John advises billing staff of the service and G0180 is billed to Mrs. Smith’s Medicare carrier.

The free text/additional information field of the CMS 1500 form should contain the beginning and end dates of certification/recertification. This is documented by entering, for instance, “B = 01/01/2011 E = 03/01/2011.” The “To” and “From” dates of service on the CMS 1500 form should be the date the doctor signed the CMS 485 form.

Document Face-to-Face Encounter for Home Health Certification

As required by the Affordable Care Act, CMS designated new requirements for home health certification via the 2011 Home Health Prospective Payment System final rule, as follows:

  • Documentation regarding these face-to-face encounters must be present on certifications (on the CMS 485 form itself) for patients with starts of care on and after Jan. 1, 2011.
  • As part of the certification form, or as an addendum to it, the physician must document when he or she, or allowed non-physician practitioner (NPP) saw the patient, and document how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services.
  • The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care.
  • In situations when a physician orders home health care for the patient based on a new condition that was not evident during a visit within the 90 days prior to start of care, the certifying physician or NPP must see the patient within 30 days after admission. Specifically:
  • If the certifying physician or NPP had not seen the patient in the 90 days prior to the start of care, a visit within 30 days of start of care would be required.
  • If a patient saw the certifying physician or NPP within the 90 days prior to start of care, another encounter is necessary if the patient’s condition had changed to the extent that accepted standards of practice would preclude the physician from ordering services without the physician or an NPP first examining the patient.

This means any 2011 certifications or recertifications your provider has already signed and billed for must have a signed dated addendum indicating the date they saw the patient and how their clinical condition supports skilled service in a homebound/hospice status.

The remaining instructions may be found in MedLearn Matters article SE1038.

Turn to G0181, G0182 for Monthly Oversight

Monthly CPO services are reported using:

G0181                  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 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                  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

These codes are reported when the physician provides month-long services that fall under CPO definitions, such as:

  • Development of care
  • Revision to care plan
  • Review of patient reports
  • Lab reviews
  • Diagnostic test reviews
  • Communication with other health care professionals
  • Integration of new information into treatment plan
  • Adjustment of medial therapy
  • Other (define)

G0181 is used to report monthly CPO services for HHA patients. This information is best documented on a spreadsheet, with rows labeled as in the aforementioned bullets.

G0182 is used to report monthly CPO services for hospice patients. Documentation should be completed the same as for G0181. The billing physician cannot be a hospice physician and attach modifier GV Attending physician not employed or paid under arrangement by patient’s hospice provider. The attending physician cannot be employed by or paid under arrangement of the patient’s hospice provider. Implied in G0182 is the expectation that the physician has coordinated an aspect of the patient’s care with the hospice during the month for which CPO services were billed.

For example, Dr. John continues as Mrs. Smith’s primary care provider. During the next year, Dr. Smith is providing complex continuity of care for Mrs. Smith (who is now receiving hospice care), requiring him to provide multiple non-face-to-face services (as indicated in the aforementioned bullets) where he is not providing certification or recertification services during this time. Dr. John documents his time on a grid form (such as the log sheet shown on the previous page) for an entire month for each service he performs. After the month has ended, he signs and dates the grid form, files it into the patient chart, and advises his billing staff to report G0182.

Normally, Medicare requires the provider number of the HHA agency or hospice to be entered on the claim form. There is no place on the claim form for that number and providers are relieved of having to report it until further notice by CMS; however, the number must be kept as part of either the CMS 485 form for certifications and recertifications, or as part of the patient’s monthly time-tracking document the physician uses.

Don’t Just Accept Denials

If your physician bills Medicare for CPO and receives a denial stating that the patient was not seen face to face during the six months prior to billing CPO, there may be some valid reasons. Read further before writing off any charges. For example:

  • The patient may have started receiving Medicare benefits during the prior six months, and there was no opportunity for a face-to-face service under Medicare, but there is a visit under another carrier:
  • According to WPS Medicare, “One of the requirements for CPO services is that the physician providing the CPO had a face-to-face evaluation and management (E/M) services within the previous six months of beginning CPO. Since Medicare did not have the patient enrolled at the time of the previous visit, the Common Working File (CWF) will not contain evidence of the previous patient encounter. The claim denial is correct. The provider should request a redetermination providing documentation of the previous face-to-face encounter. Medicare can then allow the CPO when the service meets all the requirements.”
  • The patient was previously enrolled in a Medicare Advantage plan and had not yet had a face-to-face visit since going onto Medicare hospice coverage:
  • Also according to WPS Medicare, “One of the requirements for CPO services is that the physician providing the CPO had a face-to-face evaluation and management (E/M) services within the previous six months of beginning CPO. Medicare Advantage entities do not report individual services into the Common Working File (CWF). A patient returns to Medicare fee-for-service upon electing hospice coverage. The claim denial is correct. The provider should request a redetermination providing documentation of the previous face-to-face encounter. Medicare can then allow the CPO when the service meets all the requirements.”

A grid form such as this allows the physician to document his time for an entire month for each service he performs.

CPO form


CPO Checklist

Before billing any CPO service, ensure that:

  • The patient has received Medicare covered home health services
  • The physician has devoted 30 minutes or more to supervision of the patient’s care in a given month
  • The physician has furnished a service that was face to face with the patient at least once during the six-month period before the month for which CPO is first billed
  • The physician does not have a significant financial or contractual relationship with the HHA or hospice
  • The physician is the one and only attending physician to bill for CPO for the patient during a calendar month
  • The physician documents in the patient’s medical record that the CPO services are unrelated to surgery (If billing for CPO services during a postoperative period)
  • The physician has the provider number of the patient’s HHA
  • The physician who bills CPO is the same physician who signed the CMS 485 form and personally furnished the services
  • The physician is not billing Medicare end stage renal disease (ESRD) capitation payment and CPO for the same beneficiary during the same month
  • It’s not a rural health clinic (RHC) (Certain Medicare carriers do not allow RHCs to bill CPO. If your physician practices in a RHC, verify prior to billing.)

The following services do not count as billable CPO services:

  • Getting and/or filing the chart, dialing the phone, or time on hold (these activities do not require work or meaningfully contribute to the treatment plan of the illness/injury)
  • Informal consultations with health professionals not involved in the patient’s care
  • Initial interpretation or review of study results that were ordered during, or associated with, a face-to-face encounter
  • Low intensity services included as part of other E/M services
  • Preparation or processing of claims
  • Staff time (e.g., time the nurse, nurse practitioner, physician’s assistant, clinical nurse specialist, or other staff spends getting or filing charts, calling HHAs or patients, etc.)
  • Telephoning, or transmitting, prescriptions in to pharmacists (not considered a physician service and does not require a physician to perform)
  • Travel time

Kristine Cuddy, CPC, CIMC, has more than 20 year’s experience in the medical field. She is a compliance analyst for Michigan State University’s HealthTeam, and provides independent consulting services. She has served as president and secretary of her local AAPC chapter, is a member of WPS Medicare Part B Provider Outreach and Education Advisory Group, and is an instructor at Lansing Community College.

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One Response to “Don’t Overlook Care Plan Oversight”

  1. April King says:

    I have been recenlty asked how how many visits (minimum) are required for Medicare reimbursement. I am not familiar with home helth. Can you please assist me with this?

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