Profit Potential: Home Health Plan Certification

Home health plan certification is a significant yet often ignored source of physician revenue.

By Belinda Frisch, CPC

AAPCAccording to the Centers for Medicare & Medicaid Services (CMS), physicians perform a billable service when they create and review a plan of care and oversee a home health agency’s treatment of their patients.

For example, a patient is seen in the office and requires home IV antibiotics for a systemic infection. The physician determines the type of drug, its dosage and frequency, and the duration of treatment, and then calls a home health agency to deliver this service. The physician receives a written plan of care from the Medicare-participating home health agency, reviews and agrees with the plan, sends the signed care plan back to the agency, and retains a copy in the patient’s medical record. The physician receives, reviews, and adjusts the plan in coordination with the care of the home health agency and keeps copies of all correspondence in the medical record — hence performing home health plan certification — billable and payable every 60 days.

In Upstate New York, for example, the Medicare Division’s physician fee schedule lists the rate for initial home health plan certification at $61.46 and the rate for recertification at $46.66 — not insignificant for work that physicians often provide free of charge.

Eligibility Requirements

In order to bill for these services, the following criteria must be met:

  • The patient must be under the care of the qualified physician (doctor of medicine, osteopathy, or podiatric medicine—as permitted under 42CFR 424.22) that signs the certification, and must have had a face-to-face encounter within the six months prior to the certification.
  • The physician must periodically review the services furnished by the home health agency.

Note: Time spent on home health plan certification and recertification is separate and apart from any time counted toward care plan oversight or any time spent performing any type of hospital discharge.

  • The physician must not have significant ownership interest in, or a significant financial or contractual relationship with, the home health agency from which the patient is receiving care.
  • The patient must be an eligible Medicare beneficiary.
  • The home health agency must have a valid participation agreement with the Medicare program.
  • The patient must meet Medicare’s qualifications for coverage of home health care and must receive covered services.

Billing Home Health Plan Certification

The HCPCS Level II codes used to report home health plan certification are:

G0180 Initial certification of Medicare-covered home health services, for a patient’s home health, per certification period.

G0179 Physician services for the recertification of Medicare-covered home health services, for a patient’s home health, per recertification period.

The place of service code entered on the CMS-1500 or electronic equivalent represents the place where the physician created and reviewed the plan of care, most commonly 11. Appropriate place of service codes are limited to: 11 (office), 12 (home), 22 (outpatient hospital), and 71 (state/local public health clinic).

Item 23 on the CMS-1500 or electronic equivalent must include the provider number of the home health agency from which the patient is receiving Medicare-covered services; and these services must not be billed on the same claim form as any other physician services. Initial plan of care (G0180) can only be billed when the patient has not received services for 60 days. Recertification is billable once every 60 days with appropriate documentation, such as a newly reviewed and signed plan of care.

Documentation is Key

Office staff should keep copies of all correspondence between the physician and the home health agency in the patient’s medical record, both to substantiate the billing and to serve as a permanent record of the patient’s care. A log sheet in a fixed location within the patient’s chart is a good tool for tracking the frequency of HHPC billing.

Sources:

Upstate Medicare Division. Physician Services for Certification (and Recertification) of Medicare-Covered Home Health Services

The Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual, Chapter 7—Home Health Services

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