Take a Closer Look at Care Plan Oversight

Learn the rules and track the time to receive Level 4 payment for these services.

By Maryann C. Palmeter, CPC, CENTC

Physicians and qualified non-physician practitioners (NPPs) spend a lot of time following up with patients, family members, and other caregivers to coordinate care. This time may be considered part of the coordination of care time if performed on the same date as an evaluation and management (E/M) service. Medicare also considers follow-up patient phone calls part of the pre- and post-E/M visit work if performed on the same date of service, and will not separately reimburse providers for this service. Patient phone calls made outside of the face-to-face encounter date are bundled into the E/M service, as well.

Evaluation and Management – CEMC

Care plan oversight (CPO), on the other hand, is a service that physicians and certain NPPs may bill to Medicare and other payers even in the absence of a face-to-face patient encounter. Many providers perform the work needed to bill this service, but do not submit a claim because they haven’t worked out a way to track the time, or because they feel the regulatory and documentation requirements are too burdensome. They are losing out on deserved revenue for these services. Reimbursement rates are comparable to a Level 4 established patient office/outpatient visit—well worth the effort to learn the rules and develop a way to track the time needed to bill for this service.

What Is CPO?

CPO services require recurrent physician or NPP supervision of a patient. The procedure codes vary based on the patient’s location, whether the patient is under the care of a home health agency (HHA) or hospice, the time spent each month, and the payer class (see the sidebar, Procedure Codes, on page 30 for codes and code application). CPO services are reported separately from codes for office/outpatient, hospital, home, nursing facility, and domiciliary services.

There are five types of CPO defined in the CPT® and HCPCS Level II codebooks:

  1. Supervision of a patient under the care of an HHA in a home or equivalent area
  2. Supervision of a hospice patient
  3. Supervision of a nursing facility patient
  4. Supervision of a patient in a home or equivalent area not under the care of an HHA
  5. Home ventilator management supervision

CPO is a time-based service. Medicare requires a minimum of 30 minutes per month be expended to bill for CPO. There are other CPT® codes that require fewer than 30 minutes per month; therefore, it’s important to know your individual payer’s guidelines (i.e., Does the payer follow Medicare guidelines?).

What Counts as CPO?

CPO services require complex or 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 with other health professionals not employed in the same practice who are involved in the patient’s care
  • Integration of new information into the medical treatment plan
  • Adjustment of medical therapy

Medicare will reimburse for only two CPO services:

G0181Physician 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; and

G0182Physician 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.

Look to individual payer guidelines or contracts for reimbursement rates for these codes, as well as for CPT® codes that Medicare does not reimburse.

For Medicare and payers who follow Medicare guidelines, CPO is bundled into the end stage renal disease capitation payment for the same patient during the same month. CPO is also bundled into post-discharge transitional care management services (CPT® 99495 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge and 99496 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge).

Also for Medicare, services provided incident-to a physician’s or an NPP’s service do not qualify as CPO, and do not count toward the 30-minute minimum time requirement.

Home Health CPO Coverage

Many healthcare treatments that used to be offered only in a hospital or skilled nursing facility (SNF) may now be performed in the patient’s home. For some problems, home health care is less expensive than, more convenient than, and just as effective as care provided in a hospital or SNF. The goal of home health care is to provide treatment for an illness or injury to a patient who is homebound. Home health care is rendered under a physician’s order or plan of care.

From time to time, the physician (or NPP in the same group as the physician) must review data provided by HHA workers or may need to revise the plan of care based on the patient’s response to treatment. CPO is the physician’s or NPP’s supervision of a patient receiving complex and/or multidisciplinary care provided by an HHA, a hospice, a nursing facility, or even a patient at home under a ventilator management plan of care. The patient is not present with the physician or NPP when CPO is rendered. The patient is under a certified plan of care respective to his or her environment. Certification of a home health plan or hospice care is separate from CPO, but it is required for home health care or hospice care to be paid under Medicare.

For Medicare to cover home health care, a Medicare-enrolled physician (MD, DO, DPM) must certify the plan of care. Services provided must be included in a plan of care established and regularly reviewed by a physician. The patient must need intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy. Under Medicare, such services are covered for home health patients, but are not covered for patients of SNFs, nursing home facilities, hospitals, or patients at home who are not under care of an HHA.

The physician certifies the patient needs home health care after performing a face-to-face visit with the patient. The HHA must be Medicare-certified and the patient must be “homebound,” defined as:

  • Leaving the home isn’t recommended because of the patient’s condition;
  • The patient’s condition keeps him or her from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person); or
  • Leaving home takes a considerable and taxing effort.

A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. A patient may still be considered homebound if he or she attends adult day care, as long as the patient receives the home health care in his or her home, not at the adult day care center. Note that the physician billing home health CPO may not have a significant financial or contractual interest in the HHA.

Hospice CPO Coverage

To be eligible for the Medicare hospice benefit, the patient must be certified as being terminally ill. The patient’s independent attending physician (IAP) and the hospice medical director (or physician member of the hospice’s interdisciplinary group) must certify in writing that the patient is terminally ill. A patient is considered to be terminally ill when the individual’s life expectancy prognosis is six months or less, provided the illness runs its normal course. NPPs may not complete the “Certification of Terminal Illness” for hospice patients.

Medicare defines an IAP as a doctor of medicine, doctor of osteopathic medicine, nurse practitioner (NP), or clinical nurse specialist (CNS) (but not a physician assistant (PA)) identified by the patient at the time the patient elects hospice coverage as having the most significant role in medical care determination and delivery. An IDA is neither employed, nor paid, by the hospice. CPO is not separately payable to physicians or NPs who are employed by a hospice agency. Services provided by an IDA must be coordinated with direct care services provided by hospice physicians. Only an IDA may bill Medicare Part B for hospice CPO.

When billing hospice CPO, append modifier GV Attending physician not employed or paid under agreement by the patient’s hospice provider to the procedure code.

Caution: The hospice CPO requirements discussed in this article are Medicare specific. There are separate procedure codes to report for private payers that do not adhere to Medicare regulations. You are urged to check your payer contracts for specific rules governing hospice CPO coverage.

Medicare Claim Form and Billing Requirements

When reporting CPO services to Medicare, be sure to observe the following points:

  • The HHA or hospice NPI must be entered on the claim when home health CPO or hospice CPO is billed, respectively.
  • CPO services cannot be submitted with any other services on the same claim.
  • Bill CPO only after the end of the month in which the CPO services were rendered.
  • CPO may not be billed across calendar months.
  • Submit the applicable CPO procedure code with one unit of service.

Common Medicare Denial Reasons

Common reasons why Medicare may deny a CPO claim include:

  1. Claim reported with wrong place of service code: The place of service should be office or outpatient hospital (POS 11, 22), not home (POS 12, 13) or hospice (POS 34).
  2. Incorrect date of service on claim: Report the start date as the first day of the month in which CPO was rendered, and report the end date of that month’s final day.
  3. Incorrect units of service were billed: Report one unit of service only.
  4. HHA or hospice provider number is missing: The NPI of the HHA or the hospice must be reported on the claim.

CPO During the Post-op Period

If a physician or NPP furnishes CPO during a postoperative period, payment for CPO may be made if the services are documented in the patient’s medical record as unrelated to the surgery. Modifier 24 Unrelated evaluation and management (E/M) service by the same physician or other qualified healthcare professional during a postoperative period would be appended to the CPO code if the services are unrelated to the surgery.

Home Ventilator Management CPO

Time spent managing a patient’s ventilator care is reported with CPT® code 94005 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. To be paid for this code, the patient must reside at home, a domiciliary, or a rest home; and the patient cannot be under the care of an HHA. If the patient is under HHA care, refer to the appropriate home health CPO procedure codes for the payer and the time.

The patient is not present with the provider for this service. Procedure code 94005 is reported once for at least 30 minutes of time spent within a month; do not adjust the units of service when reporting this procedure code. Either a physician or an NPP (if acting within the NPP’s state-defined scope of practice) may perform this service.

Operational Issues

You can flag patients by creating a CPO log. This should be done when the HHA or hospice sends the plan of care to the physician to certify. Communicate to physicians and NPPs where they can find the CPO “tickler” file. Anytime they perform a billable activity, they can document it in the log. You can then check the tickler file at the end of every month and, if enough billable time has been expended, submit a claim to the payer.

If using an electronic health record (EHR), you can still flag patients the same way you would with a paper record. The only difference is that the documentation is contained in the EHR. A separate entry may be needed for each date on which an activity was performed (depending on your EHR system’s capabilities). The individual responsible for billing would need to check the EHR at the end of each month, tally up the time for each CPO note, and refer to the billing chart for proper code selection based on total time, patient location, and payer class.

Documenting CPO Services

In the patient’s medical record, the physician or NPP should document the date and time spent providing CPO, and include a brief description of the activities performed.

Note that a claim cannot be billed without a diagnosis code. Make sure the documentation contains the reason why the patient is under HHA or hospice care. If this information is not contained in the CPO log, make sure the log references where to find this information.

Example: The physician documents changes in the patient’s blood pressure medication and modifies the home health care plan so the home health nurse will increase the number of weekly visits to monitor the patient’s response to the new medication.

The start date on the claim for this example is March 1, 2014 (the first day of the month in which CPO was rendered. The end date on the claim is March 31, 2014 (the last day of the month during which CPO was rendered).

 

Recent investigations and prior Office of Inspector General studies have found that home health services are vulnerable to fraud, waste, and abuse. As such, it’s important for:

  • The patient to be under a certified plan of care;
  • Services to be rendered by a certified HHA or hospice;
  • Employment or financial relationships between the physician/NPP and the HHA or hospice to be clearly delineated; and
  • Documentation to support the billing for CPO by including the activities engaged in over a calendar month and the requisite time and the reason why the activities were necessary to manage the patient’s care.

 

Procedure Codes

Home Health CPO

Patient resides in home/assisted living/rest home/domiciliary under HHA care CPO procedure code
based on time spent per month
Medicare Less than 30 minutes –
not a billable service
MedicareNon-facility and facility RVUs 3.01 G0181 (30 + minutes)
Not MedicareNon-facility RVUs 1.97

Facility RVUs 1.59

99374 (15-29 Minutes)
Not MedicareNon-facility RVUs 2.96

Facility RVUs 2.51

99375 (30 + minutes)

 

Home Patient CPO

Hospice patient CPO procedure code
based on time spent per month
Medicare Less than 30 minutes –
not a billable service
MedicareNon-facility and facility RVUs 3.03 G0182 (30 + minutes)Append modifier GV
Not MedicareNon-facility RVUs 1.97

Facility RVUs 1.59

99377 (15-29 minutes)
Not MedicareNon-facility RVUs 2.96

Facility RVUs 2.51

99378 (30 + minutes)

 

Hospice CPO

Hospice patient CPO procedure code
based on time spent per month
Medicare Less than 30 minutes –
not a billable service
MedicareNon-facility and facility RVUs 3.03 G0182 (30 + minutes)Append modifier GV
Not MedicareNon-facility RVUs 1.97

Facility RVUs 1.59

99377 (15-29 minutes)
Not MedicareNon-facility RVUs 2.96

Facility RVUs 2.51

99378 (30 + minutes)

 

Nursing Facility Patient CPO

Patient resides in nursing facility CPO procedure code
based on time spent per month
Medicare Not a billable service
Not MedicareNon-facility RVUs 1.97

Facility RVUs 1.59

99379 (15-29 minutes)
Not MedicareNon-facility RVUs 2.96

Facility RVUs 2.51

99380 (30 + minutes)

 

 

[sidebar]

NPs, PAs, and CNSs practicing within the scope of state law also may bill for care plan oversight (CPO). These qualified NPPs must have been providing ongoing care to the patient through E/M services. NPPs may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.

NPPs can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same care plan, and the physician and NPP are part of the same group practice. If an NP or CNS is providing CPO services, the physician signing the plan of care must also have a collaborative agreement with the NP or CNS. If a PA performs the CPO, the physician signing the plan of care must also be the physician who provides general supervision of the PA’s services for the practice.

Billing may be made for CPO services furnished by an NPP when:

  • The NPP has seen and examined the patient;
  • The NPP is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and
  • The NPP integrates his or her care with that of the physician who signed the plan of care.
  • NPPs may not certify the patient for home health care, nor may they sign the plan of care.

Maryann C. Palmeter, CPC, CENTC, has gained extensive billing compliance experience working on both the government contractor and physician billing ends of the healthcare spectrum. She is employed with the University of Florida Jacksonville Healthcare, Inc. as the director of physician billing compliance, and is responsible for providing professional direction and oversight to the billing compliance program of the University of Florida College of Medicine – Jacksonville. Palmeter serves as member development officer for the Jacksonville, Fla., local chapter, holds office as AAPC National Advisory Board secretary, and has been serving as a board member since 2011. Palmeter was AAPC’s 2010 Member of the Year.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

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About Has 428 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

3 Responses to “Take a Closer Look at Care Plan Oversight”

  1. Maryam Boone says:

    Hello,
    If a patient is receiving PT, OT, and ST while in a SNF facility and the primary care physcian is over seeing care plans, could this be billable to Medicare, if so how?
    Patient is not under HHA,patient resides in a facility, primary care physcian over see medical care.

  2. Lisa O'Hare says:

    iam coding and billing for care plan oversight,im getting confused by the dates required by medicare.Can you have the certification date and supervision be the same?IF not is the supervision date the first date of documented supervision verses the first day of the month?Please help !!!

  3. Sherry Turczynski says:

    I have a physician who saw a patient in the office, he is a quadriplegic and has a ventilator. I am not sure what code to use, 94005 sounds like the correct one, however, it indicates that the patient is not in the office. Now, my question is, is there a code that would apply to an in office ventilator mgt when the patient is brought into the office ?

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