Gastroenterology Coding Alert

Significant differences between the HCPCS and CPT codes for care plan oversight (CPO) are causing many gastroenterologists to put off billing for supervisory services provided to clinical nutrition patients under the care of a home health agency. While the differences between the two sets of codes can be confusing, recent clarifications issued by CMS may make it easier for gastroenterologists to rightfully claim their reimbursement dollars.

Although patients can be under the care of a home health agency for many reasons, clinical nutrition services may be the most common one in gastroen-terology. Clinical nutrition services include either parenteral (PEN, also referred to as total parental nutrition or TPN) or enteral (EN) nutrition. Many patients who are being administered PEN/EN in a home setting have long-term gastrointestinal conditions such as Crohn's disease or pancreatitis.

Not every PEN/EN patient who is at home qualifies for CPO, says Carolyn Viall, RN, MSN, associate professor of nursing at the University of North Carolina at Chapel Hill Hospital, and a member of the American Society for Parenteral and Enteral Nutrition's public policy committee. "Many patients on clinical nutrition may be at home but do not have home healthcare," she explains. "CPO is for patients with complex problems that require home health services. The clinical nutrition is only one prescribed therapy; the home health service is a separate order."

The gastroenterologist must be acting as the patient's primary care physician and have direct contact with the home health agency in order to bill these codes. "An internist or oncologist may ask a gastroenterologist for an opinion on a patient who needs enteral or parenteral nutrition," says Pat Stout, CMC, CPT, an independent gastroenterology coding consultant in Knoxville, Tenn. "But because the other physician takes over after the opinion has been rendered, the gastroenterologist cannot bill for any type of CPO service." Physician Certification Billable Only to Medicare The two billable services that a gastroenterologist may provide in this home health situation are physician certification of a home healthcare plan and care plan oversight. Physician certification includes the creation of a home healthcare plan by the gastroenterologist. The plan is dictated by the gastroenterologist to the home health agency, which transcribes the information (for Medicare patients) on CMS Form 485 and returns the form to the gastroenterologist for a signature.

In a typical home healthcare plan, the gastroenterologist may order the nurse to administer PEN/EN, monitor the patient's weight and vital signs, take lab specimens and add supplements to the PEN/EN mixture if needed, Stout explains. The gastroenterologist may also order physical therapy, bathing and light housekeeping duties. In addition to these orders, physician certification also requires establishing goals and expectations for the patient's progress.

Physician certification of a home [...]