Gastroenterology Coding Alert

Presented by Trish Bukauskas-Vollmer, CMM, CPC, CMSCS

The following supplement to Gastroenterology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Trish Bukauskas-Vollmer, CMM, CPC, CMSCS, has over 19 years in the medical field. She currently is the President and CEO of T.B. Consulting, a firm specializing in education, consulting, auditing, compliance, and initial start-up of medical offices and clinics. She is a Certified Medical Manager through the Professional Association of Health Care Office Managers (PAHCOM) and a Certified Professional Coder (CPC) with the American Academy of Professional Coders (AAPC) and American Health Information Management Association (AHIMA) and national membership director for the Professional Association of Healthcare Coding Specialists (PAHCS). She is also an active member of the American Society of Interventional Pain Physicians (ASIPP). She presents seminars and coding workshops across the country.

Care plan oversight is one of the forgotten revenue of today's practices.  Physicians all over are losing money, and they are doing this service and they are not even aware that they can bill for it.  I was recently working with the urology practice, and we had a lot of patients that were receiving home healthcare and the physicians were constantly being bothered - not being bothered, but getting telephone calls having to do orders.  What is care plan oversight?  Care plan oversight is supervision of patients under the care of home health agencies or hospices that require a complex of multidisciplinary care.  What are some of the services that are included in care plan oversight?  Care plan oversight includes regular physician development and/or revision of care plan.  When a person is an inpatient in a hospital and discharged with some home health, they might need medications, dressing changes, additional care - that is included.  Review of subsequent reports of the patient status, review of related lab and any other studies, communication with other health professionals that are not employed in the same practice - that is also involved in the patient's care.  Possibly rehab, physicians or if there is an ontologist working with the physician or maybe a cardiac specialist because the physician has some other co-morbidities - those and review of reports and things like that from them.  Integration of new information into the medical treatment plan and any adjustment of medical therapy, be it the diet, dietary medication, their therapy if they are receiving home therapy, anything when you change the therapy - that  is what needs to be documented and included.  Some of the services that are not counted for the 30 minutes: time associated with discussions with the patient, his or her families or friends, the staff getting or falling charts, travel time - if your physician does go to the nursing facility that is not covered - and  physician's time spent telephoning prescriptions to the pharmacist, unless it is medically necessary.  Now, the correct way that we can bill for care plan oversight.  You can get paid 30 minutes per month.  You get the initial initiation and then 30 minutes per month.  So when you do the care plan - a lot of my clients they send in a copy of the care plan that they were - that they instituted - and they bill for the initial and then the subsequent care plan.  Some indications for care plan oversight.  The beneficiary, they must be receiving complex treatment that requires physician's involvement in the patient's plan of care.  The care plan oversight should be furnished during the period in which the patient is receiving home health or hospice.  The physician that bills for care plan oversight must be the same physician that initially developed and signed the home health or the hospice care plan.  And it must be furnished at least 30 minutes within each calendar month.  Discharge management observation codes are not countable towards 30 minutes.  The physician provided a service that required face-to-face visit within the last six months of initiation of the care plan which - most often that does happen - they have either been in your office or they were inpatient.  And the physician saw them and they either did not, they could not come back into the office consistently or they could - they were not inpatient status.  The care plan was not routine postop care provided in the global surgical care.  Now, many times you can bill for care plan oversight following a surgery, but it cannot be just for the surgical procedure alone.  It has to be for maybe an infection due to an underlying condition - like maybe a patient that had diabetes or something like that.  And they had a wound infection that primarily was due to the poor healing from the diabetes and not solely just the surgical site alone.  The physician billing the care plan oversight is the physician who furnished them.  The physician is not billing for ESRD - End Stage Renal Disease - within the same month, and the physician that bills for care plan oversight must document the services furnished, the date, the time and the length of time of each of those services.  So anything that he or she does, they need to document what was done and about how long it took them to do that.  Some other limitations: there is no other preop or postop work, E/M services, other communication - if your physician - within that 30 months, if the patient did come back to the office, you can not charge that time in care plan oversight.  Providers billing for care plan oversight must submit the claim with no other services.  So you bill that alone on a 1500 or electronically.  And it can only be billed at the end of the month the following 30 days in which the care plan oversight was rendered.  Some things that need to be included in the plan of care: the patient's mental status - they were alert, oriented or what their mental status is.  The types of services, the supplies, any required equipment that was needed to render the care plan and the plan of treatment.  The frequency of visits that are made.  Prognosis - what is the patient's prognosis, hopeful prognosis?  Rehab potential - is this patient a candidate for possibly another rehab facility or additional ongoing rehab?  Any functional limitations, impairments of activities of daily living, anything like that that really shows the medical necessity of having this care plan that has the medical necessity of that patient receiving home health or these medical services should clearly be documented.  Any specific nutritional requirements - if the person is on a low salt diet or a low fat diet or diabetic diet.  Any medications and treatment that is needed, any specific safety measures.  With the increase with a lot of patients being diagnosed with HIV and a lot of infectious disease - right at the local colleges where I am at there was an outbreak of tuberculosis.  There is a lot of necessary precautions that need to be taken.  All of that needs to be documented.  And then any instructions for discharge or referral.  When you do the end of the care plan and you are going to discharge the home health and follow up at the office, refer them to another physician or return in 6-8 weeks or whatever - all that needs to be clearly documented.  When you are billing for care plan oversight, Medicare only covers physician supervision requiring complex multidisciplinary care within a calendar month for 30 minutes or more.  G0181 is the HCPCS code to be used for that and G0182 is the 30 minutes or more with physician supervision requiring 30 minutes or more.  When you are documenting the G0181 that is the initial calendar month - that is the initial care plan.  And then G0182 is the subsequent for the physician of a Medicare approved hospice patient.  There are commercial carriers.  There are other CPT codes when you are billing for the care plan oversight.  99374, 99375 for patients under the care of home health; 99377 and 99378 for hospice.  And then commercial carriers do allow 99379 and 99380 for physician supervision of a nursing care facility, a nursing home.  But for care plan oversight for Medicare, it is usually just home health or hospice.  If it is the nursing home they have there own specific nursing home that they want you to use for that.  The reimbursement Medicare pays very well.  That is why when my physicians were saying, "it was too much of a hassle," which is usually the common reason why a lot of people were not billing for this.  They think, "how do we know 30 minutes?"  And a lot of people think that it is 30 minutes.  It is not 30 minutes at one time; it is 30 minutes consistently.  It is not - it is when you are collectively for 30 minutes.  It could be 5 minutes today and 10 minutes tomorrow.  You might not have to change or do anything for two weeks and then the patient - the home health nurse might call in - the patient had some side effects or something.  And the physician says, "well, I can not keep track of that."  It is not that difficult.  There is some forms that you can do; I know Don Self, his website has some care plan oversight.  I just came up with a card and like a bulletin board and the physicians - just like they do when they do inpatient.  Anytime they have to do that, they will just put the patient's name and put like 20 minutes spent talking to nurse regarding this, this, this.  And they just put that and then we keep in one folder every month what all the care plans are.  And that is one person, their assigned job, and then they just take them through.  And if there is 30 minutes, they bill for it.  If there is not 30 minutes, then we cannot bill for the addition for the 30 minutes.  When you have the initial care plan oversight and you do that, you can bill for that every time you do initiate that.  It is the subsequent ones where the physicians are mostly losing money.  And I do not know about you, but my doctors are always looking on how to capture additional money, and the $152 or $161 from Medicare for work that we are doing anyway.  I think it is worth it to try to come up with some sort of format used for the documentation of those services to do.  What needs to be documented when you are billing for that?  Not a whole lot of documentation.  A lot of people think that they have to write a book when they go and do the care plan oversight of the documentation.  But you do need to support the medical necessity.  The complex and multidisciplinary modalities that involve the physician development, any revision of the care plans, the review of the subsequent reports of the patient status, any lab studies, communication with the healthcare providers and any new information, if you had to adjust the new.  So you need to put that in there, just like a quick op note.  I do like to put that the time was spent - that additional 30 minutes was spent, collectively 30 minutes was spent - and I just have my physicians break it out and do the documentation.  We usually add everything up and then write everything that was found.  Most of the work that is being performed is by the home health nurse.  However, your physician at the end of the month - if  you have a good template or a good charting mechanism in place that they can just go and write a brief paragraph and that if somebody was auditing, they could assume that yes they did have four calls from different labs, they had to order additional tests,  things like that, then you can bill for that.  When you are getting your initial care plan oversight, it is okay to have the home health nurse to initiate the care plan.  A lot of them do have forms, like formatted notes or formatted forms, that they give and your physician just signs them.  That is okay because his signature - that means that he is taking responsibility and liability of that patient that is going to home health.  So you can bill for that with that for the initial one and then the subsequent ones if it does fall in for every 30 minutes, if you are doing 30 minutes.  If you are billing for the care plan oversight, you need to clearly document.  Make sure that you do bill it correctly on a simple 1500 form solely by itself, and that your documentation does support it.  A lot of people say, "well it is a hassle to do; we do not really have the time and the manpower to do that."  Like any new project it does take time when you were initially starting that but afterwards, once you get the hang of it, you will just see that revenue coming in.  And it will be just increase revenue and it will become routine, just like when you entered any other new services that you started to provide.  Now, a lot of people get the care plan oversight billing confused with nursing home billing.  These are two different, separate entities.  When you are billing for nursing homes there are separate codes for that.  The 99301 evaluation and management, new or established patient involving annual nursing homes, and they go in the different levels.  This is just for people that are either on home health or hospice.  Oncologists routinely are a source of providers that are consistently losing revenue.  Especially, I know a lot of oncologists that they supervise several hospice patients and several hospices and they are constantly on the phone doing these kinds of things.  It is very beneficial to them to learn to come up with some sort of a format to be able to capture this.  Because they are always doing - 90% of their work is administrative work - research work, changing orders altering the meds and adding different diet things, and different forms of therapy and rehab and things like that.  So they should take advantage of that.  When your physician goes to the nursing home that also needs to be documented, but these care plan codes are not utilized.  You would use just the every time you do a visit and document accordingly with that.  Same thing with the nursing home facility discharge.  They have their own separate codes and the rest home, boarding home or custodial care.  There is also separate codes for that.  The 99321, the 99322, domiciliary or rest home visits - that is totally different than the care plan oversight for the home health agency or the hospice agency.  At this time, if there is any question before I go any further? 

Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press #, please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may re-enter the queue by pressing *1.

Q & A Session:

Question:  Hi Trish, thanks so much.  This question came in by e-mail and says that we are having a very hard time understanding and making the nursing homes understand the issue of consolidated billing.  We bill for services performed at our vascular laboratory.  I understand that we bill Medicare for the professional component and the nursing home for the technical component.  The issue is this: they continue to say they will not pay because the patient has part A and or part B Medicare plans. Please help.

Answer:  That has happened about a year or so ago that Medicare started paying the nursing homes.  Radiologists and a lot of other providers are running into the same kinds of problems.  Medicare subsidizes and pays these skilled homes, the nursing homes.  And now, if your physicians see the patients in those nursing homes or provide any therapy, any laboratory, any diagnostic studies or anything because that person received payment under their part A for a global fee, you are supposed to - your physician or our practice is supposed to bill the nursing home and collect payment from them.  This has caused a lot of denials.  This has also put a lot of burden because it is very hard to collect from the nursing homes.  I really do not have any good answer on how to do that; what we have done is make the nursing homes pay upfront before the patients come.  We have tried to do that.  A lot of the physicians - I know my radiologist - they have a problem because they have started getting the films - like a lot of the orthopedic surgeons and things - they have started having the x-rays done at the nursing home because they could not collect.  But then a lot of time they say well they are such faulty - they are not real clear pictures and things - so they will still do them and they just lose revenue.  The best thing that I can recommend is to try to call that nursing facility.  You will not get paid by Medicare.  There is no way that you can even put just a 26-professional.  This has been a thorn in a lot of the providers' side, like I said for the last year or so.  The best advice that I can give is to contact the director or whomever, the medical manager or the business manager at that nursing home, and find out what is the way that you can deal with collecting that revenue from the nursing home rather than the patient.  You can't even bill their part A, because they are giving one lump sum and that is all included in that.  And so when we bill for part A, at the same time they are denying it as bundled.

Question:  Yes, I would like some information on your billing.  You were talking about the 10 minutes and 30 minutes breaking it down in over 30-month period.

Answer:  It is over one-month period, 30-day period.  You have to have a minimum of 30 minutes.

Question:  So it is 30 minutes per month.

Comments:  Right.

Comments:  Okay.

Answer:  And you just break it down; you can do 5 minutes here, 10 minutes there or 20 minutes and then just collectively have 30 minutes in that one month.  And a lot of doctors say, "well I will never do."  But when you really started collecting and just using and trying that out, you will find that, you know what, most of the time you do spend - your physician does spend - at least 30 minutes, especially if it is a patient that is very sick or has co-morbidities or multiple complications and things like that.

Comments:  Thank you.

At this time we have no questions for this section of the presentation.

Okay, some other things that you do have to consider: that the physician who bills for the care plan oversight must be the same physician that originally initiated the care plan oversight with the home health agency or hospice.  When you have multiple partners, it does not mean that you can not send an additional person, but the person that actually bills.  You could have your partner see them like two days from now or, you know, alter that and change some things.  But the person that actually does the billing collectively - that does the billing - must be the physician that originated the care plan.  A lot of people get confused with a lot of nursing duties that are being done and they try to bill for that.  That is one of the things that you really need to clarify and have real clear distinctions for.  Yeah, your nurse - you might have your office nurse spend a lot of time dealing with the home health nurse or the home health agency or calling the pharmacy to order a prescription.  None of that is billable.  It is only billable if it is physician warranted.  If your physician due to the medical necessity, he specifically has to contact a pharmacist.  Even if your physician does call the pharmacy, they will not allow and pay for that unless it was because the patient had a contraindication or you had to worry about an allergy or something like that.  Because they feel that your nurse could have called that in.  So it is just physician time that is billable.  And physician time that is medically necessary, such as your ordering of your x-rays, your labs, reviewing the labs when you get that back, that is another particle where physicians routinely take for granted.  You might order - and I go back to oncologists because they do not spend a whole lot of one-on-one with the patients but they spend many, many minutes and hours sometimes ordering tests, reviewing the outcomes of the tests, coordinating care, doing those kinds of things.  So when you are ordering lab tests or diagnostic studies, you do have to review those and sometimes it does take time.  And a lot of the documentation - all you need to say, "20 minutes were spent or 15 minutes were spent reviewing the MRI films and study that shows blah blah blah;  15 minutes or 10 minutes were spent reviewing the EKG or the lab test, the CBC or PT, PTT," and even give some of the results.  And especially, if some of those diagnostic studies or labs lead to you having to alter or change the treatment, that is when it really shows the medical necessity of that - you know, of why you need to initiate and bill for the care plan.  The physician - also you have to have provided a face-to-face within the last six months preceding the care plan oversight and the physician may not have a significant financial or contractual relationship with the home health agency.  There is not too many, but there are some physicians now that have become entrepreneurs.  They own a part of an ASC or a part of the home health agency; if they do have ownership in the home health agency then they should not bill for that service.  The physician may not be the medical director or employee of any hospice or working, including any volunteering.  And he must document where the services were furnished, the date and length of time and the services were performed directly by him with any documentation that he has.  Other E/M services should not also be included, if you do see them.  It does not mean that you have to quit counting your 30 minutes.  If you do have a home health patient and you saw them 15 minutes, they needed some home health work and some counseling and changing and you only had 15 minutes from February 1st to February 10th.  On February 12th the patient came in, you saw them in the office and you can bill for that E/M.  Now, you can not add that E/M with that, but if after that the following day or two weeks later they did have another 15 minutes, you can still bill that care plan oversight.  It is just that you cannot include that time that was given for the office visit or if they went back to the hospital.  Is there any other question at this time?

Question:  I guess we had sent some questions and the first one was that we get from physicians the fact that they are concerned that by billing through care plan oversight, that will create a red flag and will cause them to be subject to more review.  Can you comment on that?

Answer:  I get that with a lot of different things that come out on a physician.  The only thing that I can tell them that they have the clear understanding, Medicare does have local Medicare review policies.  What I would recommend to you is to pull the local Medicare review policy; I have one from New Jersey, one from Pennsylvania and one from South Carolina.  Medicare would not allow - if it was not covered, if it was not ethical, if it was not medically necessary, Medicare would not come up with those codes.  That is what has always been my answer to them, and then what I do is usually try to pull the local Medicare review policy and then educate the physicians in five simple steps.  These are what you can document for, this is how you can document it, this is what is considered inclusive and you can not, and these are the codes to do that.  So if they are worried about that I would just alleviate - show them the documentation, and it would not raise an audit if it is medically necessary because they are very clear in their guidelines what is covered and what is not covered.  The only thing that I tell physicians that routinely does raise a flag is things that you do consistently.  I have physicians - like they say E/M coding should be a bell curve - which it should.  If you have one specialist though, that really does see a lot of sick people or terminal patients or hospice patients or a lot of infections, then they can bill for that ethically.  But if one physician does see a lot of people and they do not really need home health - it is really hard to even get approved, as you know for home health unless it is medically necessary, so they should bill for it.  But routinely, the only thing that really commonly raises a flag is when you get a big large volume of things and he might - if he really was doing a lot of home health and care plan oversight at one time, I am not saying he might not be flagged or audited.  But if his documentation is there and it was medically necessary, then that will be fine.

Question:  Hi, I have a question regarding #1, the site that you mentioned earlier, regarding the forms.  And also when we are a surgical practice and we also, besides our surgery, do a lot of wound treatment - and that is where the home health nurses mostly go in for the treatment of wounds.  The home health agencies that we deal with send the doctors a letter and they have to sign off on that letter.  And it talks about the patient, and they had a certain kind of dressing and it was changed per doctors orders they sign off and send it back.  Is other documentation required or does that suffice?

Answer:  At the end of the month, you should have other documentation; that would suffice, as far as sending back for the re-evaluation.  But for the care plan oversight to have your full 30 minutes, you would have to have other things that were done in there.  That would suffice to account for a few minutes of reviewing and changing of that dressing, but to have your full 30 minutes that would have to have other documentation.  The website again is www.donself.com, and they do have I think three or four different care plans.  I kind of looked at those and then I came up with my own, just like a little log sheet that I keep.  And we keep it for all the patients that month that have been initiated and are on care plan.  And then we kind of remind, especially when we first start that up, we kind of remind the doctors, "hey, id you contact home health or did you have any calls in the evening?"  Especially the people that are on call.  And then be sure to put your card in; be sure to document that and write that.

Question:  Thank you.  The website - was that Donself or Dawn?

Answer:  Donself.  And there is a lot of good free information on that - that when you are trying to implement any new ideas,  it really does help to give you a good starting point.

Question:  Hi, I was just wondering if, I'll just say  "physician A" initiates the care plan oversight and has gone on vacation or something and then "physician B"  does calls for them,  can that add towards the time, towards the 30 minutes?

Answer:  Yes, that can add towards the time, towards the 30 minutes, because he is incident 2 at that time.  But the physician A must bill to the documentation before it goes in.

Question:  But the other physician's documentation can add up for ...

Answer:  You can add to that, yes.

Question:  I have two questions.  One, several physicians have asked me what is a reasonable amount of time for the physician to document that he spent on reviewing a 485 or a plan of care.   And the second question is: physicians have asked - or actually their billing people have asked me - if they forgot to do their documentation and they want to go ahead and bill for it, does our documentation cover them in anyway?

Answer:  Your home health agency

Question:  Yes, if we documented that we had a conversation with physician regarding the patient's care, can we provide them a copy of our documentation for their chart, so they can go ahead and bill?

Answer:  Yes, that is what a lot of home health - they can not bill just with your documentation.  But what a lot of the home health agencies have done in order to get the physicians to go with their home health agency and things, is they have come up with a lot of the forms, have come up with really good documentation tracking mechanisms.  And then they forward that at the end of the month.  And they will even keep track with them and then the physicians, they will just document their note from that form and that really has - I have seen an improvement in a lot of physicians there.  They are more apt to provide care plan oversight and bill because it is not putting the additional burden on their staff.  And I have two home health agencies that are doing that and they have seen an increase in their referrals also. 

Question: What about the reasonable amount of time presented to you, say they spent reviewing a 485.

Answer: I would say no more than 10 minutes, unless there were - it was a very ill patient that they had to change a lot of things, do a lot of things and there was an enormous amount of orders and medications and things like that.

Question:  We have a two-part question that has to do with the location change code; when we get that how do we handle it?  And we are constantly asked by physician offices for our ID number.  We have been giving them our Medicare provider number; is that correct?

Answer:  You are a home health

Comments:  We are home health.

Answer:  Yes, your medicare provider number is okay to give them; and what I am not quite sure what you mean by the location change code.  If you are doing it in the home, you would use place of service 12.

Question:  In physician's office care plan oversight of the home care agency, we are looking for that code.

Answer:  I did not hear you what was that?

Question:  The location code for a home care agency or doctor's office to bill, is it 11?

Answer:  No it is a 12.

Question:  12 is in the home, the patient's home?

Answer:  Yes.  Because that is where you are doing the home healthcare right?

Question:  Yes, but the physician's office is wanting the location code they bill for.

Answer:  They would bill for location code 12, that this service was rendered under their direct supervision that they are liable for in the place of service location 12.

At this time we have no further questions for this section of the program.

Okay, one or two last things.  Nurse practitioners, physician assistants and clinical nurse specialists that are practicing within their scope.  They also can bill for care plan oversight.  They must be providing the ongoing care for the patient through the E/M services, and they must be the provider that signed the plan of care.  So if they are in their state and the would not be working incident 2, but they are billing under their own provider number, you can have nurse practitioners, physician assistants and clinical nurse specialists also billing for that.  The discharge planning for a hospitalized patient is included in the E/M services.  So the care plan, that part is not included in the care plan oversight.  So if they do have to initiate an additional and the patient is going to home health, then the additional orders like the part that home health agency is going to be referred, that is part of a discharge planning, the discharge billing.  And then to bill for the initial care plan oversight would be the initiation and the care plan and everything that that encompasses.  And again, if you are doing any other E/M services during the same month for which your physician is billing the care plan oversight, it has to be separate and apart from the time that you are counting for the care plan oversight.  I use my documentation that my physicians - and I get them in the habit of saying, "about 10 minutes was spent doing this" - that diagnoses have to be very very important when you are also billing for that.  The biggest thing that you want to do is make sure that you are really supporting and substantiating the medical necessity.  So list any co-morbidities.  A lot of times, people think that they will just put the reason why we are doing the home health but the reason a lot of times is multiplied due to the patient's health status.  They also do have cancer but they might also have emphysema, or they might have diabetes or they might have other things that really encompass the necessity for this home health or hospice treatment.  When you are changing the medications too, be careful that you are being very clear on that this was altered, this was changed.  When you renew, if somebody is calling in and saying, "oh, they are out of their pills and you are just renewing their medication."  That is not going to take as long as if when the patient had any reaction or this does not seem to be working.  You there that are the nurses know that when you have to change the drugs and talk to the physicians about that, it does take additional time to do.  And just document everything that was done in that time.  With the home health agencies there, how much time on an average do you guys think that you really spend?  Do you think it is easy to get these 30 minutes out of the physicians or it is just hit or miss?  You know that is the clear way to determine if that is what you are doing when you are documenting the care plan oversight.  We do not have a lot - I mean normal like urology practices, OBGYN - you might only get may be three a year.  But if you do get those three a year, you should be able to know how to bill for them.  Some of your other practices, like the wound care clinic that called in earlier, you might have more.  You want to be very careful that you are remembering that it is not just routine postoperative care.  If it is routine postoperative care, then those are part of the global days and cannot be billed for.  Is there any other question?

Question:  I may have heard you wrong but it sounded - I  wrote down early in the talk that you said if the patient was in the office during that month you could not bill for care plan oversight; and then later you explained that you can as long as you do not bill for that piece when they were in the office.  So which is it?

Answer:  No, I said you could not bill for that time of the office visit for care plan oversight.  It would have to be like if you saw them and you were doing the care plan oversight for two weeks, then they came into the office.  That would be separately billed as the office visit.  And then if you saw them and if you did any other oversight after that and that also equalled from the previous two week to then - in other words you just break out that office visit.  You do not add that 20 minutes or 10 minutes time that they spend in the office.  It has to be distinct and separately identifiable in order to bill.

Question:  We are also confused a little bit about the nurse practitioner.  Looking in the book where it says they may bill for CPO even though they are not permitted to certify patients.  And then down to bottom it says if advancement practitioner is seeing the patient only for home care, they may not bill.  That is a little confusing; do you understand that better than we do?

Answer:  They have to be seeing the patient.  They had to have been seeing the patient previously.  They had to have been treating that patient as a provider previously.  They can not just put somebody on home health that they have never seen before.  It had to have been their patient.

Question:  Do they have to have seen them face-to-face?

Answer:  Yes.

Question:  I was just wondering what you would use as a date of service?

Answer:  The date of service is the month, the date of that last month that you bill and it will be within the 30 days.  So if you bill September 30th, then the next date of service that you bill for would be October 30th or 30 days after that.

Question:  Hi, I know that we talked about earlier in this conversation, the code that you use for the 15-29 and the 30 minute care plan oversights.   Which ones would you use for the initial - putting them on home health initially?  And is there a separate one for discharge or is there everything included in those two codes.

Answer:  Everything is included.

Question:  Yes, we need clarification pertaining to the question about the physicians who are medical directors over home health agencies.  If they are medical director over a specific agency they can not bill CPO?

Answer:  They can not bill care plan oversight for services being rendered by those home health agencies for which they are a director of, no.  And you can find that in the local Medicare Review Policy and the CMS National Coverage Policy 1862 (a).

Question:  Okay, and you do say that if they are also in any other capacity besides medical director or volunteer and - what was the other one, if they had any kind of, even if they ...

Answer:  Financial ownership.

At this time we have no further questions for this section of the program.

Okay, to sum this up, the last things that you need.  Some of the reasons that claims may be denied for care plan oversight is first, that the diagnoses do not support the medical necessity.  Claims submitted for beneficiaries that were not receiving any services that were medically necessary due to what the original diagnosis, why they put it on, so you have to be consistent from month to month.  Oversight services if the patient's medical record does not support the necessary documentation for complex and multidisciplinary care.  And if it does not confirm that at least 30 minutes were spent furnishing care plan oversight within that calendar month that was billed.  Good documentation of what is needed can be found in the CMS National Policy #13 and the guidelines for billing, the coding guidelines.  When you are billing for 99379 and 80 for the care plan oversight provided to beneficiaries and nursing home facilities for skilled nursing services; when you are billing for the care plan oversight use the G0180, G0181 for Medicare; make sure that you are documenting all of the necessary diagnoses, the multidisciplinary, the need for the home health agency or the hospice care and the amount of time.  Come up with a good format for documenting and tracking and bill at the end of the calendar year.  I even have some physicians that have just a standardized template, and then they just kind of fill in the blanks of everything that they did and then put the times beside that.  And then at the end of the month we just have out transcriptionist put that into like a note format and the physician signs it.  One thing you want to remember if you are a physician office that is thinking of implementing care plan oversight, is that you do not make it real difficult for your physician.  Because he is going to think, "Well, hey! You know what this is getting to taking out more time than it is worth billing for."  But when you start showing him the revenue that can be obtained and received from care plan oversight, trust me, they will find a way to make it work.  Is there any other question?

Question:  My question has to do with can a physician bill when they initially sign the 485 for home health, the admission bill under G0180, and then after they have accumulated the 30 minutes, they could for the month, they could bill under G0181?

Answer:  G0181 is for the hospice.  G0180 is for the care plan oversight.

Question:  Okay, G0180 is care plan oversight for home health.

Answer:  Yes.

Question:  And 181 is hospice?

Answer:  Yes.

Question (AH):  And the G0179 is on the re-certification?

Answer:  Yes.

Question:  Okay, and then what is G0182 then?

Answer:  That is physician supervision requiring complex treatment within a calendar month and I believe that 182 is for the hospice.  We only have G0181 and G0182.

Question:  Okay, so 181 is not home health oversight?

Answer:  That is the home health and the G0182 is for the hospice.

Question:  Okay, alright.  What I am confused at is, can a physician bill initially the G0180 for signing the 485 basically and then at the end of the month, after they have documented their 30 minutes, they could bill for care plan oversight under G0181, is that two separate payments?

Answer:  Right.  If they have their 30 minutes.

Question:  If they have their 30 minutes and the G0181 can be billed for every month that that patient is on service?

Answer:  Every month that they are on service, yes.

Question:  And then the home health re-certification that G0179 can bill at every 60 day interval when they sign and review that 485?

Answer:  And if they review it again and then they reinitiate and reevaluate, yes.

Question:  So there are three opportunities then for physicians to bill on home health, is that correct?

Answer:  Right, if they stay on that long term.

Question:  Yeah, I understand.  Okay, very good.  So they will bill at the time of admission, the first 30 days, the second 30 days if a patient has a 60-day certification.  And then they would bill - if  they did restart the patient, then the process would start all over again with the G0179.

Answer:  Right.

Question:  Yeah.  When we submit the HCFA-1500, do we have to submit documentation with it?

Answer:  Some Medicare carriers do not require it but we always have and it just made it clear and we did not have any problems.

Comments:  It is just so clear to get paid if you submit the documentation.

Answer:  Yes.  I usually get paid the first time out if I submit the documentation.  Some have said that they have done it and they have not even requested it, but I do not take that chance; I do submit it.

Question:  I have one other question.  What is the G0179?

Answer:  That is for the re-certification every 60 days, if they are still on.  And I did not mention that - we have never had anybody that really stays on that long, but if a patient is still on for a long period of time, every 60 days you can re-certify their care plan oversight and you can reinitiate that.

Question:  We would like to know how far back can you bill pertaining to the back-billing?

Answer:  Medicare allows 18-month back billing.  Medicaid, I think it is a year, and commercials you can try as far back as you go.  I have been lucky to get some commercials, some workers comp, paid even as far as 2-2 years.

Comments:  Okay, thank you.

Answer:  But I do not know how you would go and try to find out if 30 minutes were spent on all of those.

Question:  But could it be back-billing pertaining to the certifying and re-certifying?

Answer:  Yeah, the certifying patient and the re-certifying, you can at least do that.

Question:  Is it real lucrative for the physician to be just billing for certain re-certification?

Answer:  Yes.

Comments:  Okay, we are a home health agency.  A lot of our physicians, they were really leery about doing the 30 minute because of just the lengthy stuff that they felt was involved with documentation and everything you have already mentioned, so they just prefer to just do the billing.

Answer:  They just do the G0179 and G0180.

Comments (MB):  That is right.

Answer:  Well, they are still going to receive if it is a Medicare patient approximately close to 400 dollars just on that, which is additional revenue.

Comments (MB):  That is wonderful.

Answer:  Yeah, and if you can find some sort of a format or come up with something to even track the additional 30 minutes, so that they can bill for the oversight, that would even benefit them more.

Question (MB):  Is there any suggestion that you perhaps could forward to us as a format or template that we could provide to them, that would make it easy?

Answer:  What I usually do is just go through and take your hypothetical questions that they usually do call and your standards change of meds, change of diet, therapy, things like that.  And then I just do it on a format for them, almost like what your care plan entails.  And then just put like a little line beside them and then just track in every time, because you have to as a home health agency.  When they do call and change anything you have to document that anyway.  The best thing to do is have like an extra column on one of the separate forms and then just have that attached with it.  And then just put approximately how many minutes and then at the end of the month provide that to them.

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