Internal Medicine Coding Alert

Published on Fri Sep 24, 2004 PDF

Medicare and private payers require different codes

If your internist isn't documenting his care plan oversight (CPO) services, your practice could be losing at least $135 a visit. To begin using G0179-G0182 and 99374-99380 like a pro, you should learn the different coding requirements for Medicare and private payers, and understand physician supervision and certification rules.

1. Use Different Codes for Medicare, Private Payers

Although Medicare and private payers usually pay only for face-to-face services, you can report your internist's indirect care of CPO patients and get reimbursed.
 
CPO services are time-based, indirect E/M services that include many tasks that physicians regularly perform for the long-term management of home health agency, hospice, or nursing facility patients under their care.
 
You should bill for the time the physician spent treating the patient, but make sure the physician documents the time so you can report the appropriate codes.
 
Note: All CPO code descriptors for G0179-G0182 and 99374-99380 include physician supervision.
 
"Our internists find the documentation and reporting requirements too cumbersome," says Carol Hall, CPC, coding/reimbursement specialist at Center for Health Care, a multi-specialty clinic with four internists in San Diego.
 
"The physicians feel like they don't have the time" to document with whom they've held discussions and when they review charts, she adds.
 
Problem: Your internist spends 40 minutes developing a plan of care, reviewing the patient's status, and discussing treatment with other health professionals for a patient with prostate cancer (185, Malignant neoplasm of prostate). Your physician writes off the 40 minutes as nonbillable time - and forfeits about $135 in CPO services.
 
Solution: Using the example above, if your physician oversees a Medicare hospice patient, you could report G0182 (Physician supervision of a patient under a Medicare-approved hospice [patient not present] ... within a calendar month, 30 minutes or more). Nationally, Medicare pays $135 for the code. 
 
If you're dealing with private payers, you should assign 99378 (Physician supervision of a hospice patient [patient not present] ... within a calendar month; 30 minutes or more).
 
When billing CPO services, you can't submit CPT codes 99374-99380 to Medicare, which accepts only G0179-G0182 for CPO.

2. Understand Your Physician's Role

Remember that physicians who bill CPO must have directly cared for a CPO patient within the six months immediately preceding the first reported CPO claim. For example, if the physician billed for initial hospital care (99221, Initial hospital care, per day, for the evaluation and management of a patient) three months before the CPO services, you could submit G0179-G0182 to Medicare.
 
For home health services, report G0181 (Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency ... within a calendar month, 30 minutes or more). Private payers will accept CPT's home health code 99374 (... 15-29 minutes), assuming that they spent a minimum of 15 minutes working on the CPO and the time is documented.

3. Keep the Certification Rules Straight

Medicare also requires that physicians certify and recertify all patients receiving CPO services under the care of a home health agency.
 
To report these recertification services, you should use either G0179 (Physician recertification 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 recertification period) or 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).
 
Note: You should use the initial certification code, G0180, when patients have not received Medicare-covered home health services for at least 60 days, says Brett Baker, third-party payment specialist for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Washington, D.C.
 
Be sure you assign the recertification code, G0179, when patients have received covered home health services for at least 60 days, and when the physician signs the certification after the initial certification, he adds.