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G0179 help

  1. Default G0179 help
    Medical Coding Books

    G0179 Physician re-cert for Medicare covered home health services..etc.

    Can anyone provide a little insight on how this code is billed? Its billed once a year, what about the units and date span?


  2. #2
    Medicare Part B Policy HGS Effective Date 06/15/2005 Publish Date June 2005 States Affected PA Policy Number V-48

    "The place of service code should represent the place where the preponderance of the plan development and review work was performed. Enter the provider number of the HOME HEALTH agency (HHA) from which the beneficiary is receiving Medicare-covered services in Item 23 on the HCFA-1500, or in the electronic equivalent. No other services may be billed on the same claim as the physician services for certification or recertification."

    However it could come down to carrier/payer issue
    I found this from code correct

    The CMS Form CMS-485 (the Home Health Certification and Plan of Care) meets regulatory and national survey requirements for the physician's POC, certification and recertification. (See the Program Integrity Manual for Form CMS-485 and instructions for completion.) The certification by the physician must be retained by the home health agency. 100-08 Program Integrity Manual - Exhibit 31 (located under KnowledgeBase) and Exhibit 29 gives what is on that form. or and page 39 is the form

    Claims Processing 100-04 Chapter 12 Section 180

    "180 - Care Plan Oversight Services - (Rev. 999, Issued: 07-14-06; Effective: 01-01-05; Implementation: 10-02-06)

    The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners.Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare-covered services provided by a participating home health agency or Medicare approved hospice. 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; and/orAdjustment of medical therapy.Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;Time spent by staff getting or filing charts;Travel time; and/orPhysician's time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.The physician and NPP are part of the same group practice; orIf the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; orIf the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.The NPP providing the care plan oversight has seen and examined the patient;The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; andThe NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care.. The care plan oversight services are billed using Form CMS-1500 or electronic equivalent.

    The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physician's time per month. Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:

    Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient's care with the home health agency or hospice during the month for which CPO services were billed. The physician who bills for CPO must be the same physician who signs the plan of care.

    Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services. These non-physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.

    A. Home Health CPO

    Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:

    Billing may be made for care plan oversight services furnished by an NPP when:

    NPPs may not certify the beneficiary for home health care.

    B. Hospice CPO

    The attending physician or nurse practitioner (who has been designated as the attending physician) may bill for hospice CPO when they are acting as an “attending physician”.

    An “attending physician” is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. They are not employed nor paid by the hospice

    For additional information on hospice CPO, see Chapter 11, § of this manual.

    180.1 - Care Plan Oversight Billing Requirements - (Rev. 999, Issued: 07-14-06; Effective: 01-01-05; Implementation: 10-02-06)

    A. Codes for Which Separate Payment May Be Made

    Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.

    Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered. CPO services may not be billed across calendar months and should be submitted (and paid) only for one unit of service.

    Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met.

    B. Physician Certification and Recertification of Home Health Plans of Care

    Effective 2001, two new HCPCS codes for the certification and recertification and development of plans of care for Medicare-covered home health services were created.,” §10-60, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, “Home Health Services”, §30.

    See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01, Chapter 4, “Physician Certification and Recertification of Services

    The home health agency certification code can be billed only when the patient has not received Medicare-covered home health services for at least 60 days. The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period. The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

    C. Provider Number of Home Health Agency (HHA) or Hospice

    For claims for CPO submitted on or after January 1, 1997, physicians must enter on the Medicare claim form the 6-character Medicare provider number of the HHA or hospice providing Medicare-covered services to the beneficiary for the period during which CPO services was furnished and for which the physician signed the plan of care. Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers.

    Additionally, physicians should provide their UPIN to the HHA or hospice furnishing services to their patient.

    NOTE: There is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice provider number required for a care plan oversight claim. For this reason, the requirement to include the HHA or hospice provider number on a care plan oversight claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for care plan oversight claims."

    100-01 General Info Manual Chapter 4 Section 30:

    "30 - Certification and Recertification by Physicians for Home Health Services (Rev. 1, 09-11-02)
    30.1 - Content of the Physician's Certification - (Rev. 28; Issued: 08-12-05; Effective/Implementation: 09-12-05)
    Under both the hospital insurance and the supplementary medical insurance programs, no payment can be made for covered home health services that a home health agency provides unless a physician certifies that:

    • The home health services are because the individual is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology services, or continues to need occupational therapy;

    • A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and

    • The services are or were furnished while the individual was under the care of a physician.

    Since the certification is closely associated with the plan of care (POC), the same physician who establishes the plan must also certify to the necessity for home health services. Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.

    The attending physician signs and dates the POC/certification prior to the claim being submitted for payment; rubber signature stamps are not acceptable. The form may be signed by another physician who is authorized by the attending physician to care for his/her patients in his/her absence. While the regulations specify that documents must be signed, they do not prohibit the transmission of the POC or oral order via facsimile machine. The Home Health Agency (HHA) is not required to have the original signature on file. However, the HHA is responsible for obtaining original signatures if an issue surfaces that would require verification of an original signature.

    The HHAs which maintain patient records by computer rather than hard copy may use electronic signatures. However, all such entries must be appropriately authenticated and dated. Authentication must include signatures, written initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. The HHA must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records upon request from the intermediary, state surveyor, or other authorized personnel, in the event of a system breakdown.

    See §10.1 for the effects of failure to certify or recertify.)

    30.2 - Method and Disposition of Certifications for Home Health Services

    (Rev. 1, 09-11-02)

    There is no requirement that the certification or recertification be entered on any specific form or handled in any specific way as long as the intermediary can determine, where necessary, that the certification and recertification requirements are met. The CMS Form CMS-485 (the Home Health Certification and Plan of Care) meets regulatory and national survey requirements for the physician's POC, certification and recertification. (See the Program Integrity Manual for Form CMS-485 and instructions for completion.) The certification by the physician must be retained by the home health agency.

    The following instructions pertain to required documentation of the certification and recertification period both before and after the implementation of the home health prospective payment system.

    For Dates of Service before the effective date of the Home Health Prospective Payment System (HH PPS) (October 1, 2000):

    The HHA enters the month, day, year, e.g., MMDDYYYY that identifies the period covered by the physician's POC. The "From" date for the initial certification must match the Start of Care (SOC) date. The "To" date can be up to, but never exceed 2 calendar months and, mathematically, never exceed 62 days. The "To" date is repeated on a subsequent re-certification as the next sequential "From" date. Services delivered on the "To" date are covered in the next certification period.

    Example: Initial certification "From" date 03012000; Initial certification "To" date 05012000; Re-certification "From" date 05012000; Re-certification "To" date 07012000.

    For Dates of Service on or after the effective date of HH PPS (October 1, 2000):

    The HHA enters the month, day, year, e.g., MMDDYYYY that identifies the period covered by the physician's POC. The "From" date for the initial certification must match the SOC date. The "To" date is up to and including the last day of the episode which is not the first day of the subsequent episode. The "To" date can be up to, but never exceed a total of 60 days that includes the SOC date plus 59 days.

    Example:Initial certification "From" date 10012000; Initial certification "To" date 11292000; Re-certification "From" date 11302000; Re-certification "To" date 01282001.

    NOTE: Services delivered on 11292000 are covered in the initial certification episode.

    30.3 - Recertifications for Home Health Services

    (Rev. 28; Issued: 08-12-05; Effective/Implementation: 09-12-05)

    Under both the hospital insurance and supplementary medical insurance programs, when services are continued for a period of time, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services and should estimate how long services will be needed. The recertification should be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of the plan.

    The physician must recertify that an individual needs or needed skilled nursing care on an intermittent basis or physical therapy or speech-language pathology services or, in the case of an individual who has been furnished home health services based on such a need and who no longer has such a need for such care or therapy, needs or continues to need occupational therapy. Recertifications must be signed by the physician who reviews the plan of treatment. The form of the recertification and the manner of obtaining timely recertifications are up to the individual agency."
    Hope this helps

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