A clipping from this article may help.
Care plan oversight services
At the July meeting of its Practicing Physicians Advisory Council, HCFA announced that a preliminary review of billing claims from New York state found improper reporting of the billing code for care plan oversight services, CPT code 99375.
The care plan oversight billing code allows physicians to bill for supervising the treatment of patients who are under the care of home health agencies or in a hospice or nursing facility and require complex care that involves regular supervision by the physician. HCFA found, however, that in about one third of the reviewed claims billing for oversight the dates of care did not match dates on claims submitted by home health agencies and hospices. In another third of the claims, physicians billed for care plan oversight services for dates patients were in the hospital. And some emergency medicine practitioners, radiologists and pathologists were billing for this service when they are clearly not the physician responsible for the patient's monthly care and recurrent supervision of therapy.
What are physicians doing wrong? Let's start by looking at CPT code 99375, which defines care plan oversight as: "... physician supervision of patients under care of home health agencies, hospice or nursing facility patients (patient not present) requiring 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 (including telephone calls) with other health care professionals involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy within a 30-day period, 30-60 minutes."
CPT code 99376 describes the same services but requires physicians to have spent more than 60 minutes in a 30-day period.
To clarify who may be reimbursed for reporting care plan oversight services and under what conditions, HCFA has established specific payment rules (Federal Register, Vol. 59, No. 235, Dec. 8, 1994, pgs. 63418-63423). Here is a reminder of some of those rules and restrictions:
- Physicians can bill for the oversight of patients already receiving Medicare-covered home health and hospice services but not for patients who reside in skilled nursing facilities or nursing facilities.
- To receive payment in these settings, physiciansâ€”not a nurse practitioner or physician assistantâ€”must perform the services themselves.
- Only one physician per month can bill for this service per patient. To qualify for payment, the patient's plan of care must be reviewed and revised accordingly by the attending physician responsible for recurrent supervision of therapy.
- To bill for care plan oversight services, physicians must have had a face-to-face encounter with a patient within six months of the first billing date. This ensures that the physician is actively involved in medical decision-making required to develop or modify the plan of care.
- Physicians can bill for the service in the month following hospital discharge.
- HCFA reimburses physicians for communications with other health care professionals involved in the patient's care, but will not pay for telephone calls to patients and family members. Physicians should document in the medical record which services were furnished and the date and length of time it took to provide those services.
- Physicians who have a significant financial relationship with a home health agency, who are the medical director or employee of a hospice, or who provide services under an arrangement with a hospice can't be reimbursed for care plan oversight services.
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