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Care Plan Oversight – Cert/Recert




                                    1
Goals and Objectives
 Understand The Concept of CPO
 Know the difference between CPO and
 Certification/Recertification
 Make the Information Physician Specific
 Sell The Idea to Physicians
 Reap The Rewards


                                       2
Understand The Concept of
CPO, Certification/Recertification
  Physician

                  PLUS


                           Education




  EQUALS

                                       3
What Codes are Used?
Effective January 1, 2001 HCPCS codes
were added for physician services:

  G0180 – Certification HHA patient
  G0179 – Recertification HHA patient

  G0181 – Home Health Care Plan Oversight
  G0182 – Hospice Care Plan Oversight
                                            4
Understand The Difference
  Between CPO and Cert/Recert

What is CPO        What is Cert/Recert
How does it work   How does it work
How to make it     How to make it
work for my        work for my
agency             agency



                                         5
What is Certification?
     G0180 MD Certification of HHA patient
Certification Billing Requirements

  Must be billed by the physician that signed the
  patient’s Plan of Care
  Used when a patient has not received Medicare
  covered home health services for at a least 60 days
  Copy of Certification 485 in patient’s chart is sufficient
  documentation to support physician billing
  Date of service: Date the physician signs the POC
  Billed on Form HCFA-1500
  Locator 23: HHAs 6-digit Medicare provider number
                                                               6
What is Recertification?
        G0179 MD Recertification of HHA patient
        Recertification Billing Requirements
Must be billed by the physician that recertified the patient.
   Used after a patient has received Medicare covered home health
    services for at a least 60 days*
   Copy of Recertification 485 in patient’s chart is sufficient
    documentation to support physician billing
   Date of service: Date the physician signs the POC
   Billed on Form HCFA-1500
   Locator 23: HHAs 6-digit Medicare provider number

  *The G0179 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.

                                                                            7
What is CPO?
Care Plan Oversight (CPO) is physician
supervision of patients under either the
        home health (G0181) or
        hospice (G0182) benefit
the patient requires complex or multi-
disciplinary care modalities requiring
ongoing physician involvement.

                                           8
Requirements for CPO
 The beneficiary must be receiving Medicare
 covered home health services during the
 period in which care plan oversight services
 are furnished.
 The physician must have provided a
 covered physician service that required a
 face to face encounter with the beneficiary
 in the 6 months before the first billing for
 care plan oversight services.

                                                9
Requirements for CPO
The beneficiary must require complex or multi-
disciplinary care
   •The physician must furnish at least 30
   minutes of supervision within the calendar
   month for which payment is claimed and no
   other physician has been paid for CPO
   within that calendar month
The care plan oversight services must be
personally provided by the physician who bills
for the service
                                                 10
Requirements for CPO
Billing for CPO by surgeons must not be routine post-
operative care provided in a global surgical period
Payment will be allowed for care plan oversight to
physicians providing post surgical care during the post
operative period only if the care plan oversight is
documented to be unrelated to the surgery.
The physician must NOT have a significant financial or
contractual interest in the home health agency
The physician is not the medical director or employee of
the hospice, and does not provide services under an
arrangement with the hospice
                                                           11
Requirements for CPO
Services provided incident to office visits do not
count towards the 30 minute requirement
The physician must not bill CPO during the same
calendar month in which he/she bills ESRD benefit
for the same patient
The physician billing CPO must document in the
patient’s record which services were furnished,
the date and length of time associated with those
services (see sample log)

                                                     12
Sample CPO Log for Physician
            Patient’s Name ______________________ Agency Name___________________

            Physician Signature ________________________________________

                                                                                                                                         Sub-    Time
Date (mm/dd/yyyy)                                                                                                                        total
Development of Care        minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Revision to Care Plan      minutes   Minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Review of Pt. Records      minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Lab Reviews                minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Diag. Test Reviews         minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Comm w/Health Prof.        minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Integration of New Info-
Treatment Plan             minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Adjustment/Med Therapy     Minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


Other (define              minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes   minutes


                                                                                                                     Total Time
                                                                                                                                                 13
Requirements for CPO
Physician Documentation

 Documentation must be done by the
 physician and not by the HHA
 An agency’s provision of that service to a
 physician could be viewed as a kickback
 intended to induce referrals.
 Billing must be done by the physician’s
 office staff and not by the HHA. (see Filing
 a Claim)


                                                14
CPO and Nurse Practitioners

Under the provisions of the BBA, nurse practitioners,
physician assistants and clinical nurse specialists,
practicing within the scope of State law, can bill for
care plan oversight services.
These non-physician practitioners must have been
providing ongoing care for the patient through
evaluation and management services provided as
a physician service.
If these practitioners are seeing the patient only for
home health/hospice nursing visits, they may not bill
for CPO.

                                                         15
Countable Services
  The following services are countable
  toward the 30 minute minimum for care
  plan oversight
    Review of reports, orders, treatment plans,
    or lab or study results, except for the initial
    interpretation or review of lab or study
    results that were ordered during or
    associated with a face to face encounter.


                                                  16
Countable Services
 Telephone calls with other health care
 professionals involved in the care of the
 patient
 Physician development and/or revision of care
 plans
 Review of subsequent reports of patient
 status
 Team conferences (Time spent per individual
 patient must be documented)
                                            17
Countable Services
 Medical decision making:
       integration of new information into the
 medical treatment plan
       adjustment of medical therapy
 Activities to coordinate services are countable
 if the coordination activities require the skills
 of a physician
 Time spent working on a care plan after the
 nurse has conveyed pertinent information to
 the physician
                                                 18
Non-Countable Services
 Initial interpretation of lab or study
 results ordered during a face to face
 encounter
 Physicians telephone calls to patient,
 family or pharmacy, even to adjust
 medication or treatment.


                                          19
Non-Countable Services
 Travel time , time spent preparing
 claims or for claims processing
 Low intensity services included as part
 of other evaluation and management
 services




                                           20
Non-Countable Services

 Informal consults with health
 professionals not involved with the
 patient’s care
 Time spent discussing the patient
 with office staff




                                       21
Filing a Claim
All claims for CPO must contain the 6 digit
Medicare provider number for the HHA or
hospice rendering covered Medicare services
during the period in which the care planning was
furnished.
                 FORM 1500
Item 23: Prior authorization number –
HHA 6-digit Medicare provider number
Item 32: Facility where services were furnished –
Physician’s office


                                                    22
Filing a Claim
 Dates of service entered on the
 claim form must be the first and last
 date during which documented care
 planning services were actually
 provided during the calendar month,
 not just the first and last days of the
 calendar month in which the claim is
 submitted
                                           23
Filing a Claim
Medical records for those dates must
document that 30 minutes or more of
time have been spent by physicians for
countable care planning activities as
well as which services were furnished
and the date and length of time
associated with those services

                                         24
Filing a Claim
 The physician must bill for no other
 services than CPO services on the
 claim,must bill care planning only once
 per calendar month, must bill only one
 month’s services per line item and must
 not submit the claim until after the end
 of the month in which the service is
 performed
                                        25
Filing a Claim
Beneficiary Liability
 CPO is a Medicare Part B benefit
 Medicare pays 80% of the fee schedule
 amount for physician services
  Beneficiary is responsible for 20%
 coinsurance --either through supplemental
 insurance or out-of-pocket

                                             26
How do I make it work
   for my Agency?
Be willing to invest the time to provide
the education to physician offices
  Start with your biggest referring physician
  Follow the physicians case load
  Compile notes and documentation from a
  sample of the physicians patient base



                                                27
How do I make it work for me?
 Prepare an Educational Packet
  Track documentation per physician
  Prepare spread sheet per physician
  Compile a sample month for that physician
  on a spreadsheet using his own patients
  and numbers
  Put together a presentation per physician
  that includes brief instruction, his patient’s
  documentation and his spread sheet
  showing the bottom line

                                               28
It will work!

 Sell the idea to the physicians
   Make an appointment to talk directly to the
   physician and/or billing staff
   Present him with a brief overview of home
   care criteria
   Present him with the fact that he is able to
   bill for home care services and a very brief
   outline of how

                                             29
It will work!
   Use Physician’s own numbers in your favor
   Provide a sample log for the physician’s
   use in documenting time
   Offer to instruct staff in billing procedures
   Offer to send a current list of patients
   every month




                                               30
Reap the rewards

      Increased referrals


Add Up to




                      Increased profits
                         For YOU!!

                                          31

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CPO-Cert-Recert-Presentation

  • 1. Flip the Switch On Care Plan Oversight – Cert/Recert 1
  • 2. Goals and Objectives Understand The Concept of CPO Know the difference between CPO and Certification/Recertification Make the Information Physician Specific Sell The Idea to Physicians Reap The Rewards 2
  • 3. Understand The Concept of CPO, Certification/Recertification Physician PLUS Education EQUALS 3
  • 4. What Codes are Used? Effective January 1, 2001 HCPCS codes were added for physician services: G0180 – Certification HHA patient G0179 – Recertification HHA patient G0181 – Home Health Care Plan Oversight G0182 – Hospice Care Plan Oversight 4
  • 5. Understand The Difference Between CPO and Cert/Recert What is CPO What is Cert/Recert How does it work How does it work How to make it How to make it work for my work for my agency agency 5
  • 6. What is Certification? G0180 MD Certification of HHA patient Certification Billing Requirements Must be billed by the physician that signed the patient’s Plan of Care Used when a patient has not received Medicare covered home health services for at a least 60 days Copy of Certification 485 in patient’s chart is sufficient documentation to support physician billing Date of service: Date the physician signs the POC Billed on Form HCFA-1500 Locator 23: HHAs 6-digit Medicare provider number 6
  • 7. What is Recertification? G0179 MD Recertification of HHA patient Recertification Billing Requirements Must be billed by the physician that recertified the patient. Used after a patient has received Medicare covered home health services for at a least 60 days* Copy of Recertification 485 in patient’s chart is sufficient documentation to support physician billing Date of service: Date the physician signs the POC Billed on Form HCFA-1500 Locator 23: HHAs 6-digit Medicare provider number *The G0179 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. 7
  • 8. What is CPO? Care Plan Oversight (CPO) is physician supervision of patients under either the home health (G0181) or hospice (G0182) benefit the patient requires complex or multi- disciplinary care modalities requiring ongoing physician involvement. 8
  • 9. Requirements for CPO The beneficiary must be receiving Medicare covered home health services during the period in which care plan oversight services are furnished. The physician must have provided a covered physician service that required a face to face encounter with the beneficiary in the 6 months before the first billing for care plan oversight services. 9
  • 10. Requirements for CPO The beneficiary must require complex or multi- disciplinary care •The physician must furnish at least 30 minutes of supervision within the calendar month for which payment is claimed and no other physician has been paid for CPO within that calendar month The care plan oversight services must be personally provided by the physician who bills for the service 10
  • 11. Requirements for CPO Billing for CPO by surgeons must not be routine post- operative care provided in a global surgical period Payment will be allowed for care plan oversight to physicians providing post surgical care during the post operative period only if the care plan oversight is documented to be unrelated to the surgery. The physician must NOT have a significant financial or contractual interest in the home health agency The physician is not the medical director or employee of the hospice, and does not provide services under an arrangement with the hospice 11
  • 12. Requirements for CPO Services provided incident to office visits do not count towards the 30 minute requirement The physician must not bill CPO during the same calendar month in which he/she bills ESRD benefit for the same patient The physician billing CPO must document in the patient’s record which services were furnished, the date and length of time associated with those services (see sample log) 12
  • 13. Sample CPO Log for Physician Patient’s Name ______________________ Agency Name___________________ Physician Signature ________________________________________ Sub- Time Date (mm/dd/yyyy) total Development of Care minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Revision to Care Plan minutes Minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Review of Pt. Records minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Lab Reviews minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Diag. Test Reviews minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Comm w/Health Prof. minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Integration of New Info- Treatment Plan minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Adjustment/Med Therapy Minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Other (define minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes Total Time 13
  • 14. Requirements for CPO Physician Documentation Documentation must be done by the physician and not by the HHA An agency’s provision of that service to a physician could be viewed as a kickback intended to induce referrals. Billing must be done by the physician’s office staff and not by the HHA. (see Filing a Claim) 14
  • 15. CPO and Nurse Practitioners Under the provisions of the BBA, nurse practitioners, physician assistants and clinical nurse specialists, practicing within the scope of State law, can bill for care plan oversight services. These non-physician practitioners must have been providing ongoing care for the patient through evaluation and management services provided as a physician service. If these practitioners are seeing the patient only for home health/hospice nursing visits, they may not bill for CPO. 15
  • 16. Countable Services The following services are countable toward the 30 minute minimum for care plan oversight Review of reports, orders, treatment plans, or lab or study results, except for the initial interpretation or review of lab or study results that were ordered during or associated with a face to face encounter. 16
  • 17. Countable Services Telephone calls with other health care professionals involved in the care of the patient Physician development and/or revision of care plans Review of subsequent reports of patient status Team conferences (Time spent per individual patient must be documented) 17
  • 18. Countable Services Medical decision making: integration of new information into the medical treatment plan adjustment of medical therapy Activities to coordinate services are countable if the coordination activities require the skills of a physician Time spent working on a care plan after the nurse has conveyed pertinent information to the physician 18
  • 19. Non-Countable Services Initial interpretation of lab or study results ordered during a face to face encounter Physicians telephone calls to patient, family or pharmacy, even to adjust medication or treatment. 19
  • 20. Non-Countable Services Travel time , time spent preparing claims or for claims processing Low intensity services included as part of other evaluation and management services 20
  • 21. Non-Countable Services Informal consults with health professionals not involved with the patient’s care Time spent discussing the patient with office staff 21
  • 22. Filing a Claim All claims for CPO must contain the 6 digit Medicare provider number for the HHA or hospice rendering covered Medicare services during the period in which the care planning was furnished. FORM 1500 Item 23: Prior authorization number – HHA 6-digit Medicare provider number Item 32: Facility where services were furnished – Physician’s office 22
  • 23. Filing a Claim Dates of service entered on the claim form must be the first and last date during which documented care planning services were actually provided during the calendar month, not just the first and last days of the calendar month in which the claim is submitted 23
  • 24. Filing a Claim Medical records for those dates must document that 30 minutes or more of time have been spent by physicians for countable care planning activities as well as which services were furnished and the date and length of time associated with those services 24
  • 25. Filing a Claim The physician must bill for no other services than CPO services on the claim,must bill care planning only once per calendar month, must bill only one month’s services per line item and must not submit the claim until after the end of the month in which the service is performed 25
  • 26. Filing a Claim Beneficiary Liability CPO is a Medicare Part B benefit Medicare pays 80% of the fee schedule amount for physician services Beneficiary is responsible for 20% coinsurance --either through supplemental insurance or out-of-pocket 26
  • 27. How do I make it work for my Agency? Be willing to invest the time to provide the education to physician offices Start with your biggest referring physician Follow the physicians case load Compile notes and documentation from a sample of the physicians patient base 27
  • 28. How do I make it work for me? Prepare an Educational Packet Track documentation per physician Prepare spread sheet per physician Compile a sample month for that physician on a spreadsheet using his own patients and numbers Put together a presentation per physician that includes brief instruction, his patient’s documentation and his spread sheet showing the bottom line 28
  • 29. It will work! Sell the idea to the physicians Make an appointment to talk directly to the physician and/or billing staff Present him with a brief overview of home care criteria Present him with the fact that he is able to bill for home care services and a very brief outline of how 29
  • 30. It will work! Use Physician’s own numbers in your favor Provide a sample log for the physician’s use in documenting time Offer to instruct staff in billing procedures Offer to send a current list of patients every month 30
  • 31. Reap the rewards Increased referrals Add Up to Increased profits For YOU!! 31