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Care Plan Oversight (CPO)

Care Plan Oversight (CPO) is the physician supervision of patients receiving complex and multidisciplinary care as a part of Medicare-covered services provided by participating home health agency or Medicare approved hospice.

On this page, view the below information.

Modalities

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 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 care plan
  • Adjustment of medical therapy

Provider Eligibility

Under provisions of the Balanced Budget Act of 1997, providers listed below must be practicing within the scope of State law and may also bill for CPO.

  • Physician (MD/DO)
  • Nurse Practitioner (NP)
  • Physician Assistant (PA)
  • Clinical Nurse Specialist (CNS)

Requirements

Services are covered for home health (HH) and hospice patients, but are not covered for patients of Skilled Nursing Facilities (SNFs), nursing home facilities, or hospitals.

All the below requirements must be met for services to be covered.

  • Beneficiaries must require complex or multi-disciplinary care modalities requiring ongoing physician involvement in patient's plan of care
  • CPO services should be furnished during period in which beneficiary was receiving Medicare covered HH or hospice services
  • Physicians who bill CPO must be same physician who signed HH or hospice plan of care
  • Physician furnished at least 30 minutes of CPO within calendar month for which payment is claimed
    • Time spent by a physician's nurse or time spent consulting with one's nurse is not countable toward 30-minute threshold
    • Low-intensity services included as part of other evaluation and management (E/M) services are not included as part of 30 minutes required for coverage
  • Work included in hospital discharge day management (CPTs 99238-99239) and discharge from observation (CPT 99217) is not countable toward 30 minutes per month required for work on same day as discharge but only for those services separately documented as occurring after patient is physically being discharged from hospital
  • Physicians provided a covered physician service that required a face-to-face encounter with beneficiary within 6 months immediately preceding first care plan oversight service
    • Only E/M services are acceptable prerequisite face-to-face encounters for CPO
    • EKG, lab, and surgical services are not sufficient face-to-face services for CPO
  • CPO billed by physician is not routine post-operative care provided in global surgical period of a surgical procedure billed by physician
  • If beneficiary is receiving Home Health Agency (HHA) services, physician does not have a significant financial or contractual interest in HHA
    • A physician who is an employee of a hospice, including a volunteer medical director, should not bill CPO services
    • Payments for services of a physician employed by hospice is included in payment to hospice
  • Physicians who bills CPO services is physician who furnished them
  • Services provided incident to a physician's service do not qualify as CPO and do not count toward 30-minute requirement
  • Physician is not billing for Medicare End Stage Renal Disease (ESRD) capitation payment for same beneficiary during same month
  • Physician billing for CPO must document in patient's record services furnished
  • Place of service (POS) code must represent place where majority of oversight work is performed. Appropriate POS codes are limited to:
    • 11 (office)
    • 12 (home)
    • 49 (independent clinic)
    • 71 (state/local public health clinic)
  • Implicit in concept of CPO is expectation that physician has coordinated an aspect of patient's care with HHA or hospice during month for which CPO services are billed

Countable/Non-countable Services

Services countable towards the 30 minutes' threshold that must be provided to bill for CPO include, but are limited to:

  • Review - Treatment plans, charts, patient status reports
  • Phone call with other physicians - Not employed same practice
  • Pharmacy phone/face-to-face discussions - Pharmaceutical therapies
  • Medical decision making - Wound care protocol; medication
  • Coordinate Services - If activities require physician skills
  • Additional time reviewing/signing previous order in a previous month - Beneficiary must have been under HH/Hospice

Services not countable towards the 30 minutes' threshold that must be provided to bill for CPO are:

  • Time associated with discussions with patient, his or her family or friends to adjust medication or treatment
  • Time spent by staff getting or filing charts
  • Time travel
  • Physician's time spent telephoning conversation involves discussion of pharmaceutical therapies
  • Services included in E/M
  • Signing previous orders without reviewing order prior
  • Informal consults with uninvolved physicians
  • Discussions with his/her nurse or any nurse phone calls with HHA or hospice
  • Hospital discharge (CPTs 99238 – 99239) or observation discharge (CPT 99217) work not counted

Billing

There are two HCPCS codes for certification, recertification and development of plans of care for Medicare-covered home health.

Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.

HCPC Code

Description

Appropriate Use

G0179

MD Re-certification HHA Patient

Use for re-certification after a patient has received services for at least 60 days (or one certification period). It may be reported only once every 60 days, except in rare situation when patient starts a new episode before 60 days' elapses and requires a new plan of care to start a new episode

G0180

MD Certification HHA Patient

Use when patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS G0180) cannot be filed on same date of service as supervision service (HCPCS G0181 or G0182)

 

Medicare will reimburse for only two CPO Hospice and Home Health Services.

HCPC Code

Description

Appropriate Use

G0181

Home Health Care Supervision

Use for physician supervision of patient receiving Medicare-covered services provided by participating HHA (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans

G0182

Hospice Care Supervision

Use for physician supervision of patient under Medicare-approved Hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans

 

Claim Submission

  • Submit CPTs 99201-99263 and 99281-99357 only when there has been a face-to-face meeting/encounter  
  • HHA / Hospice Provider Number: The requirement to include HHA or Hospice provider number on a care plan oversight claim for HCPCS G0181 and G0182 is waived until further notice, and thus, claims submitted with number will be rejected
  • Dates of Service (DOS): For HCPCS G0181 and G0182, submit first and last date during which documented care planning services were provided during calendar month
    • Do not submit first and last calendar date of month unless services were provided on those dates
    • Submit claim after end of month in which service is performed
    • Report care planning only once per calendar month
    • Report only one month's services per line item
  • DOS: For HCPCS G0179 and G0180, submit date physician signed certification or re-certification

Documentation

  • Claims for CPO services will be denied when review of beneficiary claims history fails to identify a covered physician service requiring a face-to-face encounter by same physician during six months preceding provision of first CPO service
  • Medical records for these services must indicate:
    • Physician spent 30 minutes or more for countable care planning activities
    • Specific service furnished, including date and length of time
    • Support need for ongoing complex medical management
    • Integration of new information
    • Adjustments to therapy 
    • Submit records, if requested
    • Include reports, if referenced
    • Reasonable and necessary CPO service
      • "Physician reviewed report" without actual report would not meet documentation needs
  • Not allowed
    • Practice not meeting Medicare guidelines
    • Documentation provided by HH/Hospice
    • Standardized Activity Summaries

Resources

Last Updated Aug 24, 2017