Home Health and Hospice

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.

Access the below information from this page.

Home Health

Care Plan Oversight (CPO)

Home Health

Certification

The Affordable Care Act requires that the certifying physician or allowed NPP must have a face-to-face encounter with the beneficiary before they certify the beneficiary's eligibility for the home health benefit. The face-to-face encounter must occur within 90 days before care begins or up to 30 days after care began. The certifying physician is required to certify that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility.

Medicare Part A and/or Part B and section 1814(a)(2)(C) and section 1835(a)(2)(A) state that when the physician refers a patient to HH, the patient must:

  • Be confined to home
  • Need skilled services
  • Be under physician care
  • Receive services under plan of care (POC) established and reviewed by a physician
  • Have had a FTF encounter for his/her current diagnosis with a physician or allowed non-physician practitioner (NPP)

Certifying physician must be enrolled in the Medicare Program and be a Doctor of Medicine (MD), a Doctor of Osteopathy (DO); or a Doctor of Podiatric Medicine (DPM). Certifying physician cannot have financial relationship with HHA unless it meets one of exceptions in 42 CFR 411.355-42 CFR 411.357

Certifying physician must attest:

  • Patient is homebound as defined by CMS
  • Patient needs intermittent SN care, PT and/or SLP services
  • Plan of care has been established and will be periodically reviewed by a physician
  • Services will be furnished while individual was or is under physician care
  • Face-to-face encounter occurred and date

The six home health disciplines included in the 60-day episode rate are:

  1. Skilled Nurse on an intermittent/part-time basis
  2. Home Health aides on an intermittent/part-time basis
  3. Physical Therapy
  4. Occupational Therapy
  5. Speech Language Pathology
  6. Social Work

Homebound Status

An individual shall be considered "confined to the home" (homebound) if both criteria is met.

Criteria One Criteria Two
One Standard Must Be Met
  • Because of Illness or injury, need aid of supportive devices such as crutches, canes, wheelchairs and walkers; use of special transportation; or assistance of another person to leave their place of residence
OR
  • Have a condition such that leaving his/her home is medically contraindicated
Both Standards Must Be Met
  1. There must exist a normal inability to leave home
  2. Leaving home must require a considerable and taxing effort

 

Longitudinal clinical information about the patient's health status is typically needed to sufficiently demonstrate a normal inability to leave the home and that leaving home requires a considerable and taxing effort.

  • Patient's diagnosis
  • Duration of the patient's condition
  • Clinical course (worsening or improvement)
  • Prognosis
  • Nature and extent of functional limitations
  • Other therapeutic interventions and results, etc.

Recertification

  • Recertification is required at least every 60 days
  • Medicare does not limit number of continuous episode recertifications for patients who continue to be eligible for HH benefit
  • Physician recertifying patient's eligibility is physician that has been monitoring POC and providing oversight of HH services

Documentation

Examples of documentation to share at the point of referral

  • Order for HH services identifying physician that will be monitoring POC with HHA
  • Documentation (anywhere in medical record) supporting need for skilled service and homebound status
  • FTF Encounter Documentation - Example: Discharge summary or interoffice progress note documenting one-on-one physician/NPP visit

Care Plan Oversight

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

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 same practice who are involved in patient's care
  • Integration of new information into 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.
  • 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.

HCPCS 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.

HCPCS 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

  • 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

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Last Updated Aug 09, 2019

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.