'Care Plan Oversight' can earn physicians thousands per month. Provide the following guidance to physicians to enhance your referral-building relationships.
adapted from the Medicare Learning Series: Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.
Applicable Billing Codes
- G0179 - physician re-certification - may be submitted per certification period
- G0180 - physician certification - may be submitted per certification period
- G0181 - home health care supervision - requires 30 minutes or more of physician (or nurse practioner's) time within a calendar month
- G0182 - hospice care supervision - Requires 30 minutes or more of physician (or nurse practioner's) time within a calendar month
Criteria for Coverage
The Centers for Medicare & Medicaid Services (CMS) Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 180.G lists criteria for coverage of CPO under Medicare:
- CPO services are furnished during the period in which the beneficiary was receiving Medicare-covered home health agency (HHA) or hospice services.
- The physician who submits the claim for CPO must be the same physician that signed the home health or hospice plan of care.
- The physician furnished at least 30 minutes of CPO within the calendar month. Time counted toward CPO may not include time spent by a nurse or time spent consulting with a nurse.
- Time counted toward hospital discharge management (CPT codes 99238-99239) or discharge from observation (CPT code 99217) may not also be counted toward CPO. Services that are separately documented and that are provided after the patient is physically discharged may be counted toward CPO.
- The physician provided a covered service that required a face-to-face encounter (i.e., Evaluation & Management (E/M) service) with the beneficiary within the 6 months immediately preceding the CPO service. EKG, lab, and surgical services do not meet this face-to-face encounter requirement.
- The CPO service may not be routine post-operative care provided during the global surgery period by the surgeon.
- For home health CPO, the physician may not have a "significant financial or contractual interest in the home health agency." For hospice CPO, the physician may not be employed by or volunteer as medical director of the hospice.
- CPO services must be submitted by the same physician that provided the services.
- Services provided "incident to" a physician's service may not be counted toward the 30-minute requirement for CPO.
- The same physician may not submit a claim for both CPO and end stage renal disease (ESRD) capitation payment for the same beneficiary during the same month.
- The physician must document, in the patient's medical record, the services furnished to the patient and date and length of time associated with these services.
CPO: Home Health
Medicare pays separately for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services when certain criteria are met.
- Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be submitted for the same date of service as the supervision service HCPCS code (G0181).
- Submit HCPCS code G0179 for re-certification after a patient has received services for at least 60 days (or one certification period).
- HCPCS code G0179 may 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.
- Special notes regarding certification and re-certification of home health care:
- Physicians play a key role in determining and documenting the medical necessity for home health care for Medicare beneficiaries. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
- For more information about required documentation for home health certification and re-certification, please refer to the CGS web article "Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)."
Submit HCPCS code G0182 for CPO services provided to patients that have elected hospice benefits under Medicare and who are in a Medicare-approved hospice.
- The patient does not have to be present in order for CPO services to be provided and claims submitted to Medicare.
- The HHA or Hospice Provider Number is required on claims for CPO (HCPCS codes G0181 and G0182).
- Electronic claims: submit the HHA's or hospice's NPI, as appropriate, in loop 2300, ref segment, with qualifier 1J.
- Paper claims: submit the HHA's or hospice's NPI, as appropriate, in Item 23.
- Claims for care plan oversight services will be denied when review of the beneficiary's claims history shows that there was no covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service.
- Medical records for these service must indicate:
- For HCPCS codes G0181 and G0182, the physician spent 30 minutes or more for countable care planning activities
- The specific service furnished, including the date and length of time
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 30, sub-section GExternal PDF
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 180External PDF
- CGS Web article "Face to Face Documentation for Home Health Certification: Important Information for Certifying Physicians and Non-physician Practitioners (NPPs)"