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Physician care plan oversight services
Last Modified: 4/13/2024
Location: FL, PR, USVI
Business: Part B
Care plan oversight (CPO) is supervision of patients under care of home health agencies or hospices that require complex and 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, and/or adjustment of medical therapy.
• G0181 Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and 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 (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more.
• G0182 Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and 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 (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more.
• Regular physician development and/or revision of care plans;
• Review of subsequent reports of patient status;
• Review of related 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 medical treatment plan, and/or
• Adjustment of medical therapy.
Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:
• Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;
• Time spent by staff getting or filing charts;
• Travel time; and/or
• Physician’s time spent telephoning prescriptions in to the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.
These services are covered only if all the following requirements are met:
• Beneficiary must require complex or multi-disciplinary care modalities requiring ongoing physician involvement in the patient’s plan of care;
• CPO services should be furnished during the period in which the beneficiary was receiving Medicare covered home health agency (HHA) or hospice services;
• Physician who bills CPO must be the same physician who developed and signed the home health or hospice plan of care;
• Physician furnished at least 30 minutes of care plan oversight within the calendar month for which payment is claimed. Time spent by a physician’s nurse or the time spent consulting with one’s nurse is not countable toward the 30-minute threshold. Low-intensity services included as part of other evaluation and management services are not included as part of the 30 minutes required for coverage;
• Work included in hospital discharge day management (codes 99238-99239) and discharge from observation (code 99217) is not countable toward the 30 minutes per month required for work on the same day as discharge but only for those services separately documented as occurring after the patient is actually physically discharged from the hospital;
• Physician provided a covered physician service that required a face-to-face encounter with the beneficiary within the six months immediately preceding the first care plan oversight service. Only evaluation and management 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 the physician was not routine post-operative care provided in the global surgical period of a surgical procedure billed by the physician;
• If the beneficiary is receiving home health agency services, the physician did not have a significant financial or contractual interest in the home health agency. A physician who is an employee of a hospice, including a volunteer medical director, should not bill CPO services. Payment for the services of a physician employed by the hospice is included in the payment to the hospice;
• Physician who bills the care plan oversight services is the physician who furnished them;
• Services provided incident to a physician’s service do not qualify as CPO and do not count toward the 30-minute requirement;
• Physician is not billing for the Medicare end stage renal disease capitation payment for the same beneficiary during the same month; and
• Physician billing for CPO must document in the patient’s record the services furnished and the date and length of time associated with those services.
• Place of service code should represent the place where the preponderance of the oversight work was performed. Appropriate place of service codes are limited to:
• 11 (office)
• 12 (home)
• 49 (independent clinic)
• 71 (state/local public health clinic)
• Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient’s care with the home health agency or hospice during the month for which CPO services were billed.
CPO services are covered for home health and hospice patients, but are not covered for patients of skilled nursing facilities, nursing home facilities, or hospitals.
Communication with nonprofessionals is part of the pre/post service work of other evaluation and management services and is not attributable to CPO.
Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must be providing ongoing care for the beneficiary through evaluation and management services (but not if they are involved only in the delivery of the Medicare covered home health or hospice service).
Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered.
CPO services may not be billed across calendar months and should be submitted (and paid) only for one unit of service.
There must be at least 30 or more minutes in one calendar month to be able to report CPO services.
The plan of care must contain all pertinent diagnoses, including:
• The patient’s mental status;
• The types of services, supplies, and equipment required;
• The frequency of the visits to be made;
• Prognosis;
• Rehabilitation potential;
• Functional limitations;
• Activities permitted;
• Nutritional requirements;
• All medications and treatments;
• Safety measures to protect against injury;
• Instructions for timely discharge or referral; and
• Any additional items the HHA or physician chooses to include.
The orders on the plan of care must indicate the type of services to be provided to the patient, both with respect to the professional who will provide them and the nature of the individual services, as well as the frequency of the services.
When reporting physician supervision of a patient receiving Medicare covered services provided by a participating home health agency, the medical record must clearly support that the following elements of the service have been met:
• Complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans are reasonable and necessary; and
• Review of subsequent reports of patient status (when performed); and
• Review of laboratory and other studies; and
• Communication (including telephone calls) with other health care providers involved in the patient’s care (when performed); and
• Integration of new information into the medical treatment plan and/or adjustment of medical therapy.
Care plan oversight codes are time based with very specific activities that may be counted towards the 30-minute minimum per calendar month. It is imperative that the medical record documentation documents the accurate date, the total time and clearly reflects the services provided to the patient as part of the CPO activity.
The medical record documentation must provide accurate, detailed information specific to the services that were performed and counted towards the 30 minutes of CPO services. Therefore, the medical record must adequately demonstrate that all of the requirements for billing CPO were met (e.g., duration of applicable telephone calls, time spent reviewing charts, time spent involved in team conferences).
Medical record documentation supplied by the health agency or hospice facility may not be substituted in lieu of the physician’s documentation.
The medical record must support that the physician provided a covered face-to-face encounter (evaluation and management service) with the patient within six months immediately preceding the first care plan oversight service.
The documentation must support that the physician who bills the care plan oversight service was the physician who provided the service.
All medical record documentation must be maintained by the physician supervising a patient receiving Medicare covered services provided by a participating home health agency and must be made available to the Medicare contractor upon request.
When billing for G0181 or G0182, enter the following on the Medicare claim form:
• National Provider Identifier of the HHA or hospice providing Medicare covered services to the beneficiary for the period during which CPO services were furnished and for which the physician signed the plan of care.
• Report the facility ID number in item 23 of the 1500 (02-12) claim form or l
oop 2300 REF 01 (1J), and the CPO number (HHA or hospice) in segment REF02 (Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers).
• Submit the first and last date during which documented care planning services were actually provided during the calendar month (Do not submit the first and last calendar date of the month unless services were provided on those dates).
• Submit the claim after the end of the month in which the service is performed.
• Report one unit of service.
• Report care planning only once per calendar month.
• Report only one month of services per line item
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