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Physician and allowed practitioner certification and recertification of home health services
Last Modified: 4/13/2024
Location: FL, PR, USVI
Business: Part A, Part B
Physician or allowed practitioner services involving certification and recertification of Medicare-covered home health services may be separately coded and reimbursed. These services include creation and review of a plan of care, and verification that the home health agency initially complies with the practitioner's plan of care. The physician or allowed practitioner work in reviewing data collected in the home health agency (HHA) patient assessment would be included in these services.
This policy defines the coverage for physician or allowed practitioner services. For information regarding coverage of home health services, please refer to the HHA manual and to the appropriate HHA intermediary.
• G0179 - Physician or allowed practitioner re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per re-certification period
• G0180 - Physician or allowed practitioner certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient’s needs, per certification period
Note: G0179 and G0180 are not included in the global surgical package and therefore, are billable and separately payable when furnished during a global period.
Physician or allowed practitioner certification and recertification will be considered medically reasonable and necessary for a patient receiving Medicare-covered home health services requiring the development of a plan of care by the physician or allowed practitioner when the following conditions are met:
• A plan for furnishing the services has been established and periodically reviewed by a physician who is a Doctor of Medicine, osteopathy, or podiatric medicine, or allowed practitioner who is a nurse practitioner (NP), certified nurse specialist (CNS) or physician assistant (PA) and who is not precluded from performing this function.
• The physician or allowed practitioner services for initial certification of Medicare-covered home health services are billable once for a certification period. This may be billed when the patient has not received Medicare-covered home health services for at least 60 days
• Physician or allowed practitioner services for recertification of Medicare-covered home health services may be billed after a patient has received services for at least 60 days when the physician or allowed practitioner signs the certification after the initial certification period. This recertification 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.
• The physician or allowed practitioner billing for certification must be the provider supervising the patient’s care. Physicians or allowed practitioners in specialties other than those commonly providing primary or comprehensive medical care to patients under the care of home health agencies may be subject to review for medical necessity.
• A physician or allowed practitioner may perform other evaluation and management services during the same month for which he/she is billing the practitioner’s services for certification/recertification. However, time counted towards the services for certification/recertification should not be included in the work or time counted towards the pre, post, and intra-service work of the evaluation and management service.
• Discharge planning for a hospitalized patient is included in the evaluation and management (E&M) codes 99217, 99238 and 99239, and is not part of the physician or allowed practitioner certification.
• Effective for claims with dates of service on or after March 1, 2020, allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at § 484.2 as a physician assistant, nurse practitioner, or clinical nurse specialist. NPs, CNSs, and PAs are required to practice in accordance with state law in the state in which the individual performs such services. Individual states have varying requirements for conditions of practice, which determine whether a practitioner may work independently without a written collaborative agreement or supervision from a physician, or whether general or direct supervision and collaboration is required.
Physician or allowed practitioner services for certification/recertification are covered for reimbursement only when performed by physicians (MD, DO and DPM) or allowed practitioners (NP, CNS and PA) with respect to those functions which he/she is legally authorized to perform per State regulations.
These services are not covered when provided by other practitioners including, but not limited to:
• chiropractors
• dentists
• optometrists
• clinical psychologists
• clinical social workers
• physical therapists
• occupational therapists
• speech therapists
Claims for services will be denied if the
physician or allowed practitioner submitting the claim is not the provider signing the HHA plan of care.
Only one physician or allowed practitioner may bill for services for certification of Medicare-covered HHA services for a beneficiary, in a 60-day period. All other claims will be denied.
Recertification services reported in excess of one per 60 days when a new plan of care is not required (e.g., patient condition worsens requiring new care plan) will be denied.
Since HHA services are usually intermittent, continued physician or allowed practitioner services to recertify Medicare-covered HHA services occurring for multiple certification periods may be subject to review for medical necessity.
Physicians or allowed practitioners in specialties other than those commonly providing primary or comprehensive medical care to patients under the care of HHAs may be subject to review for medical necessity.
Discharge planning for a hospitalized patient is included in the E&M codes 99217, 99238 and 99239, and is not part of the physician or allowed practitioner certification.
• Bill using procedure codes G0179 or G0180.
• The place of service code should represent the place where the preponderance of the plan development and review was performed.
• Enter the provider number of the HHA from which the beneficiary is receiving Medicare-covered services in Item 23 of the CMS-1500 (02-12) form, or in the electronic equivalent.
• Enter the date of the certification or recertification as the date of service in Block 24A (or electronic equivalent) on the CMS-1500 (02-12) form.
• The date of service for the certification is the date the physician completes and signs the plan of care. The date of the recertification is the date the physician or allowed practitioner completes the review.
Note: Services submitted that aren’t billed using the requirements outlined above will be denied.
When reporting
physician or allowed practitioner certification for Medicare covered home health services, the medical record must clearly support that the following elements of the service have been met:
Contacts with the home health agency; and
Review of reports of patient status (required to affirm the initial implementation of the plan).
When reporting physician or allowed practitioner re-certification for Medicare covered home health services, the medical record must clearly support that the following elements of the service have been met, including the following:
• Contacts with the home health agency; and
• Review of subsequent reports of patient status.
Documentation supporting the development of a plan of care and or certification/recertification must be maintained by the physician or allowed practitioner and be included in the patient’s medical records. If the written plan was not prepared by the provider (i.e., it was prepared by the HHA), the medical record must document the physician or allowed practitioner’s contribution to the development of the plan, or document review of the specific items entered into the plan.
Since the certification and recertification of Medicare-covered home health services include either the creation of a new or review of an existing plan of care, the following elements should be evident in the medical record:
• Patient’s mental status
• Types of services, supplies, and equipment required
• 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
• Any additional items the HHA or physician chooses to include
It is not sufficient that the HHA maintain documentation in their records for the physician or allowed practitioner. The physician or allowed practitioner must do the following:
• Maintain his/her own records (including periodic summary reports provided by the home health agency).
• All face-to-face E&M visits and any phone communications with the patient or immediate caretakers must be present in the patient’s chart (must indicate an ongoing knowledge of any changes in the patient’s condition, drugs, or other needs, and how they are being met).
Documentation must be maintained by the physician or allowed practitioner certifying/recertifying the home health services and made available to the Medicare contractor upon request.
Providers have raised the following questions concerning care plan oversight services.
1. What physician or allowed practitioner activities are considered care plan oversight services for which separate payment is allowed?
Care plan oversight includes the following physician or allowed practitioner activities: development or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication 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. Care plan oversight does not include the routine pre-and post-service work associated with visits and procedures. Also, telephone calls with patients and/or their families are not included.
What documentation is required?
Physician or allowed practitioners claiming payment for care plan oversight services must document in their records the care plan oversight services they furnish, including the dates and exact duration of time spent on the services for which payment is claimed. Care plan oversight is recognized by Medicare as a practitioner service and must be provided and documented only by the responsible physician or allowed practitioner.
How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight services?
Since care plan oversight services do not typically involve a face-to-face encounter between the patient and the physician or allowed practitioner, the patient may not be aware that the services were provided. Practitioners can help by informing their patients that Medicare will pay for these services when the specified conditions are met. Beneficiaries will also be notified regarding allowed care plan oversight services in their Explanation of Your Medicare Part B Benefits messages.
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