Care Plan Oversight Services

Care Plan Oversight (CPO) refers to a physician or allowed nonphysician practitioner's (NPP’s) supervision of patients under care of home health agencies or hospices who require complex or multidisciplinary care modalities. Nurse practitioners, physician assistants and clinical nurse specialists practicing within the scope of state law may bill for care plan oversight.

Note: Such services are not covered for patients of skilled nursing facilities (SNFs), nursing home facilities or hospitals.

CPO services require complex or multidisciplinary care modalities involving:

• Regular physician or allowed NPP 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

The CPO services require recurrent physician or allowed NPP supervision of a patient involving 30 or more minutes of the physician or NPP’s time per month. Services not countable toward the 30 minute 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 or NPP’s time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies

Implicit in the concept of CPO is the expectation that the physician or NPP 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. The practitioner who bills for CPO must be the same practitioner who signs the plan of care.

Home Health CPO
NPPs who are not the certifying practitioner can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:

• The physician and NPP are part of the same group practice; or
• If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or
• If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice

Billing may be made for care plan oversight services furnished by an NPP when:

• The NPP providing the care plan oversight has seen and examined the patient;
• The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and
• The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care

Hospice CPO
The attending physician or nurse practitioner (who has been designated as the attending physician) may bill for hospice CPO when they are acting as an attending physician. An attending physician is one who has been identified by the individual, at the time he or she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. They are neither employed nor paid by the hospice. The care plan oversight services are billed using Form CMS-1500 or electronic equivalent.

HCPCS Codes and Billing

• G0179: M.D. recertification Home Health Agency (HHA) PT
• G0180: M.D. certification HHA patient
• G0181: Home health care supervision
• G0182: Hospice care supervision

How to Submit a Claim

• Providers billing 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
• Do not bill CPO services across calendar months and should be submitted (and paid) only for one unit of service
• Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met
• Submit CPT® codes 99202–99263 and 99281–99357 only when there has been a face-to-face meeting/encounter
• HHA / Hospice Provider Number: The requirement to include the HHA or Hospice provider number on a care plan oversight claim for HCPCS codes G0181 and G0182 is waived until further notice and, as a result, claims submitted with the number will be rejected
• Dates of service: For HCPCS codes G0181 and G0182, submit the first and last dates during which documented care planning services were actually provided during the calendar month
  • Do not submit the first and last calendar dates 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 care planning only once per calendar month
  • Report only one month's services per line item
• Dates of service: For HCPCS codes G0179 and G0180, submit the date physician signed the certification or recertification
• The home health agency certification code can be billed only when the patient has not received Medicare covered home health services for at least 60 days
• The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period
• The home health agency recertification code will 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
• 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
• 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 filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).

Documentation

• Claims for care plan oversight services will be denied when review of the beneficiary’s claim history fails to identify a 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 services must indicate:
  • The physician spent 30 minutes or more for countable care planning activities
  • The specific service furnished, including the date and length of time

References

• CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 30, Sub-section G (PDF)
• CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 12 (PDF), Section 180 (PDF)