Monday, January 12, 2015

CPT (G0180 and G0179) - Documentation Requirements

Procedure code and Description

G0180 Initial Certification (no services in past 60 days)

G0179 Re-certification (every 60 days)

Face-to-Face Encounters and Certification for Home Health Care and Physician Documentation Requirements (G0180 and G0179

Physician play a key role in documenting eligibility and medical necessity for home health care for Medicare beneficiaries. If you certify the need for home health care for any of your patients, we encourage you to review this article carefully. As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face (FTF) encounters with your patients regarding home health care and certification of need. Medicare provides payment for physician initial and re-certification of Medicare-covered home health services under a home health plan of care (G0180 and G0179).


L&I allows attending providers to charge for E/M services in:

• Nursing facilities,
• Domiciliary, boarding home or custodial care settings and
• The home

The attending provider (not staff) must perform these services. The medical record must document the medical necessity as well as the level of service.

Background: Qualifying Criteria for the Medicare Home Health Benefit

To qualify for the Medicare home health benefit, under section 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act, Medicare beneficiaries must meet all of the following requirements:

•    Be confined to the home;
•    Under the care of a physician;
•    Receiving services under a plan of care established and periodically reviewed by a physician;
•    Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
•    Have a continuing need for occupational therapy.

The Centers for Medicare & Medicaid Services (CMS) further defines “intermittent,” for purposes of this benefit, as “skilled nursing or home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and fewer than 35 hours per week).” CMS also defines home confinement; we strongly encourage you to review the definition of home confinement in its entirety in the CMS Medicare Benefit Policy Manual (the web address to access this manual is provided at the end of this letter).

Major Documentation Errors

Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a nationwide, significant, and continuing increase in denials related to documentation for the FTF.  The most common error is insufficient documentation of clinical findings by the physician/non-physician practitioner (NPP) to show:

•    The encounter was related to the primary reason for home care
•    How the patient’s condition supports the patient’s homebound status; or
•    How the patient’s condition supports the need for skilled services

Acceptable FTF documentation does not have to be lengthy or overly detailed.  However, the FTF documentation must show the reason skilled service is necessary for the treatment of the patient’s illness or injury, based on the physician’s clinical findings during the face-to-face encounter, and specific statements regarding why the patient is homebound.

Following are examples of FTF documentation that, used alone, are considered insufficient documentation.

Homebound StatusNeed for Skilled Services
“Functional decline”“Family is asking for help”
“Dementia” or “confusion”“Continues to have problems”
“Difficult to travel to doctor’s office”List of tasks for nurse to do
“Unable to leave home”/ “Unable to drive“Patient unable to do wound care”
“Status post total hip”

Examples of appropriate documentation include:

•    “Wound care to left great toe. No s/s of infection, but patient remains at risk due to diabetic status.  Skilled nurse visits to perform wound care and assess wound status.  Patient on bed to chair activities only.”

•    “Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema.  Short of breath with talking and ambulation of 1-2 feet.  Nurse to assess respiratory status for s/s of recurring infection/ changes in respiratory status.”

•    “CHF, CLL, weakness, 3+ edema in R & L legs; needs cardiac assessment, monitoring of signs & symptoms of disease, and patient education; homebound due to shortness of breath with minimal exertion, e.g., walking 5 feet.”

•    “Status post right total hip replacement. Needs physical therapy to restore ability to walk without assistance. Homebound temporarily due to requiring a walker, inability to negotiate uneven surfaces and stairs, inability to walk greater than 5 - 10 feet before needing to rest. ”

In all cases, your documentation must be specific to that patient’s condition at the time of your encounter with him or her.

Who May Document the FTF Encounter?

The FTF encounter must be performed by the certifying physician, a physician who cared for the patient in an acute or post-acute facility during a recent acute or post-acute stay and has privileges at the facility, or a qualified nonphysician practitioner (NPP) working in conjunction with the certifying physician.  An NPP in an acute or post-acute facility is able to perform the FTF encounter in collaboration with or under the supervision of the physician who has privileges and cared for the patient in the acute or post-acute facility.  That NPP can then report the FTF encounter to the certifying physician.

Medicare guidelines also contain specific documentation requirements:

The certifying physician must document that the FTF visit took place, regardless of who performed the encounter.

If the FTF encounter was not performed by the certifying physician, the NPP or physician who cared for the patient and performed the FTF must provide the face-to-face record of the FTF encounter to the certifying physician.  NPPs performing the FTF encounter in an acute/post-acute facility must inform the physician they are collaborating with, or under the supervision of, so that the physician can inform the certifying physician of the clinical findings of the FTF.

The certifying physician cannot merely co-sign the encounter documentation if performed by an NPP.  He or she must complete/sign the form or a staff member from his or her office may complete the form from the physician’s encounter notes, which the certifying physician would then sign.
The FTF encounter documentation must be clearly titled, dated, and signed by the certifying physician before the home health agency submits a claim to Medicare and must include:
The date of the FTF encounter, and Clinical findings to support that the encounter is related to the primary reason for home care, the patient is homebound, and in need of Medicare covered home health services.

Finally, because the FTF encounter is a requirement for payment, when the FTF encounter requirements as outlined above are not met, the home health agency’s entire claim is denied.  For cases in which the beneficiary’s condition otherwise warrants Medicare coverage of skilled home health services, but FTF encounter documentation is insufficient, the beneficiary’s ability to receive this skilled care may be jeopardized.

Home health agencies may ask you to provide supporting documentation from your medical records to ensure that Medicare will cover home health services. You are permitted, and strongly encouraged, to provide this documentation, the disclosure of which is permitted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). No specific authorization is required from your patients in order to do this. Also, please note that you may not charge the home health agency for providing this information. We ask you to work in partnership with these agencies so they can provide appropriate and medically necessary care for your homebound patients.

Medicare Guidelines

There is a difference in the percentage split of initial and final payments for initial and subsequent episodes for patients in continuous care. For all initial episodes, the percentage split for the two payments is 60 percent in response to the RAP and 40 percent in response  to the claim. For all subsequent episodes in periods of continuous care, each of the two percentage payments is 50 percent of the estimated case-mix adjusted episode payment. The case-mix and wage-adjusted national 60-day episode payment is adjusted for case-mix based on the patient’s condition and care needs or case-mix assignment. The payment is also adjusted to account for area wage differences.

What codes should I use on physician claims when certifying/recertifying eligibility for home health services? Use these HCPCS codes on physician claims when certifying/recertifying eligibility for home health services:

• HCPCS code G0180 – Physician certification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)

• HCPCS code G0179 – Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)

If a HHA claim is not covered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support the patient’s eligibility for the Medicare home health benefit, a physician’s claim for certification/recertification of eligibility for home health services (HCPCS codes G0180 and G0179, respectively) is also not considered a Medicare-covered home health service.

Code Type Description G0180 Certification (Physician Only)Used when the patient has not received Medicare-covered home health care for at least 60 days.

* Ordering the plan of care
* Signing the 485 (Plan of Care)
* Documenting the face-to-face encounter

G0179 Recertification (Physician Only)

Used when patients have received Medicare-covered home health services over the past 60 days. Billing for recertification should be reported only once every 60 days, unless the patient starts a new episode before 60 days have elapsed and requires a new plan of care to start a new episode.  G0181 Care PlanSupervision (Physician or other NPP) Used to document care plan supervision totaling 30 minutes or more during a calendar month. (Cannot be filed on same date as G0180)

What Qualifies as Care Plan Supervision?

* Review of charts, reports, treatment plans, lab and other  test results outside initial patient review * Telephone calls to other health care professionals involved in care of patient (not in office) * Telephone call/discussions with pharmacist about medication therapies * Medical decision making * Activities to coordinate services requiring the skills of a physician * Team conferences * Documenting services provided (includes time to write a note about service provided, decision making performed, time spent on countable services) * Time spent on activities undertaken on day of hospital discharge separately documented as occurring after physical discharge from hospital

What does not Qualify as Care Plan Supervision*?

Office staff time spent getting/filing charts, calling Home Health Agencies or patients/families * Physician time spent to call in prescriptions to pharmacy * Physician time getting/filing chart, dialing phone, or on hold waiting * Travel time * Time spent preparing/processing claims * Initial time spent reviewing results of tests ordered during face-to-face encounter * Informal consultations with health professionals not involved in the patient’s care * Time spent on day of hospital discharge to manage the discharge plan

To qualify for CPO payments, the patient must:

* Be receiving Medicare covered home health services during the period in which the care plan oversight servicesare furnished.

* Require complex or multi-disciplinary care modalities requiring ongoing physician involvement in the patient's plan of care.

To receive CPO payments, the physician must:

* Be the same physician who signed the home health or hospice plan of care.

* Furnish at least 30 minutes of care plan oversight within the calendar month for which payment is claimed and no other physician has been paid for care plan oversight within that calendar month.

* Have provided a covered physician service that required a face-to-face encounter with the beneficiary within the 6 months immediately preceding the provision of the first care plan oversight service.

* Not bill CPO during the same calendar month in which he/she bills ESRD benefit for the same beneficiary. Non-Physician Practitioners and Care Plan Supervision Services Nurse Practitioners (NPs) and Physician Assistants (PAs) may provide care plan supervision (G0181) services if they:

* Are part of the same group practice as the physician who signed the plan of care * If an NP, they must have a collaborative agreement with the physician who signed the plan of care * If a PA, the physician who signed the plan of care must also provide general supervision over the PA.

* Are providing on-going care for the beneficiary through evaluation and management services * Provide 30+ minutes of services; the 30+ minutes cannot be divided between multiple people * Have their own Medicare billing number

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