Care Plan Oversight. Home Health Certification. July 23, Agenda

Transcription

1 Care Plan Oversight Hme Health Certificatin July 23, 2014 Agenda Care Plan Oversight Why We Are Prviding the Educatin Prcedure cdes Descriptin f Services Wh Can Perfrm Frequency f Services Face-t-Face Encunter Requirements Date f Service Claim Submissin Financial r Cntractual Obligatin Mdifiers Hme Health Certificatin and Recertificatin Why We Are Prviding the Educatin Prcedure Cdes Descriptin f Services Wh Can Perfrm Frequency f Services Face-t-Face Encunter Requirements Date f Service Claim Submissin Financial r Cntractual Obligatin Mdifiers 08/13/

2 Care Plan Oversight (CPO) Why we are prviding this specific educatin Dcumentatin t supprt the physician services can be imprved. There are specific claim submissin guidelines. Prcedure cdes G0181 Physician supervisin f a patient receiving Medicare-cvered services prvided by a participating hme health agency (patient nt present) requiring cmplex and multidisciplinary care mdalities invlving regular physician develpment and/r revisin f care plans, review f subsequent reprts f patient status, review f labratry and ther studies, cmmunicatin (including telephne calls) with ther health care prfessinals invlved in the patient s care, integratin f new infrmatin int the medical treatment plan and/r adjustment f medical therapy, within a calendar mnth, 30 minutes r mre. G0182 Physician supervisin f a patient under a Medicare-apprved hspice (patient nt present) requiring cmplex and multidisciplinary care mdalities invlving regular physician develpment and/r revisin f care plans, review f subsequent reprts f patient status, review f labratry and ther studies, cmmunicatin (including telephne calls) with ther health care prfessinals invlved in the patient s care, integratin f new infrmatin int the medical treatment plan and/r adjustment f medical therapy, within a calendar mnth, 30 minutes r mre. Descriptins f CPO Service Supervisin f patient receiving Medicare cvered cmplex r multi-disciplinary care prvided by a hme health agency (HHA) r hspice. The physician has nging invlvement in the patient s plan f care. These services are nt available fr patients in a skilled nursing facility, nursing facility, r hspital. Physician s dcumentatin shws he/she has crdinated an aspect f the patient s care fr the mnth billed. The practitiner billing fr CPO has dcumentatin f their invlvement in the patient s care. Services included in the CPO Regular physician develpment and/r revisin f care plans; Review f subsequent reprts f patient status; Review f related labratry and ther studies; Cmmunicatin with ther health prfessinals nt emplyed in the same practice wh are invlved in the patient s care; 08/13/

3 Integratin f new infrmatin int the medical treatment plan; and/r Adjustment f medical therapy. CPO requires 30 minutes r mre f the physician s time per mnth. Less than 30 minutes is nt separately billable t Medicare. The practitiner must dcument in the patient s medical recrd the date(s) and length f time assciated with the services. There are services prvided that are nt cunted tward the 30 minute threshld. Time assciated with discussins with the patient, his/her family r friends t adjust medicatin r treatment; Time spent by staff in getting r filing charts; Travel time; and/r Physician time spent in telephning prescriptins int the pharmacist unless the telephne cnversatin invlves discussin f pharmaceutical therapies. Time spent by nursing staff r in cnversatins with nursing staff. Lw intensity services as part f additinal evaluatin and management services. Time spent in prviding discharge management services fr a hspital r bservatin unit. CPO services ccur after patient is physically discharged frm the facility. Implicit is the expectatin that the physician has crdinated as aspect f the patient s care fr the mnth. Wh can perfrm Nurse practitiners, physician assistants, nurse midwives, and clinical nurse specialists, practicing within the scpe f State law, can prvide and bill fr CPO. The Nnphysician practitiner (NPP) must have been prviding nging care fr the patient thrugh evaluatin and management services. Physicians wh are respnsible fr the care f the patient during the receipt f hme health r hspice service and wh have prvided previus care fr the patient prir t beginning hme health r hspice. The physician signing the hme health r hspice plan f care. Hme Health CPO A NPP can prvide CPO nly if the physician signing the plan f care prvides regular nging care under the same plan f care as the NPP and either: The physician and NPP are part f the same grup practice; r If the NPP is a nurse practitiner r clinical nurse specialist and the physician signing the plan f care has a cllabrative agreement with the NPP; r If the NPP is a physician assistant, the physician signing the plan f care is als the physician wh prvides the general supervisin f the physician assistant services in the practice. The NPP may bill fr CPO when: The NPP has seen and examined the patient; The NPP is nt functining as a cnsultant fr a single medical cnditin, but rather is prviding multidisciplinary crdinatin f care; and The NPP integrates his/her care with the physician wh signed the plan f care. 08/13/

4 Hspice CPO The physician r NPP billing fr CPO has been designated by the patient as the attending physician and has the mst significant rle in the determinatin and delivery f the medical care. CPO services cannt be part f pst-perative care in the glbal perid f a surgery. Dcumentatin must shw the separatin. Services prvided as incident t a physician s service d nt qualify as CPO and d nt cunt tward the 30-minute requirement. The physician is nt billing fr end stage renal disease (ESRD) capitatin payment fr the patient during the same mnth. The dcumentatin may be cmpleted by a resident under the teaching physician guidelines. Hwever, since these are time-based prcedure cdes, the teaching physician wuld dcument his/her presence during the time required. The same resident/teaching physician wuld have t have prvided the previus face-tface service. Frequency Medicare can allw the service nce per mnth. Face-t-Face Encunter Requirements The physician must have prvided an evaluatin and management service within the 6 mnths immediately preceding the first CPO service. Additinal services such as diagnstic testing, surgical services, etc. d nt meet this requirement. Services prvided as incident t the physician d nt meet this requirement. Patients previusly enrlled in a Medicare Advantage plan will nt have the infrmatin available in the Natinal Claims Histry file t supprt the previus face-t-face encunter. These services will deny n the claims level f prcessing. Prviders can submit an appeal supplying the dcumentatin f the face-t-face encunter. Patients ineligible fr Medicare at the time f the face-t-face encunter will nt meet this requirement. Submit an appeal with the dcumentatin f the face-t-face encunter. Date f Service The date f service is the date the CPO is cmpleted and signed. Claim Submissin Charge fr CPO must be the nly service submitted n a claim. Claims are submitted at the end f each mnth fr which services are prvided. The place f service cde represents the place where the majrity f wrk was perfrmed. The requirement t include the Natinal Prvider Identifier (NPI) f the HHA r hspice is temprarily waived until such time as the standard submissin methds can accmmdate the infrmatin. 08/13/

5 Physicians and NPPs must prvide their NPI t the HHA r hspice fr inclusin in their recrds. Financial r cntractual bligatin Practitiners emplyed by the Hspice r HHA cannt bill CPO services separately. Practitiners prviding services under arrangement t the Hspice r HHA cannt bill CPO services. Practitiners prviding vluntary services (including vluntary medical directr) t the Hspice r HHA cannt bill CPO services. Mdifier Dcumentatin and medical recrd must supprt the use f the mdifier. GV Identify the attending physician. 25 Evaluatin and Management n the same day as a prcedure. 24 Evaluatin and Management within the pst-perative perid f a surgery. 57 Evaluatin and Management n the day befre r the same day as a majr surgery. 08/13/

6 Why We Are Prviding the Educatin Hme Health Certificatin and Recertificatin The Office f the Inspectr General (OIG) has identified payment fr Hme Health Agency (HHA) services as an issue f incrrect payments. Link t OIG reprt is cntained in the resurce dcument. Reprt shws dcumentatin frm the physician cmmunity des nt supprt payment f the hme health service. The majrity f errrs are due t insufficient dcumentatin. The dcumentatin missing is the titled, signed and dated face-t-face encunter, the clinical findings shwing the patient is hmebund, and the dcumentatin shwing why the patient needs intermittent skilled nursing services r therapy services. The OIG reprt shws $2 billin Medicare payments in errr. The HHA respnding t the requests either did nt have dcumentatin f the face-tface encunter r the dcumentatin did nt have at least ne f the required elements. Prcedure Cdes G0180 Physician certificatin hme health patient fr Medicare cvered hme health service under a hme health plan f care (patient nt present), including cntacts with hme health agency and review f reprts f patient status required by physicians t affirm the initial implementatin f the plan f care that meets patient needs, per certificatin perid. Use G0180 t bill physician services fr initial certificatin f Medicare cvered hme health services. G0179 Physician recertificatin hme health patient fr Medicare cvered hme health services under a hme health plan f care (patient nt present), including cntact with hme health agency and review f reprts f patient status required by physicians t affirm the initial implementatin f the plan f care that meets patient needs, per recertificatin perid. Use G0179 t bill physician services fr recertificatin f Medicare-cvered HH services. Descriptin f Services Dcumentatin supplied t the HHA identifying the need fr services and the services required. 08/13/

7 Wh Can Perfrm The physician wh signs the plan f care A physician wh attends the patient in an acute r pst-acute setting, but des nt fllw the patient in the cmmunity may certify the need fr hme health care, establish and sign the plan f care, and then hand-ff the patient t their cmmunity physician. A physician wh attends the patient in an acute r pst-acute setting, but des nt fllw the patient in the cmmunity may initiate rders fr hme health and then handff the patient t the cmmunity physician t review and sign the plan f care. Frequency f Services The initial certificatin is payable when the physician determines the patient needs hme health services and cmpletes the rder/certificatin. The recertificatin is valid n the 61 st day and after the initial certificatin. Prcedure cde G0179 and G0180 have separate requirements The certificatin cde (G0180) is used when the patient begins an episde f hme health care and has nt received hme health services during the preceding 60 days. The recertificatin service (G0179) is used when the patient has been receiving hme health care fr at least 60 days. The recertificatin service (G0179) can be cntinued during the patient s cntinued requirement fr hme health services. The recertificatin is nly payable nce every 60 days. Exceptin when the patient ends an episde f hme health, starts a new episde befre 60 days and requires a new plan f care. Face-t-Face Encunter Requirements The certificatin frm n file with the HHA must shw the face-t-face encunter and the dcumentatin as listed abve. Fr hme health certificatin, the practitiner must title, date, and sign a face-t-face encunter perfrmed by himself/herself, an apprved NPP r physician in an acute r pst-acute setting within the preceding 90 days. The requirement may als be met with a face-t-face encunter in the 30 days fllwing the start f hme health. The dcumentatin will shw the physician s cntinued invlvement in the patient s care. There are specific requirements fr the certificatin fr hme health services. The face-t-face encunter must be within 90 days prir r 30 days after the start f care. The dcumentatin includes an explanatin f why the clinical findings supprt the patient s hmebund status and the need fr either intermittent skilled nursing services r therapy services. The dcumentatin must indicate Hme Health Face-t-Face Encunter and be signed and dated by the physician. The dcumentatin must be mre than lists f diagnses, recent injuries r prcedures. 08/13/

8 The dcumentatin must explain why the findings f the encunter supprt the medical necessity f the services requested and the patient s hmebund status. The dcumentatin must include a brief narrative describing hw the patient s clinical cnditin as seen during that encunter supprts the patient s hmebund status and need fr skilled services. There are tw elements required in the brief narrative. The patient must be: Cnfined t the hme. The patient shall be determined t be cnfined t the hme if bth the fllwing tw criteria are met: The patient, because f illness r injury, need supprtive devices, special transprtatin r assistance f anther persn in rder t leave the residence, r Have a cnditin such that leaving the hme is medically cntraindicated. And There must be a nrmal inability t leave hme and leaving hme must require a cnsiderable and taxing effrt. Require skilled services. The narrative will describe the skilled services t be prvided. See SE1405 fr a listing f skilled services and/r therapy services. The patient may be able t leave hme under cnsiderable r taxing effrt t Receive health care treatment Attend a licensed r state certified r accredited adult day care prgram Attend a religius service Other absences f an infrequent r relatively shrt duratin. The physician dcumentatin may be in a hand-written dcument, part f the electrnic medical recrd, and/r transcribed. It is nt acceptable t prvide this infrmatin verbally t the Hme Health agency. In situatins where the physician certifies the patient fr hme health care fr a new cnditin nt evident during the previus (within 90 day) encunter, the certifying physician r NPP must see the patient within 30 days f admissin if the patient s cnditin has changed t such an extent that accepted standards f practice wuld preclude the physician frm rdering services withut first examining the patient. The face-t-face encunters can be perfrmed via tele health services in rural areas. Plan f Care Requirements as apprpriate Cntain all pertinent diagnses Patient mental status Type f services, supplies and equipment needed. Frequency f visits Prgnsis Rehabilitatin ptential Functinal limitatins Activities permitted Nutritinal requirements 08/13/

9 Medicatins and treatments Safety measures Instructins fr timely discharge r referral The need fr skilled versight f unskilled services Infrmatin cncerning the nature and frequency f individual services. Plan f care is reviewed, updated as apprpriate, and signed every 60 days. Date f Service The date f service is the date the certificatin is cmpleted and signed. Claim Submissin The place f service cde represents the place where the majrity f wrk was perfrmed. The date f service is the date the plan, certificatin, r recertificatin was signed by the practitiner. The requirement t include the Natinal Prvider Identifier (NPI) f the Hme Health r Hspice is temprarily waived until such time as the standard submissin methds can accmmdate the infrmatin. Physicians and NPPs must prvide their NPI t the HHA fr inclusin in their recrds. Financial r cntractual bligatin Practitiners emplyed by the HHA cannt bill the certificatin r recertificatin separately. Practitiners prviding services under arrangement t the HHA cannt bill separately. Practitiner prviding vluntary services (including vluntary medical directr) t the HHA cannt bill separately. Mdifier Dcumentatin and medical recrd must supprt the use f the mdifier. 25 Evaluatin and Management n the same day as a prcedure. 24 Evaluatin and Management within the pst-perative perid f a surgery. 57 Evaluatin and Management n the day befre r the same day as a majr surgery. 08/13/