Can LTPAC physicians bill for Home Health Care Plan certification / recertification?

August 5th, 2013 by Rod Baird

Today’s blog has two purposes. One is to pass along some useful billing guidance we received from our Region IV CMS office on using Place of Service Codes in LTPAC billing. The second is to show how difficult it is to behave as a fully “compliant” medical practice.

Question: What Place of Service Code should an institutional physician (one without a clinical office) use if submitting Medicare claims for Home Health Care Plan certification. The face-to-face encounter (a prerequisite) occurred in an institution. The certification and required note was done after the patient was discharge to home.

Rod Baird

Answer: According to the CMS Region IV office, it is proper to use POS 11 (Office). “The process of doing paperwork aside from the actual examination or other hands-on care delivered to a patient should be considered as being done in the ‘office’ regardless of whether a separate office exists.“

Follow-up question: A similar issue arises for assisted living patients (POS 13 or 33). In these settings, the physician actually renders continuing care as the primary care provider. However, all MACs deny claims for G0180 and G0179 if those POS codes are reported. Again, for the physician without a clinical office, how do they legally report these services?

Answer: “Under the circumstances described, they are not falsifying a claim by coding it as office.”

To my knowledge, this is the first time that a knowledgeable CMS representative has confirmed that physicians who do not have a physical “clinical office” are able to use POS 11 (Office). It is a logical, and now those of us representing LTPAC physicians need to get this position “manualized.” That is the only way to immunize providers from retrospective audit denials and costly recoupments.

Here is some background on why many of us (in large groups) feel this is a major compliance risk, even though there is now some written regional guidance.

We are part of a LTC physician practice management consortium, The Vision Group. It’s a collegial band of practice managers who meet privately to share strategies and work out regulatory challenges unique to LTPAC physician practices. Much of my thinking on PQRS, eRx and EHR programs arose from those group discussions.

The obscure billing issues (above) became a major discussion during our March meeting. If you aren’t deeply familiar with CMS regulations you probably think this is a no-brainer. The physician making the face-to-face determination of need for HHA care, and subsequently certifying the resulting Plan of Care, meets the clinical requirements for submitting a claim. There is a pair of HCPCS codes for Care Plan Certification and some LCDs (local coverage decisions) that outline required documentation. So, why can’t you bill?

The members of The Vision Group represent approximately 400 LTC physicians/extenders and submit almost a million claims annually. With these volumes, billing departments have the experience to determine patterns of claim payment and denial.

Our billing departments reported (universally) that claims for Home Health Care Plan certification / recertification (G0180/G0179) were denied if the POS was SNF, NF, ALF or Congregate Care. Each of us had asked for guidance on the “correct” POS code and were told the only codes that were acceptable were Office (POS 11) or Home (12).

Separate CMS guidance gives very specific instructions on how the physician should select a POS Code. The citation below comes from the online CMS Medicare Claims Processing Manual (100-4), Chapter 26 (Completing and Processing Form CMS-1500 Data Set)

 10.6 – Carrier Instructions for Place of Service (POS) Codes

(Rev. 2679, Issued: 03-29-13, Effective: 04-01-13, Implementation: 04-01-13)

For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service.

So, will we go ahead and begin using “Office” when a LTPAC physician performs Care Plan Certification?  For the practices I am directly responsible for, the answer is “yes.” Others need to make their own assessment since the “guidance” from Region IV is both “regional” and carries far less weight than the “manual.”

This is a single example, of many, showing how CMS policy/regulation fails to keep abreast of changing practice patterns, or that the authors were simply unaware of how care is actually delivered. In either case, the person liable for the imprecise language/understanding is the provider. This problem affects every corner of provider reimbursement and is a major reason that Americans pay more for health care than any other country.

There must be a better way!

Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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