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Physician Payment for Medicare Care Plan Oversight

IBC Government Services * Fiscal Intermediary

To: Chief Executive Officers of Providers for which IBC Government Services is Medicare Intermediary.

The Centers for Medicare & Medicaid Services (formerly known as the Health Care Financing Administration) announced changes in its payment policy for physician care plan oversight services furnished in 1995. This change was initiated to pay for extensive physician oversight of the care delivered by home health agencies and hospices to Medicare beneficiaries. These services are to be billed to the Medicare Part B Carrier by the physician.

In 1994, the CPT added two codes for care plan oversight services, 99375 and 99376. These codes were included in the 1994 Medicare fee schedule as codes that were bundled into the payment for visits and other procedures.  Separate payment for the care plan oversight codes was not allowed in 1994.

In general, Medicare continues to consider care plan oversight services to be included in the payment for other services. However, Medicare will allow separate payment for care plan oversight services furnished on or after January 1, 1995 under the following conditions:

  1. The services are furnished by a physician to a beneficiary receiving Medicare-covered home health or hospice services;
  2. The physician has furnished a service requiring a face-to-face encounter with the patient at least once in the 6 months prior to the first billing for the service; and
  3. The physician does not have a significant financial relationship with the home health agency, is not the medical director or employee of the hospice, and does not provide services under arrangement with the hospice.

If the above conditions are met, Medicare will:

  1. Allow payment to one physician per patient per month for care plan oversight if it involves 30 or more minutes of the physician's time per calendar month.
  2. Allow payment for 30 or more minutes of care plan oversight to a physician providing post-surgical care during the post-operative period only if the care plan oversight is documented to be unrelated to the surgery and billed with modifier 24.
  3. Allow payment under CPT code 99375 only. CPT code 99376 will remain bundled since payment for care plan oversight services beyond 60 minutes per month is included in the payment for CPT code 99375.
  4. Base Payment on 1.61 total relative value units (RVU) for payment in 1995 (1.06 work RVUs, 0.51 practice expense RVUs, and 0.04 malpractice expense RVUs).

Some physicians have raised the following questions concerning care plan oversight services.

Q1. What physician activities are considered care plan oversight services for which separate payments is allowed?
A1. Care plan oversight includes the following physician 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 is not included.

Q2. What documentation is required?
A2. Physicians 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 physician service and must be provided and documented only by the responsible physician.

Q3. How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight services?
A3. Since care plan oversight services do not typically involve a face-to-face encounter between the patient and the physician, the patient may not be aware that the services were provided. Physicians 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 the Explanation of your Medicare Part B benefits messages.

Questions from Home Health and Hospice Providers may be directed to (215) 241-2500. Questions that physicians' offices may have should be directed to the appropriate Carrier.


    Additional Resources

    Billing for the Professional Services of Physicians
    How to Fund Your Palliative Care Program
    Concurrent Session A
    June 2002, Seattle, WA
    Charles F. von Gunten, MD, PhD. FACP
    PowerPoint Presentation

    Data Collection Tool for Hospital Utilization and Cost Patterns

    Questions and Answers Related to Care Plan Oversight Information
    Department of Health & Human Services/HCFA
    Division of Medicare (HCFA is now known as Centers for Medicare & Medicaid Services/CMS)

    Payments to Physicians for Services Provided Concurrently by More than One Physician
    Medicare Part B Carriers Manual Section 2020



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