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:
- The services are furnished by a physician to a
beneficiary receiving Medicare-covered home health or hospice services;
- 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
- 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:
- 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.
- 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.
- 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.
- 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
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.
- 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.
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
Q3. How will beneficiaries know that they may be responsible for additional coinsurance payments for care plan oversight
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
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.
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
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
Other Resources By
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