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)
We have received numerous inquiries from regions, carriers, and
physicians regarding Medicare policy as related to physician care plan oversight
Attached is a collection of some of the more frequently asked
questions and our response to these questions. We believe that a question and
answer document, sent to carriers, will assist in educating carrier personnel
and physicians about the guidelines associated with care plan oversight. In
addition to the questions in Attachment A, we have received calls regarding
whether certain activities are countable toward the 30-minute requirement.
Attachment B lists the activities about which we have received inquiries.
The responses to these questions are based on national policies governing when a
physician could bill care plan oversight and when it would be appropriate for the
carriers to pay separately for these services. The responses should not be
construed as claims processing requirements. The Bureau of Program Operations
has issued claims processing requirements for care plan oversight. Any addition
to or modifications of those instructions would be implemented through the
regular systems change cycle.
Questions and Answers for Care Plan Oversight
Question 1: Can a physician other that the
physician who signed the plan of care (i.e. attending physician) bill for care
Response 1: The physician who bills for care plan
oversight must be the same physician who signs the plan of care.
Question 2: Under what conditions can the
medical director of a home health agency sign the plan of care for the Medicare
Response 2: Physicians may sign the plan of care for a
home health agency if they do not have significant ownership in or a
significant financial relationship with the home health agency.
Significant ownership is defined as:
- having direct or indirect ownership interest of 5
percent or more in the capital, stock, or the profits of the home health
- Having an ownership interest of 5 percent or more in any mortgage,
deed of trust, note, or other obligation that is secured by the agency, if that
interest equals 5 percent or more of the agency's assets.
Significant financial or contractual relationship is defined as:
Question 3: Can a volunteer medical director of a hospice bill for
care plan oversight? Response 3: No. According to Section 418.3 of the Code
of Federal Regulations a volunteer within a hospice is considered an employee of
the hospice. Payments to the hospice already include payment for services of the
hospice physicians in establishing and overseeing the plans of care. Separate
Part B payments are limited to physicians who are not affiliated with the
hospice (see CFR 418.304). Thus, the volunteer medical director is considered an
employee of the hospice and cannot bill separately for care plan oversight under
the physician fee schedule.
- receiving any compensation as an officer or director (i.e., board of directors) of the HHA.
- having direct or indirect business transactions with the HHA that, in any year, amount to more
than $25,000 or 5 percent of the agency's total operating expenses, agreements,
purchase orders, or leases to obtain services, supplier, equipment, and space.
Question 4: Can a carrier determine care plan oversight not
medically necessary although the Regional Home Health Intermediary (RHHI) has
approved payment for either home health or hospice care?Response 4: Although the RHHI has approved payment for
either home health or hospice care, this does not automatically mean that
payment for care plan oversight is warranted. As for all services paid for by
Medicare, the care plan oversight services for which Medicare will pay must be
medically necessary. Further, for those care plan oversight services for which
we will recognize separate payment, the patient must require complex or
multi-disciplinary care modalities involving regular physician development
and/or revision of care plans, review of subsequent reports of patient status,
or review of related laboratory and/or other studies. Participation of a
beneficiary in covered home health or hospice care does not alone qualify the
beneficiary's physician for separate payment for care plan oversight.
Question 5: If a group of physicians are members of a group practice
in which one of the members of the group practice has either significant
ownership or financial interest in an HHA, can the other physicians in the group
practice sign the plan of care and bill for care plan oversight? Response 5: YES. If the group itself has no ownership
interest in the Home Health Agency, the other members of the group can sign the
plan of care and be paid for care plan oversight services.
Question 6: Will we pay for care plan oversight for a hospice
patient who resides in a SNF/NF? Response 6: Under normal circumstances, we do not pay
for both SNF care and hospice care. However, if the hospice beneficiary is in
the SNF receiving respite or general inpatient care under the hospice benefit,
or is a dually entitled beneficiary, or is a private paying resident, Medicare
will pay for care plan oversight related to the hospice services if all other
conditions for payment are met. The attending physician cannot be an employee of
the hospice. Care plan oversight is included in the prospective rate of the
hospice if the physician is an employee of the hospice. We will pay for care
plan oversight services if the attending physician is not an employee of the
hospice, the care plan oversight services are document to be related to the
hospice plan of care and the duration of time spent by the attending physician
overseeing the hospice plan of care during the month is 30 minutes or more.
Question 7: Can a home health agency's records serve as
documentation of the physician's care plan oversight activities? Response 7: NO. We require that the physician who
furnishes the services document which services were furnished and the date and
length of time associated with those services.
Question 8: Can the
attending physician's time spent discussing, with his/her nurse, conversations
his/her nurse had with the home health agency count toward the 30 minute
requirement?</dt> Response 8: NO. Such time spent with his/her nurse does
not count toward the 30-minute threshold. However, the time spent by the
physician working on the care plan, after the nurse has conveyed the pertinent
information to the physician, is countable toward the 30 minutes.
Question 9: Can care plan
oversight be reported and paid when furnished by nurse practitioners and
physician assistants? Response 9: NO. Section 1851(m) of the Act provides
coverage of home health services where those services are furnished under a plan
of care established and periodically reviewed by a physician. Further, sections
1814(a) (2) © and 1835 (a) (2) (A) of the Act require physicians to certify the
need for home health services. Thus, physicians are required by current law to
perform certain functions (such as signing the plan of care) and, therefore,
only physicians may be paid for care plan oversight.
Question 10: Can the time
another physician spends working on the patient's care with the attending
physician who actually signed the care plan be counted toward the 30 minute
requirement? Response 10: NO. Only the time the attending physician
spends on care plan oversight is countable. The time spent by other physicians
is not countable toward the 30-minute requirement. Payment for care plan
oversight is for the time spent by one physician (i.e., the physician providing
Question 11: Why does HCFA require the physician billing for care plan oversight
services to have seen the patient at least once in the 6 months prior to the
first billing for care plan oversight? Response 11: We believe that the medical management of
patients with complex health care needs should be linked with a face-to-face
evaluation of the patient. We do not believe that it is unreasonable to specify
that a physician be required to see a patient within the 6 months prior to the
initial billing for care plan oversight.
Question 12: Do
physicians need to see their patient every 6 months in order to bill for care
plan oversight? Response 12: NO. HCFA does not require physicians to see
beneficiaries at regular 6-month intervals after the initial encounter 6 months
prior to the first billing of care plan oversight.
Question 13: Will HCFA permit
payment for care plan oversight services during the same month that a physician
bills for hospital discharge day management? Response 13: YES. We have decided to allow payment for
care plan oversight services for patients receiving covered home health and
hospice services during the month following hospital discharge if the other
conditions for payment are met.
Question 14: What site of service
should be indicated on the claim form for care plan oversight? Response 14: The physician should indicate the location
where the majority of the services were furnished. Since care plan oversight is
not necessarily a face-to-face service and the physician is likely to perform
countable activities in the office setting, the site of service is likely to be
the physician's office. However, if the majority of time spent on care plan
oversight activities is at a site other than the physician's office that other
site of service should be identified.
Question 15: Does the physician need to send in his/her documentation
requirements when they submit billing to care plan oversight? Response 15: No. The documentation requirements are to
be kept by the physician unless requested by the Medicare carrier.
Question 16: Can rural health clinic (RHC) physicians
receive a separate payment for physician care plan oversight services?Response 16: NO. RHC physicians do not receive separate
payments for services provided to RHC patients at the RHC or other medical
facilities. Medicare pays the RHC for the RHC services provided to Medicare
patients. RHC services include physicians' services. The RHC is paid only on per
visit basis for the face-to-face encounters the physician may have with the
Medicare patient. If the RHC incurs any additional costs as a result of the
physician providing this service, (in addition to the compensation paid by the
RHC to the physician), the RHC may include the cost in its cost report to
determine the RHC's all inclusive payment rate.
Question 17: Will Medicare pay for overseeing the care of a patient who is
not receiving Medicare covered home health or hospice benefits?Response 17: NO. Medicare will pay separately for care
plan oversight services only for patients who receive Medicare covered home
health or hospice benefits.
Question 18: If Medicare will not pay for overseeing the care of a patient who does not receive
Medicare covered home health or hospice benefits, can the physician charge the
beneficiary for those services?Response 18: NO. This service is covered and payment is
bundled into the payment for other visits and procedures.
The following activities are countable toward the 30-minute requirement for care plan oversight.
CARE PLAN OVERSIGHT
Countable (physicians' time dedicated toward an individual
- review of charts, reports, treatment plans, or lab or
study results except for the initial interpretation or review of lab or study
results that were ordered during or associated with a face-to-face encounter
- telephone calls with other health care professionals
(not employed in the same practice) involved in the care of the patient
- team conferences (must document time spent per individual patient)
- telephone or face-to-face discussions with a
pharmacist about pharmaceutical therapies
- medical decision making
- activities to coordinate services (if the coordination
activities require the skills of a physician)
- documenting the service provided which includes
writing a note in the patient chart describing services provided,
decision-making performed, and amount of time spent performing the countable
CARE PLAN OVERSIGHT.
The following activities are not countable toward the 30-minute requirement for
care plan oversight.
Not Countable (covered; bundled into other services and
separately countable; some activities included in practice expense): .
- time the
nurse, NP, PA, CNS, or other staff spends getting or filing charts, calling
HHAs, patients, etc.
- physician telephone call to patient or family, even to
adjust medication or treatment
- physician time spent telephoning prescriptions
into the pharmacist; not a physician service, does not require a physician to
- physician time getting and/or filing the chart, dialing the phone, or
time on hold (these activities do not require physician work or meaningfully
contribute to the treatment of the illness or injury)
- travel time
- time spent preparing claims and for claims processing
- initial interpretation or review of
lab or study results that were ordered during or associated with a face-to-face
- low intensity services included as part of other E & M services.
informal consults with health professionals not involved in the patient's care
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