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CPO Background

On January 1, 1995, the Medicare program implemented rules providing reimbursement to physicians for time spent overseeing the plan of care of certain home care and hospice patients under Medicare Part B.

Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare-covered services provided by a participating home health agency or Medicare approved hospice.

CPO services require complex or multidisciplinary care modalities involving:

  • Regular physician development and/or revision of care plans;
  • Review of subsequent reports of patient status;
  • Review of related laboratory and other studies;
  • Communication with other health professionals involved in the patient’s care;
  • Integration of new information into the medical treatment plan; and/or
  • Adjustment of medical therapy.

The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physician’s time per month. Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:

  • Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;
  • Time spent by staff getting or filing charts;
  • Travel time; and/or
  • Physician’s time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.

Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient’s care with the home health agency or hospice during the month for which CPO services were billed. The physician who bills for CPO must be the same physician who signs the plan of care.

Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services. These non-physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.

Care Plan Oversight Reimbursement

Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.

Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered. CPO services may not be billed across calendar months and should be submitted (and paid) only for one unit of service.

Effective 2001, two new HCPCS codes for the certification and recertification and development of plans of care for Medicare-covered home health services were created. See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01, Chapter 4, “Physician Certification and Recertification of Services,” §10-60, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, “Home Health Services”, §30.

HCPCS G0179 (Re-Certification)

Physician re-certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per re-certification period.

The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period. The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

HCPCS G0180 (Initial Certification)

Physician certification for Medicare-covered home health services under a home health plan of care (patient not present), including contacts with home health agency and review of reports of patient status required by physicians to affirm the initial implementation of the plan of care that meets patient's needs, per certification period.

HCPCS G0181 (Care Plan Oversight – Home Health)

Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) 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, within a calendar month, 30 minutes or more.

HCPCS G0182 (Care Plan Oversight – Hospice)

Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) 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, within a calendar month, 30 minutes or more.

CPO Regulations

42 CFR Sec. 414.39 Special rules for payment of care plan oversight.

  • General - Except as specified in paragraphs (b) and (c) of this section, payment for care plan oversight is included in the payment for visits and other services under the physician fee schedule. For purposes of this section a non-physician practitioner (NPP) is a nurse practitioner, clinical nurse specialist or physician assistant.
  • Exception - Separate payment is made under the following conditions for physician care plan oversight services furnished to beneficiaries who receive HHA and hospice services that are covered by Medicare:
    1. The care plan oversight services require recurrent physician supervision of therapy involving 30 or more minutes of the physician's time per month.
    2. Payment is made to only one physician per patient for services furnished during a calendar month period. The physician must have furnished a service requiring a face-to-face encounter with the patient at least once during the 6-month period before the month for which care plan oversight payment is first billed. The physician may not have a significant ownership interest in, or financial or contractual relationship with, the HHA in accordance with Sec. 424.22(d) of this chapter. The physician may not be the medical director or employee of the hospice and may not furnish services under an arrangement with the hospice.
    3. If a physician furnishes care plan oversight services during a postoperative period, payment for care plan oversight services is made if the services are documented in the patient's medical record as unrelated to the surgery.

Special rules for payment of care plan oversight provided by non-physician practitioners for beneficiaries who receive HHA services covered by Medicare.

  1. An NPP can furnish physician care plan oversight (but may not certify a patient as needing home health services) only if the physician who signs the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for care plan oversight and either–
    1. The physician and NPP are part of the same group practice; or
    2. If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or
    3. If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.
  2. Payment may be made for care plan oversight services furnished by an NPP when:
    1. The NPP providing the care plan oversight has seen and examined the patient;
    2. The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multi-disciplinary coordination of care; and
    3. The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care.

[59 FR 63463, Dec. 8, 1994; 60 FR 49, Jan. 3, 1995; 60 FR 36733, July 18, 1995 as amended at 69 FR 66423, Nov. 15, 2004; 70 FR 16722, Apr. 1, 2005]

[14 CFR Section 414.39 http://edocket.access.gpo.gov/cfr_2008/octqtr/42cfr414.39.htm]

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