Are You Aware of the Whistleblower Provisions of the False Claim Act ?
Stark vs. Anti-Kickback: A Quick Comparison

Care Plan Oversight describes the physician or other healthcare professional’s supervision of patients in hospice, nursing facilities or those receiving care through home health agencies. CPO reimbursement covers initial certification, any re-certifications and care plan supervision. However, only physicians can bill for initial certification and re-certification and only one physician can bill per month. The code is determined by the amount of time spent and complexity of the case. Medicare covers only if the physician furnished at least 30 minutes of Care Plan Oversight within the calendar month for which payment is claimed. (CMS Medicare Benefit Policy Manual, Covered Medical and Other Health Services, Chapter 15, Section 30-G). The beneficiary must be receiving Medicare covered hospice or home health services during time of CPO and require complex or multi-disciplinary modalities that require ongoing physician involvement.

The CPO documentation must include date and amount of time with each encounter and must be done by the physician.  The physician must have had a face-to face encounter with the patient within 6 months of billing for the CPO. In addition, the physician may not be an employee or medical director of the hospice, nursing home or home health agency. Any activities that may be offered by the facilities or agencies to help the physicians with time documentation or tracking may be viewed as referral kick- back violations.

CPO is scrutinized and has led to another success story for the Medicare Fraud Task Force. The DOJ announced a 45-month prison term for a medical biller in a Chicago physician group guilty of a 5- year conspiracy for committing health care fraud. According to the investigative report, Medicall billed for $4 million in services that were never provided. Medicare paid for more than 1 million dollars of these claims. Many of the fraudulently billed services included claims for overseeing patient care plans (Care Plan Oversight- CPO) which the doctors either did not provide based on absent or insufficient documentation or could not have provided due to billing for more than 24 hours in a day.

Here are some helpful tips to consider when billing for CPO:

Factor this in to CPO time:

  • Reviewing charts, reports and treatment plans
  • Reviewing lab and other diagnostic studies (not the initial review)
  • Discussing drug treatment needs with pharmacist (not routine refill of prescriptions)
  • Phone conversations with other health professionals (not employed by same practice) involved in patient’s care
  • Team conferences
  • Coordinating care if physician or NPP is required.
  • Documenting services provided (include time to write note, medical decision making, time spent on activities after hospital discharge not relating to discharge plan)
  • Making and implementing changes to treatment plan.

Do NOT Factor this in to CPO time:

  • Calling in Prescriptions / refills
  • Physician calls to family/patient
  • Travel time
  • Time spent preparing claims
  • Initial review of test results at face to face encounter

(Nicoletti, B. How to Document and Bill for CPO, FPM 2005)


Related Posts

Leave a Reply

Your email address will not be published.

Fill out this field
Fill out this field
Please enter a valid email address.