LCD/NCD Portal

L29259

 

PHYSICIAN CERTIFICATION AND RECERTIFICATION OF HOME HEALTH SERVICES

 

11/24/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

• For information concerning coverage of home health services, please refer to the Home Health Manual and to the appropriate Home Health Intermediary.

• Medicare will consider physician certification (and recertification) medically reasonable and necessary for a patient receiving Medicare-covered home health services requiring the development of a plan of care by the physician when the following conditions are met:

o The physician must participate in the development of the plan of care and review of data collected in the home health agency’s patient assessment in addition to signing the certification statement.

 In addition, documentation must indicate an ongoing knowledge of any changes in the patient’s condition, drugs, or other needs and how they are being met.

o The physician services for initial certification of Medicare-covered home health services are billable once for an episode of home health care.

 This may be billed when the patient has not received Medicare-covered home health services for at least 60 days.

o Physician services for recertification of Medicare-covered home health services may be billed after a patient has received services for at least 60 days after the physician signed the initial certification.

 This recertification may be billed only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapse.

o The physician services for initial certification cannot be billed unless the patient has not received any Medicare-covered home health services for at least 60 days.

 If less than 60 days have elapsed since the patient has received Medicare-covered home health services, the code for recertification should be billed.

o  The physician billing for physician certification must be the provider supervising the patient’s care.

 Physicians in specialties other than those commonly providing primary or comprehensive medical care to patients under the care of home health agencies, may be subject to review for medical necessity.

• A physician may perform other evaluation and management services during the same month for which he/she is billing the physician’s services for certification/recertification.

o However, time counted towards the services for certification/recertification should not be included in the work or time counted towards the pre, post, and intraservice work of the evaluation and management service.

• Discharge planning for a hospitalized patient is included in the E&M codes 99217, 99238 and 99239, and is not part of the physician certification.

 

CPT/HCPCS Codes

 

 

G0179 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

G0180 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

 

 

Documentation Requirements

• Documentation supporting the development of a plan of care and data review must be maintained by the physician in the patient’s medical records.

o If the written plan was not prepared by the physician (i.e., it was prepared by the HHA)

 The medical record must document the physician’s contribution to the development of the plan.

Or

 Document review of the specific items entered into the plan.

• It is not sufficient that the HHA maintain documentation in their records for the physician.

o The physician must maintain his/her own records including periodic summary reports provided by the home health agency.

o In addition, documentation of all face to face (E&M) visits and any phone communications with the patient or immediate caretakers must be present in the patient’s chart.

o This documentation must indicate an ongoing knowledge of any changes in the patient’s condition, drugs, or other needs and how they are being met.

o Each review of a patient’s plan of care must contain the signature of the physician and the date of review.

Treatment Logic

• Physician’s services involved in physician certification (and recertification) of Medicare-covered home health services may be separately coded and reimbursed.

• These services include creation and review of a plan of care and verification that the home health agency (HHA) initially complies with the physician’s plan of care.

• The physician’s work in reviewing data collected in the home health agency’s patient assessment would be included in these services.

•  This policy defines the coverage for physician services. For information concerning coverage of home health services, please refer to the Home Health Manual and to the appropriate Home Health Intermediary.

 

Sources of Information and Basis for Decision

 

11/24/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

© Automated Clinical Guidelines, LLC 2009-2014

 

CMS LCD L29259 Physician Certification and Recertification of Home Health Services