L29259-LCD

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Local Coverage Determination (LCD) for Physician Certification and Recertification of Home Health Services (L29259)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29259

LCD Title

Physician Certification and Recertification of Home Health Services

Contractor's Determination Number G0179

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 11/24/2009 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-2, Medicare Benefit Policy, Chapter 7, Section 30.5-30.5.3

CMS Manual System, Pub. 100-1, Medicare General Information, Eligibility and Entitlement, Chapter 4, Section 30

-30.3

42 Code of Federal Register 424.22

Indications and Limitations of Coverage and/or Medical Necessity

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.

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:

- 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.

- 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.

- 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.

- 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.

- 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. 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.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

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

G0179 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

PHYSICIAN CERTIFICATION FOR MEDICARE-COVERED HOME HEALTH SERVICES UNDER A HOME HEALTH G0180 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

ICD-9 Codes that Support Medical Necessity XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

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

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

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity. Sources of Information and Basis for Decision

N/A

Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2010

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2010 Revised Effective Date: 11/24/2009

LCR B2009-111

December 2009 Update

Explanation of Revision: Under the “Documentation Requirements” section of the LCD, language was added to clarify requirements around the physician’s signature and date of the plan of care. The effective date of this revision is based on process date.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29259) replaces LCD L16718 as the policy in notice. This document (L29259) is effective on 02/02/2009.

Reason for Change Typographical Correction