Download Care Plan Oversight Policy - UnitedHealthcare Community Plan

REIMBURSEMENT POLICY
CMS-1500
Care Plan Oversight Policy
Policy
Number
2017R0033C
Annual
Approval
Date
7/13/2017
Approved
By
Payment Policy Oversight Committee
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure
that you are reimbursed based on the code or codes that correctly describe the health care services
provided.
UnitedHealthcare Community Plan reimbursement policies uses Current Procedural
®
Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines.
References to CPT or other sources are for definitional purposes only and do not imply any right to
reimbursement.
This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when
specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic,
regulatory requirements, benefits design and other factors are considered in developing reimbursement
policy.
This information is intended to serve only as a general reference resource regarding UnitedHealthcare
Community Plan’s reimbursement policy for the services described and is not intended to address every
aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use
reasonable discretion in interpreting and applying this policy to health care services provided in a
particular case. Further, the policy does not address all issues related to reimbursement for health care
services provided to UnitedHealthcare Community Plan enrollees.
Other factors affecting reimbursement supplement, modify or, in some cases, supersede this
policy. These factors include, but are not limited to: federal &/or state regulatory requirements,
the physician or other provider contracts, the enrollee’s benefit coverage documents, and/or other
reimbursement, medical or drug policies.
Finally, this policy may not be implemented exactly the same way on the different electronic claims
processing systems used by UnitedHealthcare Community Plan due to programming or other constraints;
however, UnitedHealthcare Community Plan strives to minimize these variations.
UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new
version of the policy on this Website. However, the information presented in this policy is accurate and
current as of the date of publication.
UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System
known as iCES Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan
reimbursement policies.
®
*CPT is a registered trademark of the American Medical Association
Application
This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare
products.
This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form
(a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and
all network and non-network physicians and other qualified health care professionals, including, but not
limited to, non-network authorized and percent of charge contract physicians and other qualified health
care professionals.
Payment Policies for Medicare & Retirement, UnitedHealthcare Community Plan Medicare and
Employer & Individual please use this link.
Medicare & Retirement and UnitedHealthcare Community Plan Medicare Policies are listed under
Medicare Advantage Reimbursement Policies.
Employer & Individual are listed under Reimbursement Policies-Commercial.
Proprietary information of UnitedHealthcare Community Plan. Copyright 2017 United HealthCare Services, Inc. 2017R0033C
REIMBURSEMENT POLICY
CMS-1500
Policy
Overview
Care Plan Oversight (CPO) Services refer to physician and other health care professional supervision of
patients under the care of home health agencies, hospice, or nursing facilities. Care Plan Oversight
services are reported separately from codes for office/outpatient, hospital, home, nursing facility, or
domiciliary services. Code selection for Care Plan Oversight Services is determined by the complexity
and approximate time spent by the physician or other health care professional within a 30-day period.
Reimbursement Guidelines
UnitedHealthcare Community Plan considers Care Plan Oversight Services to be reimbursable services
when submitted with the following codes only:

CPT codes 94005, 99340, 99375, 99378, 99380, 0405T

HCPCS codes G0179, G0180, G0181, G0182
CPO services are reimbursed for 30 minutes or more per Centers for Medicare & Medicaid Services
(CMS) guidelines.
The following codes are not reimbursable for Care Plan Oversight Services:

CPT codes 99339, 99374, 99377, 99379

HCPCS codes S0220, S0221, S0250, S0270, S0271, S0272
State Exceptions
Arizona
Arizona Medicaid is exempt from this policy based on state requirements
Iowa
Effective 1/1/16 the Iowa Qualified Health Plan (IAQHP) product (excluding
HAWKi – Product ID IAHI and IAHIC) allows code S0220 to be billed for Care
Plan Oversight services.
New Mexico
Codes G0179, G0180, G0181, and G0182 are not covered for Medicaid NonDual members.
Texas
TX Star Kids allows codes 99399, 99374, 99377, and 99379 to be
reimbursed for Non-Face-to-Face Clinician Supervision of a Home Health
Client.
Wisconsin
Wisconsin Medicaid does not cover Care Plan Oversight services.
Questions and Answers
Q: Does UnitedHealthcare Community Plan reimburse Care Plan Oversight Services codes for less
than 30 minutes?
1
A: UnitedHealthcare Community Plan follows CMS payment methodology for reimbursement of
Care Plan Oversight Services. According to the CMS Medicare Benefit Policy Manual, Covered
Medical and Other Health Services, Chapter 15, Section 30, these services are covered only if the
physician furnished at least 30 minutes of Care Plan Oversight within the calendar month for which
payment is claimed.
Proprietary information of UnitedHealthcare Community Plan. Copyright 2017 United HealthCare Services, Inc. 2017R0033C
REIMBURSEMENT POLICY
CMS-1500
Codes
CPT code section
94005
Home ventilator management care plan oversight of a patient (patient not
present) in home, domiciliary or rest home (eg, assisted living) requiring
review of status, review of laboratories and other studies and revision of
orders and respiratory care plan (as appropriate), within a calendar month, 30
minutes or more
99339
Individual physician supervision of a patient (patient not present) in home,
domiciliary or rest home (eg, assisted living facility) 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 related laboratory and other studies, communication (including
telephone calls) for purposes of assessment or care decisions with health
care professional(s), family member(s), surrogate decision maker(s) (eg,
legal guardian) and/or key caregiver(s) involved in patient's care, integration
of new information into the medical treatment plan and/or adjustment of
medical therapy, within a calendar month; 15-29 minutes
99340
Individual physician supervision of a patient (patient not present) in home,
domiciliary or rest home (eg, assisted living facility) 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 related laboratory and other studies, communication (including
telephone calls) for purposes of assessment or care decisions with health
care professional(s), family member(s), surrogate decision maker(s) (eg,
legal guardian) and/or key caregiver(s) involved in 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
99374
Supervision of a patient under care of home health agency (patient not
present) in home, domiciliary or equivalent environment (eg, Alzheimer's
facility) requiring complex and multidisciplinary care modalities involving
regular development and/or revision of care plans by that individual, review of
subsequent reports of patient status, review of related laboratory and other
studies, communication (including telephone calls) for purposes of
assessment or care decisions with health care professional(s), family
member(s), surrogate decision maker(s) (eg, legal guardian) and/or key
caregiver(s) involved in patient's care, integration of new information into the
medical treatment plan and/or adjustment of medical therapy, within a
calendar month; 15-29 minutes
99375
Supervision of a patient under care of home health agency (patient not
present) in home, domiciliary or equivalent environment (eg, Alzheimer's
facility) requiring complex and multidisciplinary care modalities involving
regular development and/or revision of care plans by that individual, review of
subsequent reports of patient status, review of related laboratory and other
studies, communication (including telephone calls) for purposes of
assessment or care decisions with health care professional(s), family
member(s), surrogate decision maker(s) (eg, legal guardian) and/or key
caregiver(s) involved in 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
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REIMBURSEMENT POLICY
CMS-1500
99377
Supervision of a hospice patient (patient not present) requiring complex and
multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of
patient status, review of related laboratory and other studies, communication
(including telephone calls) for purposes of assessment or care decisions with
health care professional(s), family member(s), surrogate decision maker(s)
(eg, legal guardian) and/or key caregiver(s) involved in patient's care,
integration of new information into the medical treatment plan and/or
adjustment of medical therapy, within a calendar month; 15-29 minutes
99378
Supervision of a hospice patient (patient not present) requiring complex and
multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of
patient status, review of related laboratory and other studies, communication
(including telephone calls) for purposes of assessment or care decisions with
health care professional(s), family member(s), surrogate decision maker(s)
(eg, legal guardian) and/or key caregiver(s) involved in 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
99379
Supervision of a nursing facility patient (patient not present) requiring
complex and multidisciplinary care modalities involving regular development
and/or revision of care plans by that individual, review of subsequent reports
of patient status, review of related laboratory and other studies,
communication (including telephone calls) for purposes of assessment or
care decisions with health care professional(s), family member(s), surrogate
decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in
patient's care, integration of new information into the medical treatment plan
and/or adjustment of medical therapy, within a calendar month; 15-29
minutes
99380
Supervision of a nursing facility patient (patient not present) requiring
complex and multidisciplinary care modalities involving regular development
and/or revision of care plans by that individual, review of subsequent reports
of patient status, review of related laboratory and other studies,
communication (including telephone calls) for purposes of assessment or
care decisions with health care professional(s), family member(s), surrogate
decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in
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
0405T
Oversight of the care of an extracorporeal liver assist system patient requiring
review of status, review of laboratories and other studies, and revision of
orders and liver assist care plan (as appropriate), within a calendar month, 30
minutes or more of non-face-to-face time
HCPCS code section
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
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REIMBURSEMENT POLICY
CMS-1500
to affirm the initial implementation of the plan of care that meets patient's
needs, per certification period
G0181
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 review 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
G0182
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
S0220
Medical conference by a physician with interdisciplinary team of health
professionals or representatives of community agencies to coordinate
activities of patient care (patient is present); approximately 30 minutes
S0221
Medical conference by a physician with interdisciplinary team of health
professionals or representatives of community agencies to coordinate
activities of patient care (patient is present); approximately 60 minutes
S0250
Comprehensive geriatric assessment and treatment planning performed by
assessment team
S0270
Physician management of patient home care, standard monthly case rate
(per 30 days)
S0271
Physician management of patient home care, hospice monthly case rate (per
30 days)
S0272
Physician management of patient home care, episodic care monthly case
rate (per 30 days)
Resources
Individual state Medicaid contracts, regulations, manuals & fee schedules
®
American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and
services
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and
services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS
Release and Code Sets
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REIMBURSEMENT POLICY
CMS-1500
History
7/13/2017 Policy Approval Date Change (no new version)
5/20/2017 Application Section: Removed UnitedHealthcare Community Plan Medicare products as
applying to this policy. Added location for UnitedHealthcare Community Plan Medicare
reimbursement policies
1/1/2017 Annual Policy Version Change
History prior to 1/1/2015 archived.
10/17/2016 State Exceptions Section: Exception added for Texas
7/13/2016 Policy Approval Date Change (no new version)
5/23/2016 State Exceptions Section: Exception added for Wisconsin
3/7/2016 State Exceptions Section: Exception added for Pennsylvania
1/1/2016 Annual Policy Version Change
Policy Change: Reimbursement Guidelines and CPT Codes section updated
History prior to 1/1/2014 archived.
12/7/2015 State Exceptions Section Updated: Exception for Iowa clarified
10/6/2015 State Exceptions Section Updated: Added exception for Iowa
7/8/2015 Policy Approval Date Change (no new version)
3/1/2015 Application Section: Removed reference to location of policy for Mississippi Chip (no new
version)
2/14/15 Application Section: Revised
State Exceptions Section: Arizona exception revised
1/1/2015 Annual Policy Version Change
History prior to 1/1/2013 archived.
1/30/2006 Policy implemented by UnitedHealthcare Community & State
Proprietary information of UnitedHealthcare Community Plan. Copyright 2017 United HealthCare Services, Inc. 2017R0033C