PHYSICIAN BILLING FOR MEDICARE

Home Health Certification & Recertification

The billing code and corresponding reimbursement for Tennessee is:

Billing Code	Tennessee Reimbursement	Description
GO 180	$73.57	Physician services for reviewing and signing initial certification of Medicare-covered services by a home health agency
GO 179	$57.02	Physician services for reviewing and signing recertification of Medicare-covered services by a home health agency

  Questions and Answers:

Q: How much time does a physician have to file cert/recert claims?

A. Under a long established CMS regulation, reimbursement rules allow providers anywhere from 15 to 27 months to submit payment requests, depending on the month in which the service was performed. Physicians should consult 42 CFR §424.44 for specific time limit requirements.

Q: Can the time physicians spend certifying or recertifying a patient for home care count toward the minimum 30 minutes needed to qualify for a Care Plan Oversight (CPO)?

A. CMS’s policy on the issue stated that doctors may not count cert/recert time toward the 30-minute monthly CPO minimum.

Q. Must a physician review a patient’s OASIS assessment, which can run to 20 pages or more, in order to qualify for certification/recertification payments?

A. The doctor may use OASIS review to justify certifying or recertifying claims, but isn’t obligated to do so. Q. The 1997 Balanced Budget Act permits a nurse practitioner or physician assistant to bill Medicare for CPO.

Q.Does that mean the NP/PA also can bill for certification or recertification?

A. No. Under Medicare regulations, only physicians may order home health services. The term “physician” includes osteopaths, podiatrists and psychiatrists, as well as medical doctors.

Q. What documentation must a doctor provide to qualify for the cert/recert payments?

A. Physicians, at a minimum, should retain copies of the CMS-485 and any interim or telephone orders they’ve approved.

Q. If a patient is discharged from a facility with initial home health orders from a facility staff physician, and not the patient’s primary care physician, who may bill for the initial certification?

A. The physician who orders, reviews and signs for the initial certification (CMS-485) may bill.