New Medicare Guidance for Nurse Practitioners Providing Services in a Home Care or Hospice Setting

Article Outline

• Biography
• Copyright

• 
  • View Large Image
  • Download to PowerPoint

• Howard L. Sollins

• 
  • View Large Image
  • Download to PowerPoint

• Donna J. Senft

• 
  • View Large Image
  • Download to PowerPoint

• John F. Lessner

On June 23, 2006, the Centers for Medicare and Medicaid Services (CMS) issued Transmittal 993, amending the Medicare Claims Processing Manual. (Providers should, by now, be aware that CMS no longer publishes its key manuals in paper but only electronically. Also, the former “Carrier’s Manual” is no longer being updated, and its provisions have been brought into various electronic manuals, one of which is the Claims Processing Manual.)

One of the tasks for which physicians may submit claims under the Medicare Physician Fee Schedule is Care Plan Oversight. Historically, the CMS manual has prohibited nonphysician practitioners (NPP; such as nurse practitioners, physician assistants, and clinical nurse specialists, all of which are a type of NPP) otherwise eligible to bill Part B from submitting Care Plan Oversight claims. This has been based on the principle that the practitioner who signs the home health plan of care must be the same practitioner providing the care plan oversight, and because a physician was required to sign the plan of care, an NPP could not bill for the oversight services.

This requirement is changed so that even though a physician signs the care plan, an NPP can provide care plan oversight and be reimbursed for the service so long as certain other requirements are met. Where the revised standard is met, NPP claims for home health care plan oversight provided by an NPP will be paid so long as the service is provided by an eligible NPP after January 1, 2005. This is the case even though the NPP is not permitted to sign the home health care plan.

The same transmittal clarifies care plan oversight services for hospice patients.¹ It permits care plan oversight services to be billed by an NPP who is a practitioner and who has been identified by the hospice patient to be the patient’s attending physician. However, there is an exception that does not permit this to be done when the physician or NPP is employed or contracted by the hospice, in which case care plan oversight is not separately payable.

The CMS Medicare Claims Processing Manual Section 180 contains this revision. It defines “care plan oversight” of a home health beneficiary as physician supervision of a patient receiving complex or multidisciplinary care as part of a Medicare-covered services furnished by a Medicare participating home health agency or Medicare approved hospice. NPPs must be permitted to provide this service under the stated scope of practice. In addition, the NPP may not bill for care plan oversight if the NPP’s only involvement has been with the delivery of the Medicare home health or hospice services but must otherwise provide ongoing evaluation and management services. Similar language with respect to care plan oversight services furnished to hospice beneficiaries is included in Section 40.1.3.1 of the Claims Processing Manual.

Care plan oversight services require complex or multidisciplinary care modalities involving the following:

The care plan oversight services must but those requiring recurrent physician supervision of a patient involving 30 or more minutes of that practitioner’s time per month, not including:

Only a physician may sign the home health plan of care. Even though an NPP may provide billable care plan oversight services, the physician signing the care plan must also provide regular, ongoing care of the patient. Also,

In addition, the NPP providing care plan oversight services

In the case of hospice services in which a nurse practitioner (as opposed to any other NPP) acts at the “attending physician” (the practitioner having the most significant role in the determination and delivery of medical care), the nurse practitioner may not otherwise be employed by or paid by the hospice to bill for care plan oversight.

Home health care plan oversight services will be paid no more than once per calendar month, per patient.

Where claims were erroneously denied for care plan oversight services furnished by eligible nurse practitioners after January 1, 2005, those claims may be reopened and adjusted by Medicare contractors.

• 1 The requirement to include the home health agency or hospice provider number otherwise required for a care plan oversight claim, on the Health Insurance Portability and Accountability Act standard ASC X12N 837 form is waived temporarily until a new version of this electronic standard format is adopted and includes a place for this provider number.