Medicare Payment and Reimbursement

Beyond the Medicare Annual Well Visit: Maximizing Revenue for Hospital-Owned Practices

February 21, 2017 2:39 pm

Routine services can present new revenue opportunities for hospital-owned practices.

Underutilized revenue opportunities may be available to hospital-owned physician practices that focus on Medicare populations. Many practices routinely perform services such as screenings and addiction counseling but may not capture those services in their revenue stream. The reason might be that they physicians do not provide adequate documentation, that billers are not trained on how to capture the services, or that the practices are not aware that the work being provided is billable.

Most of these services require the use of an HCPCS code, often from the G series range. When those services are performed by a qualified provider, documented, captured, and reported with the appropriate code, they can present valuable revenue opportunities. Some of the most common of these services are discussed below and shown in the exhibit below.

Clinical Optimization of Medicare Services

According to the HIPAA Code Set requirements, the Common Procedural Terminology (CPT®) code set established by the American Medical Association (AMA) is the official source for professional fee codes, known as Category I codes. CPT codes describe the majority of services performed and reported by clinicians in many medical practices.

HCPCS codes, developed by the Centers for Medicare & Medicaid Services (CMS) are known as Category II procedure codes and describe a medical service or supply. All medical practices should have an up-to-date version of a HCPCS book to accurately report services performed by their clinicians. In particular, practices should understand HCPCS G codes, which are used to identify professional healthcare procedures and services that either lack a CPT code or have been assigned a code that CMS regards as inadequate to define the service in question.

In addition to the G codes, there are many other HCPCS codes that hospital-owned practices should review. In accordance with the code set rules, a provider should check first for a CPT code, and then, if none is available or acceptable by CMS, an HCPCS code.

Alcohol Screening and Counseling

All Medicare beneficiaries are eligible for alcohol screening and behavioral counseling interventions to reduce alcohol misuse. Medicare covers an annual alcohol screening and, for those who screen positive, will cover up to four brief face-to-face behavioral counseling interventions per year. The counseling is provided to those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence. To be eligible for counseling, a patient must be competent and alert at the time of counseling and must receive counseling in a primary care setting from a qualified primary care physician or other primary care practitioner. In addition, the patient must display at least three of the following:

  • Tolerance
  • Withdrawal symptoms
  • Preoccupation with acquisition and/or use
  • Persistent desire or unsuccessful efforts to quit
  • Sustained social, occupational, or recreational disability
  • Continued use despite adverse consequences

The Medicare coinsurance and Part B deductible are waived for this preventive service.

Smoking and Tobacco Cessation Counseling

Medicare Part B has covered smoking and tobacco cessation counseling since 2008, but some physicians have not taken advantage of this billing opportunity. Outpatient and hospitalized Medicare beneficiaries who use tobacco can receive counseling regardless of whether they exhibit signs or symptoms of tobacco-related disease. As is the case with alcohol counseling, a patient must be competent and alert at the time of counseling, and the counseling must be furnished by a qualified physician or other Medicare recognized practitioner. Medicare beneficiaries are eligible for two cessation attempts per year, comprising a total annual benefit of eight intermediate or intensive sessions (four per cessation attempt). The beneficiary’s deductible and copayment/coinsurance amounts are waived.

Counseling for smoking and tobacco cessation lasting three minutes or less is covered by Medicare within the payment for a standard evaluation and management (E&M) office visit. If the smoking and tobacco cessation counseling exceeds three minutes, providers may bill for it separately using the following codes:

  • CPT 99406: Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes.
  • CPT 99407: Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes.

Providers must document the appropriate diagnosis codes in their notes for the encounters along with the amount of time spent on tobacco cessation counseling and some details of the counseling and the context in which it was provided.

Prostate Cancer Screening

Medicare covers an annual prostate cancer screening test for men over age 50. Such tests include digital rectal exams (DREs) and prostate-specific antigen (PSA) blood tests. The code for a DRE is G0102, and the code for a PSA test is G0103.

Billing and payment for a DRE, however, is bundled into the payment for a covered E/M service when the two services are furnished to a patient on the same day. If the DRE is the only service provided or is provided as part of a service that is not covered, HCPCS code G0102 may be payable separately, assuming the other coverage requirements are met. One challenge with this screening is that it must be billed separately from an E&M visit.

A practice could optimize this benefit (and overcome the challenge of separate billing) by establishing periodic screening times and bringing Medicare-age men in just for this service. Diagnosis code Z12.5 (special screening for malignant neoplasms, prostate) would be used when billing Medicare for either service. DREs are subject to the Medicare deductible, but no coinsurance or deductible applies to the PSA test.

Home Health Physician Certification

CMS will make no payments for covered home health services that a home health agency provides unless a physician makes a number of certifications.

The physician must certify that home health services are needed because the individual is confined to his/her home and needs intermittent skilled nursing care, physical therapy, and/or speech-language pathology services. Where a patient’s sole skilled service need is for skilled oversight of unskilled services, the physician must include a brief narrative describing the clinical justification of this need as part of the certification, or as a signed addendum to the certification.

The physician also must certify that a plan for furnishing such services to the individual has been established and is periodically reviewed by a physician, and that the services were furnished while the individual was under the care of a physician.

Finally, the physician must certify that the individual had a face-to-face encounter with an allowed provider type no more than 90 days prior to or within 30 days after the start of home health care services. In addition, the encounter must be related to the primary reason the patient requires home health services and the certifying physician must also document the date of the encounter. a

When services are continued past an initial 60-day episode of care, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services. The recertification should be obtained at the time the plan of care is reviewed because the same interval is required for the review of the plan. The physician must include an estimate of how much longer the skilled services will be required and must provide a certification similar to that originally provided.

Hospice Certification and Recertification Requirements

To be eligible for the Medicare hospice benefit, a patient must be certified by a physician as terminally ill. An individual is deemed to be terminally ill if the medical prognosis sets the individual’s life expectancy at six months or less if the illness were to run its normal course.

The certification and recertification is a critical piece of documentation necessary to ensure Medicare payment for hospice services. The hospice facility must obtain verbal or written certification of the terminal nature of the illness no later than two calendar days (by the end of the third day) after the start of each benefit period (initial and subsequent). Initial certifications may be completed up to 15 days before hospice care is elected. Recertifications may be completed up to 15 days before the start of the next benefit period. The certification should be based on the clinical judgment of the hospice medical director (or physician member of the interdisciplinary group) and the patient’s attending physician, if he or she has one. b

The written certification/recertification must include the following:

  • The statement that the patient’s medical prognosis for life expectancy is six months or less if the terminal illness runs its normal course
  • A brief narrative written by the certifying physician—as either part of the certification/recertification form or an addendum to the form—explaining the clinical findings that support this prognosis
  • The benefit period dates that the certification or recertification covers

It should be noted that administering home health and hospice certifications is a cumbersome process that can cause havoc in a typical primary care office workflow. To do so efficiently, healthcare organizations should implement a tracking system, preferably within the electronic health record (EHR) system, and use a care coordinator to oversee the process.

Care Plan Oversight

Care plan oversight (CPO) is a means for a physician to be paid by Medicare for supervision and oversight of patients under either the home health benefit (HCPCS G0181) or the hospice benefit (HCPCS G0182). The home health services may include the following:

  • Development of an individualized plan of care
  • Telephone calls with other healthcare physicians involved with the care
  • Plan-of-care revisions
  • Activities involving coordinating of care
  • Documentation of planning
  • Medical decision making
  • Review of treatment plans and analysis of labs, tests, and data analytics
  • Team conferences

The beneficiary must require complex and/or interdisciplinary care. The physician may not have a significant financial or contractual interest in the home health agency, may not be the medical director or an employee of the hospice, and may not by providing service under arrangement.

The physician must maintain a 30-day log of the covered activities that constitute the CPO. The activities recorded must be related to the diagnosis for which a patient was enrolled in the home health or hospice program. If the physician is treating other diagnoses, they should be reported like any other E&M service with the modifier “GW” appended. The physician also may request payment for face-to-face services related to the diagnosis for which the patient is enrolled in home health or hospice by appending modifier “GV” to the E&M code.

Power Mobility Devices (PMDs)

Power-operated vehicles (POVs)—also known as scooters—and power wheelchairs are collectively classified as PMDs and covered under the Medicare Part B Durable Medical Equipment benefit. CMS defines a
PMD as a covered item of durable medical equipment that a patient uses in the home. To satisfy Medicare’s PMD medical necessity requirements, a patient’s mobility limitation must:

  • Significantly impede the patient’s ability to participate in one or more mobility-related activities of daily living in customary locations in the home
  • Be unresolvable sufficiently and safely using an appropriately fitted cane or walker
  • Impair the patient’s upper extremity function to the point that he or she cannot self-propel an optimally configured manual wheelchair in the home to perform mobility-related activities of daily living during a typical day

CMS has provided on-line guidance outlining additional coverage guidelines for both scooters and power wheelchairs. c The process to obtain a PMD requires that a Medicare patient have a face-to-face examination performed by a physician or other provider. The physician or other provider must then send the supplier a written prescription with supporting documentation, at which time the supplier will respond by creating and sending the provider a detailed product description. The provider then must review, sign, and date the product description and return it to the supplier, at which point the supplier will deliver the PMD to the patient.

The Medicare program pays only for healthcare services that are medically necessary and requires that physicians certify the medical necessity for power wheelchairs or POVs and for some related options/accessories.

CMS has developed a Certificate of Medical Necessity Form for Motorized Wheelchairs (Form HCFA 843) and a similar form for POVs (Form HCFA 850). These forms require information to be completed by the patient’s physician, the supplier, and any other nonphysician clinician involved in the assessment of the patient related to this certification.

Section B of the form contains information representing a clinical assessment of the patient’s current condition. The nonphysician completing this section must be an employee of the physician or a qualified Medicare provider practicing within their scope of practice. For example, physical and occupational therapists meet these standards. The supplier is not authorized to complete Section B.

To ensure physicians are making appropriate and compliant use of such services, physician enterprises should conduct a review of all CPT/HCPCS codes that their providers have reported and identify potential gaps in billing appropriately for these services. New templates or macros also may need to be developed within the EHR to facilitate the required documentation.

Finally, each provider’s overall workflow should be reviewed to ensure all staff members work together efficiently and effectively to deliver worthwhile, fully covered preventive services to Medicare beneficiaries who can benefit from them, and increase the practice’s revenue in the process.

Cathy Zito is CEO, Lighthouse Care Advisors LLC, Cockeysville, Md., and a member of HFMA’s Maryland Chapter.

Joette P. Derricks 
is CEO, Derricks Consulting, Hunt Valley, Md., and a member of HFMA’s Maryland Chapter.


a. See CMS, Medicare Benefit Policy Manual, “Chapter 7: Home Health Services,” revised May 11, 2015.

b. See CMS, Medicare General Information, Eligibility, and Entitlement, “Chapter 4: “Chapter 4: Physician Certification and Recertification Services,” revised Sept. 16, 2016.

c.  CMS, Power Mobility Devices: Documentation & Coverage Requirements, The Medicare Learning Network, CMS, September 2016.


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