Effective Date: December 1, 2020

Purpose:
This policy provides reimbursement guidelines for billing of physician certification and re-certification for Medicare-covered home health services under a home health plan of care.

Scope:
Products included:

• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• Procedure Code 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


• Procedure Code 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 to affirm the initial implementation of the plan of care that meets patient's needs, per certification period

Policy:
Horizon NJ Health shall reimburse both physician certification and re-certification for Medicare-covered home health services when all of the below criteria is met.

Physician re-certification for home health services will be allowed once every two (2) months. Claims billed beyond once every two (2) months shall deny.

Claims for certification and re-certification will be denied if the physician submitting the claim is not the physician signing the home health agency’s plan of care (the primary physician). The place of service on the claim should represent the place where the preponderance of the plan development and review was performed. The date of service billed on the claim should be the date physician signed the certification or re-certification.

The following providers are not eligible to submit for home health certification and re-certification:

• Chiropractors
• Dentists
• Optometrists
• Clinical Psychologists
• Clinical social workers
• Physical therapists
• Occupational therapists
• Speech therapists
• Physician assistants
• Nurse practitioners
• Certified clinical nurse specialists

The physician certification must meet the following requirements:

• The patient needs intermittent skilled nursing (SN) care, physical therapy (PT), and/or speech-language pathology (SLP) services
• The patient is confined to the home
• A home health plan of care (POC) has been established and will be periodically reviewed by a physician
• Services will be furnished while the individual was or is under the care of a physician
• A face-to-face encounter:
  • Occurred no more than ninety (90) days prior to the home health start of care date or within thirty (30) days of the start of the home health care
  • Was related to the primary reason the patient requires home health services
  • Was performed by a physician or allowed non-physician practitioner

The physician re-certification must meet the following requirements:

• Be signed and dated by the physician who reviews the home health POC
• Indicate the continuing need for skilled services (the need for occupational therapy [OT] may be the basis for continuing services initiated because the individual needed SN, PT, or SLP services)

"CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. “The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon NJ Health shall deny physician recertification for home health services (Procedure code G0179) when billed more than once every two (2) months.

Horizon NJ Health shall deny claims for physician certification and re-certification for home health services (Procedure codes G0180 and G0179) when submitted by one of the following specialties: Chiropractors, Dentists, Optometrists, Clinical psychologists, Clinical social workers, Physical therapists, Occupational therapists, Speech therapists, Physician assistants, Nurse practitioners or Certified clinical nurse specialists.

Horizon NJ Health shall deny claims for physician certification and re-certification for home health services (Procedure codes G0180 and G0179) when documentation requirements are not submitted.

Resources:

CMS Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing

CMS MLN ICN 908143, November 2019, Medicare Home Health Benefit

Novitas Solutions, Physician certification and recertification of home health services

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.