American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to provide home care without losing your shirt

Possible hikes in reimbursement may take some of the frustration out of caring for homebound patients

From the September 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Amanda Loudin

When an elderly woman became too sick to leave the house, she called her physician to arrange a house call. The doctor, however, said that he didn't see patients at home and told the woman to go to the local emergency room.

Undaunted, the patient made a few more calls and found a home care agency that would send a physician to see her immediately. The patient was so happy with having someone see her at home that she called her physician again—this time to have her records transferred to the home care agency.

Scenarios like this illustrate how physicians who refuse to see patients at home may suffer the consequences. "We see literally 40 new patients a day who have left their physicians because they don't provide home care," said C. Gresham Bayne, MD, president of Call Doc, a large home care agency in San Diego, Calif., and associate clinical professor of medicine at University of California, San Diego Medical School. "Those who don't get into home care will see their practices hurt."

But physicians find themselves in a bind. While they certainly don't want to lose patients—and income—to home care agencies and doctors who make house calls, they also don't want to spend their time driving to patients' homes. Medicare pays around $70 to see an established patient at home, an amount that often doesn't even begin to cover travel time alone. And even though physicians can bill for time spent on the phone with nurses and reviewing orders and lab reports under Medicare's care plan oversight codes—G0064, G0065, G0066—the bottom line just isn't worth the trouble for many physicians.

That may change soon. Medicare is in the process of revamping its home care codes in a way that could dramatically increase reimbursement for physicians. According to Dr. Bayne from Call Doc, Medicare is considering new CPT codes that would raise average Medicare pay for house calls to $200 for established patients and $300 for new patients. If the new codes are approved, physicians would be able to bill for home care using nine Medicare home care codes instead of the current six. A final decision on the new codes is expected by the end of the year.

It could come at just the right time. The nation's growing elderly population, improved portable technology and patient demand are making home care a growth industry; Medicare paid for 280 million home health visits last year alone, more than twice the number of visits it paid for in 1992.

While you'll probably never get rich from home care, here are some tips to make the best of it—for you and your patients—right now:

Evaluate your practice. The first step is to evaluate your practice to determine how you'd like to be involved in home care. If you have only a few elderly patients or other patients who could potentially benefit from home care, for example, take a limited approach and offer home care as an option to a handful of patients. On the other hand, if the number of elderly patients you see is high, you might explore becoming a medical director of a home care agency-and draw a salary for your efforts.

Find an agency. To provide your patients with home care services without having to visit them at home every other day, establish a working relationship with one or two home care agencies. While physicians are responsible for signing all orders, many leave the majority of the care to the home care agencies, frequently consulting with the nurses, social workers and other agency team members. "Talk to the others on the home care team regularly," said Patricia P. Barry, ACP Member and chief of geriatrics at Boston University Medical Center. "Take advantage of visiting nurses who can be your eyes and ears. They are very experienced and can give you a great deal of information."

While the law gives patients the first choice in naming an agency, most turn to their physician for that decision. If you haven't established a relationship with a home care agency and don't make the selection, social services will—and you'll be stuck working with people you don't know. "Study the agencies and get to know them as you would the hospital with which you affiliate," suggested Joanne G. Schwartzberg, MD, director of the AMA's department of geriatric health.

Maximize your time. If you're going to make house calls, cut the time it takes to provide your patients with home care. Getting to home care appointments, which often turns into the biggest time consumer, can be kept to a minimum by bunching appointments together in a specific geographical area. "You want to minimize your travel time," said Dr. Barry. "Schedule several appointments in one neighborhood. Some of our physicians even set appointments up so that they can stop by to see patients on their way home."

Bill for supervision-carefully. As long as you spend 30 to 60 minutes a month talking to a home care nurse about a patient, signing orders and reviewing lab results—even if you do it on the phone—you can bill for your time. You must have seen the patient in person in the last six months, and you can't have any financial relationship with the home care agency providing the care. (If you're a medical director at the agency, you can't use these codes.) These codes pay about $80 per month.

Be warned, however, that you can count time spent talking about a patient's case only if you are talking directly to the nurse or patient. If a home health nurse talks to your nurse about a patient and your nurse then relays that information to you, you can't bill for that time. In addition, you can't bill for telephone calls you make to patients or pharmacies to adjust medications.

Also keep in mind that only one physician can bill for these services per month. According to Leslie Witkin, a practice consultant with Physicians First in Orlando, Fla., if a generalist and subspecialist are both caring for a patient at a home or hospice—spending time on the phone talking to nurses, reviewing lab tests, etc.—the one who is signing off on orders should be billing for care plan oversight. If more than one physician bills for care plan oversight, though, HCFA tends to pay the claim that comes in first, so bill promptly.

Ms. Witkin also said that physicians who dislike Medicare rules and regulations so much that they don't bother to bill for these services are losing out. "These are patients who you are spending time on, and you can—and should—be paid," she said.

Keep good records. In order to bill using care plan oversight codes for patients at home, you need to keep track of the time you spend with these patients. "Write everything down," said the AMA's Dr. Schwartzberg. "Keep track of your phone calls and document all of the time you invest in these patients. This is important not only for reimbursement, but for potential legal issues down the road."

Ms. Witkin said that one way to track your time is to create a folder of patients receiving their care at home and keep it near your phone. "At the beginning of the period when you discharge a patient from the hospital, start a progress sheet with the patient's name," she said. "Keep documenting the services you provide for that patient, and when you reach 30 minutes, tell the billing person and file the sheet in the medical record."

Use a point person. To better coordinate discussions with staff at home care agencies, establish a point person. "You may have 10 nurses in an agency, and each one may have one of your patients," said Marie O. McCollum, RN, assistant vice president of utilization review, home care division, of Integrated Health Services in Brunswick, Ga. "Rather than having all 10 nurses contact you, channel their reports through one liaison at the agency."

The same goes for your own office. "Teach a receptionist or someone else in your practice to handle the paperwork," the AMA's Dr. Schwartzberg suggested. "Make sure that the receptionist knows the difference between a true emergency that you need to handle right away and a call that can wait until you have time to return it."

Amanda Loudin is a freelance writer based in Columbia, Md.

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