American Academy of Home Care Physicians
Promoting the art, science and practice of medicine in the home.

2000 Vol. 12 No. 3
Issn# 1049-0027
Government Update

News from the Federal Register and HCFA:
By: C. Gresham Bayne, MD

Removal of devitalized tissue, without use of anesthesia (G0169)
This code was created because the CPT codes 11040 through 11044 for debridement were created to describe complex surgical services requiring the use of general anesthesia. Many practitioners, including physical therapists, occupational therapists, and nurses, do active wound care under physicians' orders. Active care involves the use of high pressure water jets, scissors, or scalpels. Wound care involving use of dressings, gauze, or medications, but not active tissue removal, should not be coded using HCPCS code G0169. The service to be coded with HCPCS code G0169 typically involves regular removal of devitalized tissues in ulcers or non-healing wounds. We have created this code to eliminate the confusion involved in using debridement codes, some of which have 10 day global periods. This code will be recognized as a therapy service for purposes of the outpatient rehabilitation payment system and will replace the CPT codes 11040 and 11044 for use by physical and occupational therapists. [Ed. Note: code G0169 is approved for .90 RVUs (about $32) for 2000.]

Negotiated Rulemaking for Ambulances finishes work
On February 14, 2000 the process of negotiated rulemaking finished with the announcement of the new fee schedule for ambulances. Payment will begin under the new rule on Jan1, 2001 and phased in over four years. Payment will be based upon a base rate and a mileage rate, with special provisions for paramedic intercepts in rural areas.
Pertinent to the home care population are the restrictions below on destinations to and from which Medicare will now pay for an ambulance: [42 CFR 410.40(c)] (c) Limits on origins and destinations. Medicare Part B pays for ambulance transportation of a beneficiary [42 CFR 410.40(c)(1)] (1) To a hospital or CAH or SNF, from any point of origin; [42 CFR 410.40(c)(2)] (2) To his or her home, from a hospital or CAH or SNF; or [42 CFR 410.40(c)(3)] (3) Round trip from a hospital or CAH or a participating SNF to an outside supplier to obtain medically necessary diagnostic or therapeutic services not available at the hospital or CAH or SNF where the beneficiary is an inpatient. Note that Medicare does not pay for a homebound patient's transportation to a surgicenter, laboratory, non-hospital imaging center, or a doctor's office.

New definition of critical care promulgated.
On occasion, home care physicians are found caring for critically-ill patients in the home. The following quotation from HCFA Program Memorandum B-99-43 cites the circumstances under which such services may be billed as critical care. Note the site of service no longer has to be in the hospital, if reasonable and necessary. (B) Definition of Critical Care Services CPT 2000 has redefined critical care services as follows: "Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient....The care of such patients involves decision making of high complexity to assess, manipulate, and support central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic, or respiratory failure, postoperative complications, overwhelming infection, or other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. It may require extensive interpretation of multiple databases and the application of advanced technology to manage the patient. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of physician attention described above." "Critical care services include but are not limited to, the treatment or prevention or further deterioration of central nervous system failure, circulatory failure, shock-like conditions, renal, hepatic, metabolic or respiratory failure, post operative complications, or overwhelming infection. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility."

Signature Standards Reviewed
As more and more physicians become mobile and need to create orders through electronic means, such as an electronic medical record, it may be useful to review the Medicare Carriers Manual Section on a valid physician signature. Note the reference to both fax and computer methods: 3057. B. Physician (Supplier) Signature Requirement The rules below apply to both assigned and unassigned claims unless otherwise indicated. [14-3-3057.B.1] 1. In a claim for services furnished by an individual physician (or supplier), the physician may: [14-3-3057.B.1.a] a. In an unassigned claim, provide an itemized bill on his own letterhead -no physician signature required. (See =A73001.) An HCFA-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physician's own letterhead. [14-3-3057.B.1.b] b. Sign item 25 of HCFA-1500. (See =A74011.4.) [14-3-3057.B.1.c] c. Sign one time certification letter for machine-prepared claims submitted on other than paper vehicles. (See =A73055.1.C.2.) [14-3-3057.B.1.d] d. Auahorize an employee (e.g., nurse, secretary) to enter the physician's signature in item 25 of the HCFA-1500. (See =A73055.1C1 and 4011.4.) [14-3-3057.B.1.d(1)] (1) Manually [14-3-3057.B.1.d(2)] (2) By stamp-facsimile or block letters [14-3-3057.B.1.d(3)] (3) By computer [14-3-3057.B.1.e] e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physician's signature in item 25 of the HCFA-1500, followed by the agent's name, title, and organization (e.g., a billing agent might enter by stamp. Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service). Alternatively, the agent may simply enter the physician's signature.