American Academy of Home Care Physicians - Info for Home Care Professional and Health Care Providers: FAQ

I am a physician who would like to start a house call practice. What first steps should I take and what things should I consider when getting started?
Know what you hope to get out of your practice. The easiest means of starting a home care practice is to add home visits to your practice for those patients who are not able to get to your office without difficulty. Many physicians incorporate a half-day session or see the patient at lunch or before/after clinic. Very quickly, you will discover if you wish to do home visits full-time or extend the number of hours that you spend doing home visits. If you are ready to pursue your own full-time home care business, you will need to decide what type of practice you want (primary care, urgent care, etc.) You may choose to supplement your home visit revenue (start-up or long term) by pursuing directorships of hospices, nursing homes or home health agencies, by developing a relationship with a hospital practice, or by working part-time in an ER or urgent care center. In addition to our popular booklets, the Academy now offers a Practice Management Tool Kit containing many helpful articles, Q&A, and standards of conduct. We also hold an annual Practice Management seminar, for both beginning and advanced providers, in conjunction with our Annual Meeting.
How do I justify taking time away from the office to make house calls?
Medicare now pays significantly more for house calls than ever before. New technology allow for complete testing and treatment in the home, and the liability risk from house calls is actually less than that of office-based care. Instead of "losing track" of your frail patients as they migrate through the health care system during a medical crisis, you can encourage them to call your office for management decisions. Complex, immobile patients will no longer slow down your office turnover or compromise staff time. Physicians who make house calls are often perceived as "better" and "more caring" by patients, who often refer relatives for care. Making house calls may actually help grow your office practice!
How do I finance the start-up?
Financing can be from personal resources, banks, investor capital, hospitals, insurers or grants. You can also work as a contractor or employee of a company that provides house calls. Remember, it may be months before you see significant money from insurance payments. Medicare pays in a timely manner, so it is wise to have your Medicare numbers in place prior to starting your practice.
How do I market my practice/recruit patients?
Word of mouth is always the best source of referrals. Other sources include (but are not limited to) discharge planners at hospitals, sub-acute units, and hospices; home care agencies, Area Agency on Aging, various church or religious groups, senior centers, high-rises and apartments, adult day care centers, and your local Alzheimer's Association office. Giving presentations, participating in health fairs, and/or making media appearances are often effective methods of spreading the word.
Do I need to enroll with Medicare? Medicaid?
Unless you are in a wealthy area where your patients can all pay privately, you will need to enroll with Medicare. The decision to enroll with Medicaid generally depends upon your state, the level of reimbursement, and level of bureaucracy that working with the program entails.
Where is the actual Medicare text that defines homebound status?
The Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, defines homebound status and skilled services. Excerpts from this chapter are also included in our booklet, "Making Home Care Work in a Medical Practice." The homebound definition applies to home health agency patients; however, medical necessity must be demonstrated for patients receiving house calls. A CMS intermediary directive outlined the "medical necessity" qualification. Your local Medicare intermediary may issue LCDs (Local Carrier Determinations) further defining the qualifying conditions for "medical necessity."
Where can I find samples of a contract between a physician and nurse practitioner?
The AAHCP has several sample contracts. Please contact our office for specific information.
What type of equipment should I carry with me?
Your equipment will vary according to the type of practice you have chosen to pursue. For a chronic care model, the house call bag may include blood pressure cuffs with interchangeable bulb and gauge (regular, obese, pediatric), gloves with lubricant and hemocult slides, otoscope/ophthalmoscope, glucometer (calibrated daily), peak flow meter, digital thermometer, tape measure, hammer and tuning fork, bandage scissors, toenail clippers (industrial strength), portable scale, sterile scissors, forceps, disposable scalpel, and sterile gauze and tape. A durable soft attach� or overnight bag with multiple pockets works well. Purchase compact equipment to avoid removing instruments from the office. Be sure to include a stationery folder with necessary forms, prescription blanks, appointment cards, progress note paper, and referral phone numbers. Many providers are now experimenting with Electronic Medical Records (EMRs), as the technology has become affordable and easy to acquire and use to become paperless.
Are the costs of driving to the patient's home billable?
No, unfortunately. As the Academy continues its efforts to educate CMS officials about the need to comply with OBRA 89 legislation and pay physicians for the work they do providing beneficiaries with medical care, payment for "travel expenses," remains uncovered by either the "work" or "practice" expense methodologies. Whether it is paid for or not, it is a critical aspect of the unique practice of home visits.
Should I buy or lease an automobile for making house calls?
A reliable and safe automobile is an absolute necessity. Your mileage and other auto expenses will be deductible. Consider leasing an intermediate or larger car, as the greatest risk in performing house calls is the hazard of vehicular accidents. Many providers drive inexpensive, used cars. If the automobile is listed under your business, be careful to prohibit anyone but employees from driving the car, unless you purchase a special additional insurance policy.
Do most physicians work alone or with a team?
Home care/assisted living visits may be delivered by an informal or formal home care team. You will need to decide which professionals will be part of your team and which will provide services on referral. In some systems, this includes a physician, nurse practitioner, social worker, PharmD, nutritionist, visiting nurse, and home health aide. In a more informal system, the provider interfaces with community-based agencies for skilled nursing, rehabilitation, and social services as needed. The local practice environment will determine the model best suited to your practice.
Do most practices have an office staff and office space? Do I need to hire a receptionist, or is voice mail sufficient?
Unless you have large amounts of capital, you will likely start (and may stay) working out of a home office unless you already have a practice. Until you need it, do NOT rent office space. Do what it takes to get the practice off the ground, but hire basic office staff as soon as you can. The key to any efficient mobile practice is in the administrative office (dispatcher/triage person).
How many patients does the "typical" house call provider see in a week?
Five patients can be seen in their homes in a half-day session; more, if visits can be scheduled in close proximity. On average, patients are seen 10-12 times per year; more often when less stable, and less often if very stable. An experienced NP or PA can handle a caseload of 60-70 stable homebound patients on a half-time basis.
I'm the only physician in my practice. How do I handle vacation/holiday coverage?
Consider whether your system will allow NPs/PAs to take calls and whether there is a physician back-up for medical issues outside the scope of the NP. Nurse practitioners can often identify a collaborative physician who can serve as a back-up for medical issues. Determine the NPs scope of practice, such as whether the hospital allows NPs to admit and/or interact with hospital staff when managing inpatients.
How do I recruit providers?
Often, the best recruitment is done locally by word of mouth. If you are unable to find the right person(s) locally, you can advertise or contact residency program directors from primary care programs and geriatric fellowships. List-servs can be very useful.
My patient needs a service Medicare won't pay for. What do I do?
Try to arrange for someone else who will be paid for the service to perform the service. For example, for labs that require an iSTAT, you can use home health or draw the blood and give it to the caregiver with a prescription and directions to the nearest lab drop-off point.
Should I hire billing staff or use an outside company?
This can be a complicated decision. If you have experience with billing and coding and have billing software that you or your staff are comfortable using (or can acquire such software at reasonable cost), then you may wish to bill yourself for the greater accountability this will provide. If you decide to use a billing service, talk to colleagues whom you trust, be sure to get references and make sure you have an escape clause. If you are unhappy with your billing company, find someone else to work with!
How do I make house calls economically feasible?
The Academy has been victorious in getting CMS to raise Medicare payment levels, thereby making house calls a financially viable option for the primary care physician. The 2006 rate change made by CMS makes reimbursement for visits to assisted living facilities comparable to that of house calls. It is crucial to stay productive while you are out "on the road," and vital that you become well acquainted with Medicare rules for coding and billing. If you are able to overcome the overhead problems inherent in the practice of home care medicine, you can expect to be reimbursed at a rate competitive with income from a clinic-based outpatient practice. The best way to ensure adequate income is to join a house call group medical practice or utilize the expertise of a house call management services organization specializing in provider services.
What are the rules and regulations associated with involving PA's in long-term care?
For nursing home related questions, see the American Medical Directors Association website, www.amda.com. For home care related questions, please refer to the AAHCP booklets "Making House Calls a Part of Your Practice" and "Making Home Care Work in a Medical Practice."
Do home care physicians bill "incident to" under the Medicare Policy Chapter 15, Section 60, Services and Supplies Furnished Incident to a Physician's/NPP's Professional Service?
No, valid housecall programs in the private sector should NOT bill "incident to," although some attempt to do so. The reason they might attempt it is because "incident to" services are paid based upon 100% of the allowed physician fee schedule, whereas billing correctly under the NPP's provider number pays at 85% of the allowed PFS amount.
The reason no one logically can or should bill "incident to" is that there has always been a requirement for DIRECT supervision for "incident to" billing (physician/NPP in the building and immediately available at the time of provision of services). Why would one bill "incident to" when one payment will not cover the cost of both physician and NPP present during the housecall? Of course, a driver/employee, non-licensed staff accompanying the physician and taught to draw blood, do EKGs, etc. can be a valid reason to bill "incident to," but the payment would not change, since the physician/NPP is already there billing the full amount.
One EXCEPTION: The direct supervision rules are excepted in HPSAs. One OBSERVATION: AAHCP has made comments from time to time about the necessity of having a physician/NPP present when the home health nurse does wound treatment. If the nurse were a bona fide employee of a bona fide medical group with the same NPI billing credentials and the care was reasonable and necessary, the physician/NPP could bill the nurse's wound care as "incident to" in addition to their own services.

BILLING — GENERAL

What CPT codes do I use to bill a visit to a patient's home or to an assisted living facility?
Home visits are billed using codes 99341-99350. Visits to domiciliary care facilities are billed using CPT codes 99324-99337. For specific code information, including, Approximate Medicare Allowable Charges, see our booklets, "Making House Calls a Part of Your Practice," or "Making Home Care Work in a Medical Practice." These booklets are updated annually.
Does AAHCP update the CPT codes and Medicare payment rates every year?
Yes, the Academy updates its booklets and website annually to reflect the current codes and fee schedule. In 2006, CMS accepted the AAHCP proposal to pay providers caring for patients in domiciliary care facilities rates comparable to those paid for house calls. This resulted in new rates applying to nine instead of the previous six codes equivalent to codes used for home visits.
What place of service codes do I use for house calls and domiciliary care?
There are several place of service codes that affect providers of home care medicine. For house calls, use Code 12 (Home), which covers any location other than a hospital or other facility where the patient receives care in a private residence. For domiciliary care, the codes are as follows: Code 13 for Assisted Living Facility, Code 14 for Group Home, Code 15 for Mobile Unit, Code 33 for Custodial Care Facility, or Code 34 for Hospice.
Can I bill all new patients up front, even if they claim to have Medicare?
No. You must bill CMS for all Medicare services unless you opt out for two years, meaning you cannot receive any monies from CMS for two years. (If you opt out, you must forewarn patients before they are seen).
What is the correct provider type code and practice type code to list on a Medicaid application?
Medicaid provider applications vary from state to state. Each provider's NPI application (which replaces the UPIN) requires selecting provider type(s). Over time, Medicaid should move to using the same taxonomy. Unfortunately, they did not include home medicine as a practice type (yet).
How do I bill for hospice?
Effective April 1, 2002, CMS implemented the following changes in reporting services for hospice beneficiaries. All bills submitted to Medicare carriers for patients enrolled in a Medicare hospice program must contain one of the following modifiers:
GW: Service not related to the hospice patient's terminal condition
GV: Attending physician not employed or paid under agreement by the hospice provider
Q5: Service furnished by a substitute physician under a reciprocal billing arrangement
Q6: Service furnished by a locum tenens physician
What codes do I use to bill a prolonged visit?
Prolonged Evaluation and Management Services are now covered for house call codes. For example, if an initial house call Level 4 (CPT 99344) has >90 minutes with the patient, both 99344 and 99354 could be billed. If a subsequent house call Level 4 (CPT 99350) has >90 minutes with the patient, both 99350 and 99354 could be billed. Additional � hour increments could be billed using CPT 99355.
The specific citation is as follows:

"15511.1 PROLONGED SERVICES AND STANDBY SERVICES (CODES 99354-99360)
15511.1 Prolonged Services (Codes 99354-99355)

A. Required Companion Codes. Pay prolonged services codes 99354-99355 when they are billed on the same day by the same physician as the companion evaluation and management codes and: br>
- The companion codes for 99354 are 99201-99205, 99212-99215, 99241-99245; or 99341-99345, 99347-99350 to be used;"
Many of our home care patients have primary or secondary psychiatric diagnoses, and we provide the primary medical care, including medication management. We have been receiving reduced payment for psychiatric diagnoses such as Delirium, Depression and Agoraphobia from our Medicare carrier. Should we use psych codes?
In general, psychiatric ICD-9 codes (e.g. 291-313, excluding 313.0 — Alzheimer's) should only be used if substantially all of the visit is focused on the psychiatric problem. In such cases, Medicare pays a smaller portion of the allowable cost than for comparable visits for medical diagnosis. Thus, the patient owes more per visit. The total owed to the physician is the same, however.
See also: http://www.aafp.org/fpm/20001100/15unde.html
If a patient has Medicare primary and Medicaid secondary, without any other co-insurance, will I get any payment from Medicaid?
With dual eligible patients (Medicare and Medicaid), most states have set their Medicaid fee schedule at about 80% of Medicare so that they will not be obliged to pay the Part B co-pays. For medical services provided to such patients in those states, if you are enrolled as a provider with the government health plans, you are not allowed to collect more than the 80% of the Medicare fee schedule that Medicare pays (since the 80% of Medicare covers 100% of the Medicaid allowed charges in most states). The Balanced Budget Act of 1997 defined this as legal at the federal level.
How do I find out if a patient is eligible for hospice benefit?
The guidelines for hospice eligibility have been adopted by Medicare hospice intermediary, so can be found on its Web sites at: http://www.ugsmedicare.com/providers/lmrp/documents/Hospice%20LCD%2001-01-04.pdf. In addition, these guidelines are available in PDA format at www.infingo.com/mninfo.htm. You have to also download the reader to view the content on Palm or Windows PC PDAs (Free). Individual Medicare-certified hospice programs are permitted to have more restrictive eligibility criteria, such as limiting enrollment to patients who have certain diagnoses or who have a caregiver living with them.
How do I fold telephone calls into the next face-to-face visit?
Phone calls area always bundled into the nearest-in-time E/M code when they do not qualify for Care Plan Oversight. In clinical documentation, by referring to patient phone calls since a prior visit, it may be possible to increase the level of the history while phone calls to other people may increase the complexity of decision making. This can permit use of a higher reimbursed Evaluation and Management CPT code. If you make phone calls during a home visit to patient relatives or caregivers, or even skilled nurses, the aggregate time of the visit and calls counts towards care coordination/counseling- face-to-face visit time- which can be used in lieu of the E/M clinical charting requirements to enhance reimbursement.
Can I see a Medicare patient in his or her home who does not qualify for a house call and charge a fee as long as the patient or I don't file any claim with Medicare? Can I charge Medicare for a hotel call to a sick patient who is on vacation?
It is illegal for any physician to take money from a Medicare fee-for-service patient without billing Medicare first unless the doctor has had them sign an appropriate Advanced Beneficiary's Notice for non-covered services or "opted out" of Medicare as a Participating Provider for a minimum of two years.
The term "opt-out" means the doctor will be unable to participate in CMS reimbursement for two years, and that patients will have to pay for all rendered services, even ones that otherwise would have been covered by Medicare. The "opt-out" rules apply to all organizations for which the physician works, as it is tied to the individual physician, not the entity(s) through which he or she practices. In other words, if a physician sees patients as a member of a medical group which is a Medicare Participating Provider, he or she CANNOT act differently by taking cash from Medicare patients while moonlighting on a hotel visit. Hence, the issue of the patient not being housebound is irrelevant to the question of taking cash: you cannot do it unless you "opt out" of the Medicare program (or have the member sign an appropriate ABN)...and that means from all your other clinical activities as well!
How do I "opt out" of Medicare?
According to section 4507 of the Balanced Budget Act of 1997, certain Medicare physicians and practitioners are permitted to "opt out" of Medicare for two years for all covered items and services that he or she furnishes to Medicare beneficiaries.
In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician or practitioner, and to pay the physician or practitioner without regard to any limits that would otherwise apply to what the physician or practitioner could charge.
To opt out of Medicare, participating physicians must first terminate their Medicare Part B participation agreement. Participating providers are only permitted to opt out at the beginning of each calendar quarter. To do this, a provider must submit a valid affidavit at least 30 days before the first day of any quarter (January, April, July or October). Non-participating providers and practitioners may opt out at any time. Certain healthcare provider categories cannot opt out of Medicare.
What if you finish a house call and the patient asks you to stay and go through all of his or her medications, throw out the expired ones, consolidate the duplicates and change the oil in their car for $100 cash? Is this illegal?
Organizing and consolidating the extended pharmacy in the home may be a medically reasonable and necessary service for some patients. Bill the appropriate E/M code for the home visit and the prolongation code if the time is documented and more than 30 minutes than the typical time for the level of home visit billed has expired. You would not accept cash for such services since they are covered under existing CPT codes. However, nothing in the CMS rules precludes billing and collecting cash from patients for non-medical services, such as changing the oil in their car.
What about Medicare HMO patients?
Medicare HMO patients may be treated as "cash pay," as none of the restrictive payment rules apply. You should, however, consider giving them an EOB, as increasingly some HMOs are cognizant of the value in paying Medicare rates for house calls and may reimburse the patient at that level.
Is there an official Medicare position on billing physician home/domiciliary care visits at Adult Day Care centers?
To our knowledge, no, you cannot bill for services to an Adult Day Care setting, as it is neither an office nor a home.
Is it OK to exchange information about the fees I charge with other physicians?
Physicians should be very cautious about sharing information with one another concerning the fees they charge for physician services. According to the antitrust laws, exchanges of price and cost information among competing health care providers may have an anticompetitive effect that outweighs any pro-competitive justification for the exchange. In particular, exchanges of future prices for provider services are very likely to be considered anticompetitive.
If I'm an opt-out provider, can I bill a code for after hours care using the ABN?
All of the codes below are "B" rated codes, meaning they are bundled into the relevant E/M code:
99050 after hours care
99051 weekend care
99056 out of office services
99060 out of office emergency care
Where are the code types (A, B, C, N, etc.) posted?
Go to your Carrier website and look for the 2008 Physician Fee Schedule. The type of code is listed in one of the left hand columns and they are national designations.

BILLING — CERTIFICATION AND RE-CERTIFICATION

What codes are used to bill for certification and re-certification?
The HCPCS code for initial certification of home health care patients is G0180. This code applies only to new orders and there should rarely be more than one bill for a particular patient during any 60-day interval. Code G0179 is used when a physician re-certifies a subsequent episode of care. Typically, this will occur every 60 days in prolonged episodes and may also be used if a patient requires a complete renewal of orders midway through a 60-day interval due to a change in condition. (Be careful not to use this code when certifying medical equipment and other services, and note that it does not apply to the many "change orders" or other documents that a home health agency sends for physician signature throughout the care process).
Do the certification/re-certification codes include physician certification of hospice?
No. These codes are used only when the physician certifies or re-certifies home health plans of care.
Can an NP or PA bill for initial certification and re-certification?
No.
Can home care referrals initiated from the hospital be billed for certification?
No. The time to make a home care or hospice referral is bundled into hospital and nursing home discharge day codes.
What type of documentation is required for billing certification/re-certification?
While no specific documentation requirements were enumerated, physicians should retain a copy of the signed HCFA-485 (home health plan of care), signed interim or telephone orders, and any other documentation that supports the provision of these services.

BILLING — CARE PLAN OVERSIGHT

What codes are used to bill for Care Plan Oversight?
Care Plan Oversight (CPO) of greater than 30 minutes for home care is billed using G0181. CPO of greater than 30 minutes for hospice care is billed using G0182.
What are the rules governing NPs/PAs billing for CPO? Does the physician need to see the patient?
NPs and PAs can bill for Care Plan Oversight. The Medicare Benefit Policy Manual, Chapter 15, clarifies that nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for CPO and outlines the requirements for billing. They are reimbursed at 85% of the physician rate. There is no requirement for the physician needing to see the patient in order to sign a 485. Billing for certification requires that you attest that the patient is under your care. For CPO, a face-to-face visit must have occurred within six months prior to CPO date of service.
Can a NP or PA sign the plan of care for CPO?
No. Medicare regulations require a physician to sign the home health plan of care. However, if the NP/PA performs 30 minutes or more of CPO, and has his/her own billing number, he/she can bill independently for those services.
Can the 30 minutes of CPO be split between physician and NP/PA?
No. Only the practitioner that performs can bill for the service. That person must perform and document 30 minutes or more of CPO in the calendar month.
How are certification/re-certification and CPO billed?
Physicians must use Form HCFA-1500. The claim must include the six-digit Medicare provider number of the home health agency in block 23 of the form.
What type of documentation is required for billing CPO?
The documentation of work, such as discussing the patient's care with the home health agency or other health care professionals, arranging for services, reviewing records or lab data, revising the plan of care, completing forms and documenting supervision, should be maintained in the record. The services furnished, the dates, and length of time for each service should be included in the record.
I've read about Care Plan Oversight codes 99339-99340. Can I use them?
These codes can be used, but Medicare will not reimburse for them.
Where can I obtain information regarding non-physician practitioner (NPP) payment for Care Plan Oversight?
Please see our "Public Policy" page for the final CMS ruling on NPP signings. Previously, only the physician of record as signing the 485 could be paid. However, retroactive to January 1, 2005, NPPs can be paid when meeting the usual documentation and medical necessity requirements in the Transmittal.
Can podiatrists bill for CPO?
The CMS manual for home health care states that the definition of �physician� includes MD, DO and DPM. Podiatrists can certify home care plans of care related to conditions within their scope of practice (as determined by their licensing state) and, therefore, should be able to bill for certification/recertification to Medicare and CPO to all payers.

TECHNOLOGY

Do most house call physicians provide labs, X-ray, EKG, and other ancillary services in the home?
Some physicians do carry hand-held EKG, goniometer, fingertip pulse oximeter, or andioscopes. Many are able to have venipuncture, portable X-rays, and EKGs performed by independent mobile companies. You may need to work with your hospital, home health agency, or develop the ability yourself if these services are not available in your area. The decision to add ancillary services can be a difficult one, and a choice you will want to consider unless your start-up business plan has included X-ray, lab, and other diagnostic services. Since the decision is often based largely on financial timing, leasing equipment may make sense.

CLINICAL MATTERS

What about wound care in the home?
The physician is ultimately responsible for a wound, even in home care. While physicians typically and appropriately depend upon nurses to plan and implement care of wounds, this should not promote disinterest by the physician. If IV antibiotics are required or when a wound is present in a patient receiving parenteral or enteral nutrition, collaboration will be necessary between the home care nurse, home infusion pharmacist, and physician. The Academy has developed An Approach to the Management of Pressure Ulcers: A Home Care Perspective to enable primary care physicians, NPs, PAs and nurses to use best practices in preventing and treating typical pressure ulcer wounds found in home care. The monograph covers all aspects of wound care management and is available on CD-ROM from the Academy. (Category 1 CME also available).

ELECTRONIC MEDICAL RECORDS (EMRs)

How do I manage the volume of paper medical records? Are EMRs the answer?
There are many benefits to choosing an electronic medical record. Many providers of home care medicine find that a paperless office is now easier than ever and more convenient, whether a solo provider or a large multi-specialty group. Possible benefits of an EMR include improved record keeping, recording and documentation, better communication, and availability of your records at any location. For a detailed presentation on assessing your needs, EMR features, and deciding which one is right for you, see "Choosing an Electronic Medical Record" in the Practice Management section of our website.
How do I choose the right EMR, and what about IT support?
Begin by assessing your needs and anticipated growth rate. Consider whether you wish to purchase an integration or separate system. There are several inexpensive, user-friendly programs on the market. The Academy list-serv can be a great resource in learning what other practices have used. For small groups, you may not need IT support beyond that which is provided by your software vendor, however, a support contract with a local software group is often desirable. For more information, see "Choosing an Electronic Medical Record" in the Practice Management section of our website.

MALPRACTICE

What should I do about malpractice coverage?
The AAHCP recently performed a Lexis Nexis search that revealed only three cases involving house call practices and malpractice. The actual med-mal risk in this type of practice is low. However, some providers have reported difficulty getting malpractice coverage despite the low risk. Call your medical malpractice insurer and ask to speak to their actuary. You may be able to obtain reduced rates based on the lower volume of patients during your house call days and based on the lower malpractice exposure within the geriatric population. If the premium shock is too great to bear, consider a "shared risk" policy for your group or ask for a large deductible that indicates to the carrier your assessment of the low risk you anticipate. For more information, see the "Malpractice Information," section of the Academy's website on the Member Resources page.

STARK RULES

What do I need to know about Stark rules?
The "Stark law" prohibits physicians from making referrals to providers who render "designated health services" if referring physicians have an ownership or investment interest in or compensation arrangement with the providers. Two provisions are of particular interest to Academy members, the Personal Service Consulting Arrangements Exception and the Payment Methodology rule. For details, see the April 2004 issue of Frontiers or visit the Information for Home Care Professionals section of our website.
Where can I find the latest updates to the Stark rules?
On September 5, 2007, updates to the Stark rules were published in the Federal Register, revealing a useful change for physicians serving as medical directors of home health agencies (a role that falls under Stark). The previous requirement that compensation be at fair market, based upon surveys of emergency room physicians or published salary surveys of similar specialists has been removed. Fair market compensation is still required, but no specific definition is given. Other requirements about advance determination of compensation and no link to number of referrals remains. For an advance view of the rules, see http://www.cms.hhs.gov/PhysicianSelfReferral/Downloads/CMS-1810-F.pdf. Pages 20-23 address fair market value. Pages 457-458 address the special provision for home care physicians.
I have been working with a home health agency who is asking me to see their hospice patients and they will pay for it. Are there any Stark violations?
Hospices are excluded from Stark regulations, but anti-kickback rules apply. For Medicare patients, if you are not the primary physician (i.e. certifying the hospice admission), you must bill the hospice for the visit(s). [Carrier will deny claim unless you are the primary physician]. You should have a written contract with the hospice. You may agree on any amount/fee schedule, but the hospice will only be reimbursed by Medicare (in addition to their per diems) at the Medicare fee schedule rate. If you have a medical director type relationship, you also bill the hospice at your negotiated rate.

STANDARDS OF CONDUCT/ETHICS

Is there a set of standards or ethics common to all home care physicians?
Yes. The AAHCP has developed a Standards of Conduct that can be found in the Member Resources section of our website. The AMA Principles annotated for Home Care are also available from the AAHCP.

CREDENTIALS AND TRAINING

Is there a standard credential for those practicing home care medicine?
Yes. The Home Care Credentialing Examination enables home care medical providers to demonstrate their proficiency. Patients also benefit from proficiency testing and the Academy's recognition of those who receive the credential since the exam assesses the knowledge and skills identified by respected exerts as necessary to provide safe and effective medical care in the home. For information about the exam, visit http://www.aahcp.org/hccei.shtml.
Is training available for Medical Directors of HHAs?
Yes. The AAHCP offers training and certification specifically for home health agency (HHA) directors. As models for reimbursement to HHAs stabilize, interest is growing among agency management to have involved medical directors. If you or your agency is interested in having a custom course/certification examination designed, please contact us.

PROMOTING HOME CARE MEDICINE

I want to get the word out about the benefits of home care medicine. How can I help?
Join the Academy! If you are not already a member, visit the Membership page of our website for information about member benefits and opportunities. The American Academy of Home Care Physicians is a 501(c)(3) nonprofit organization, offering many opportunities for donations and sponsorship. Individual and corporate contributions are welcome and are tax deductible. Donations can be given as unrestricted funds or to support specific projects such as educational seminars, conferences and the AAHCP's Annual Scientific Meeting, creation and updating of Academy publications, AAHCP website updating, and administration of the home care certification examination. Memorial and tribute gifts can also be made in memory or honor of an individual. If you are practicing home care medicine, you can also help spread the word by speaking about house calls at local or national meetings of your professional associations and/or writing newsletter articles.

RESOURCES

Where else can I find resources?
The AAHCP offers many publications, tool kits, templates, a bi-monthly newsletter and a member list-serv, plus members-only resources on our website.
We also have a section on our website entitled "Links to Other Sites" which contains helpful links to many medical organizations, government agencies, member links, and associations. The Academy holds an Annual Scientific meeting, Practice Management seminar, and co-sponsors other meetings on home care medicine nationwide.

Revised July 18, 2008