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NE Rural Health Association Certified Rural Health Clinics Rural Health Clinic Billing & Coding Janet Lytton, Director of Reimbursement Rural Health Development.

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Presentation on theme: "NE Rural Health Association Certified Rural Health Clinics Rural Health Clinic Billing & Coding Janet Lytton, Director of Reimbursement Rural Health Development."— Presentation transcript:

1 NE Rural Health Association Certified Rural Health Clinics Rural Health Clinic Billing & Coding Janet Lytton, Director of Reimbursement Rural Health Development Kearney, NE April 15,

2 2 Changes in CMS RHC billing regulations; Understand the impact of CMS changes to the RHC Understand the general billing and many billing "challenges Q & A

3 3 RHC MEDICARE BENEFIT POLICY Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 166 issued 1/1/13, effective 3/1/13 MM8504 issued 11/22/13 updates effective 1/1/14

4 RHC STAFFING RHC Staffing MUST employ NP or PA (W-2 or owner) NP, PA or CNM at least 50% of clinic hours A Locum Tenens NP or PA would not meet reg It has been proposed to allow contract services to meet this regulation, however, it has not be approved 4

5 RHC UPDATED REGULATIONS 40.1 – RHC Visit Location Clinic, Home, ALF, NF, SNF Any location except IP or OP hospital or CAH Medicare IP Rehab Fac; Hospice Facility In a location other than the RHC if: Practitioner is compensated by the RHC Cost of service is included in the RHC cost report RHC is required to post hours of operations All services during scheduled hrs are RHC services It was discussed to have clear schedules Cannot rotate from clinic to hosp during RHC hrs 5

6 Medicare Part A Revenue Codes 521Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All services and CPT codes, I.e. drugs, supplies, are bundled with the visit code charges, your system will have itemized 6

7 RHC UPDATED REGULATIONS 40.3 – Multiple Visits Same Day, Payable if Patient has second visit for additional DX A medical visit and a mental health visit same day IPPE and Medical Visit and Mental Health Visit (up to 3) AWV and a Mental Health Visit Clinic visit and Hosp admit is per your MAC WPS & Cahaba will allow if medically necessary 7

8 RHC UPDATED REGULATIONS 40.4 – Global Billing All procedures in the RHC are not subject to Globals If RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 mod If RHC prov performs hosp proc, bill w/54 mod, and then bill each visit at clinic level as not in global Services never included in global surgical package Initial visit to determine surgery required Visits unrelated to DX for surgical procedure Treatment for underlying condition or an added course of treatment which is not part of normal recovery 40.5 – 3-Day Payment Window RHC services are not subject 8

9 RHC UPDATED REGULATIONS 50.1 – RHC Services Physician Services & services & supplies incident to NP, PA, CNM Services & services & supplies incident to CP and CSW Services & services & supplies incident to Visiting Nurse services in HHA shortage area Medicare allowed Preventive Services Influenza, Pneumococcal & Hepatitis B Vaccinations IPPE AWV All Medicare-covered preventive services 9

10 Medicare RHC Covered Services E & M services Procedures Professional Component of diagnostic tests Injections Dressings Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals not separately billable for RHCs but indirectly paid CMS Manual Chapter 13 Section 50 10

11 GLOBAL BILLING 40.4 – Global Billing All procedures in the RHC are not subject to Globals If RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 mod If RHC prov performs hosp proc, bill w/54 mod, and then bill each visit at clinic level as not in global Services never included in global surgical package Initial consultation Visits unrelated to DX for surgical procedure Treatment for underlying condition or an added course of treatment which is not part of normal recovery 11

12 RHC UPDATED REGULATIONS 50.3 – Emergency Services Neither IRHCs or PBRHCs are subject to EMTALA Must have drugs & biologicals commonly used in life-saving procedures Non RHC Services MCR excluded services, i.e. dental, hearing & eye tests Technical component of an RHC service Laboratory Services DME, Prosthetic devices, Braces Ambulance Services Hospital Services, ASC, MCORF Telehealth distant-site services Hospice Services (if for DX of hospice) Auxiliary Services, i.e. language interp, transp, security 12

13 RHC UPDATED REGULATIONS 80.1 – Charges & Waivers Must charge all patients the same rates May waive copays and deductibles after good faith determination made that pt is in financial need but cannot be on a routine basis (42 U.S.C. 1320a7a(6)(A)) 80.2 – Sliding Fee Scale Not required, but may have Must be applied to all patients Policy must be posted If based on income, must document that info from pt Copies of wage statements or income tax return no required Self-attestations are acceptable 13

14 RHC UPDATED REGULATIONS 90 – Commingling Sharing space, staff, supplies, equipment and/or other resources with an onsite Medicare Pt B or Medicaid FFS practice operated by the same RHC providers. Commingling is prohibited to prevent: Duplicate reimbursement or selectively choosing a higher or lower reimbursement rate for services May NOT furnish RHC services as a Pt B provider in the RHC or in an area outside the RHC such as a treatment room adjacent to the RHC during RHC hours of operation If RHC is in the building with another entity the RHC space MUST be clearly defined. If RHC leases/rents space, all costs must be offset by the fees paid Does not prohibit provider going to hosp for emergencies Must follow schedules for hospital and RHC time 14

15 PHYSICIAN SUPERVISION – Physician Supervision At least one supervisory visit every 2 weeks onsite CMS has a proposed rule submitted in the Feb 7 Federal Register to allow the off site reviews to be completed, but as off today, the regulation has not been changed. It is expected that by the end of the year, these proposals will be put in place. 15

16 HOSPICE SERVICES 200 – Hospice Services Can treat Patient for condition not related to hospice DX, must use a condition code of 07 on claim to be paid If treat hospice ailment, cannot bill for visit, even if medically necessary and must look to the hospice company for payment or write off. Cannot send to Pt B. CMS has asked for methods to allow for these services to be billable but at this time, they are not. Providers should coordinate care with the Hospice Co. 16

17 RHC UPDATED REGULATIONS 210 – Preventive Health Services Only the professional services are billed as RHC TCs are billed as nonRHC Must use the appropriate G-codes Flu and Pneumo Vaccines Hepatitis Vaccines Many preventive services have no copay or deductible Diabetes Counseling and Medical Nutrition Services Not separately billable but incident to service Costs allowed on the cost report 17

18 2014 Medicare Rates Patient Deductible = $147 per year IRHC Rate = $79.80/visit PBRHC PPS Hospital Rate = $79.80/visit PBRHC <50 bed hospitals = No limit 18

19 Forms & Paperwork Required Consent to be treated Authorization to Bill HIPAA Privacy notification Medicare Secondary Payer Questions asked (keep 10 yrs) Pub Chapter 3, section 20 Required each time the patient presents to the clinic ABN issued if applicable Given when service does not meet medical necessity Routine services contractually non-covered do not require an ABN, I.e. physical, can use the NEMB form Surgical Consent Coordination of Benefits Customer Service for CWF am–8 pm EST TDD Beneficiaries, providers, attorneys, third party payers 19

20 All billable services must be documented in the patient record to support billing of procedures and E & Ms Each service must be specific CBC is only a CBC, not CBC with differential Injection given must be ordered in chart and also noted as given by the nurse Lesions must be noted as to size, number, method of removal, closure method Follow-up or plan with patient instructions must be documented If more than one visit per day, document date and time If counseling is reason for visit, then time in and out can be used to determine E & M Level 20

21 PATIENT RECORDS All pages of the Medical Record must have patient identifier All Reports must be reviewed and signed off with patient receiving results that is documented All documentation must be authenticated Signature Electronic signature – affirmation and password protectedDO NOT leave screen on when leave room Stamped signature is not allowed (CR5971, SE0829) with the exception for a provider that is disabled and cannot sign his/her name 21

22 Coding Levels of Care DOES IT MATTER HOW WE CODE A VISIT? Patient payment is affected Medicare considers OVER CODING as a violation of the fraud and abuse regulations because of the additional reimbursement Medicare considers UNDER CODING as a violation of the fraud and abuse regulations because it encourages patients to overuse the clinic 22

23 All Procedure Codes that are normally performed in a physicians clinic are applicable in the RHC If your coder is also your biller, the knowledge of what service to bill to which payer is imperative Some CPT codes will have to be split billed, i.e. EKG, xray prof & tech comp 23

24 Productivity Standards Physician FTE (Full Time Equivalent = 40 hrs/wk, 52 wks/yr or 2080 hrs year) 4,200 visits per each FTE PA, NP, CNM 2,100 visits per each FTE VISITS OF ALL PAYER CLASSES ARE COUNTED TO DETERMINE PRODUCTIVITY STANDARD 24

25 What is a Visit? Face-to-Face with the Provider Physician, PA, NP, CNM Clinical Social Worker or Clinical Psychologist Medically necessary Does it require the skills of a Provider? Payer Class All payer classes are counted in the total visit count Place of Service Clinic, Home, NH, SNF/SW B, Scene of Accident Level of Service All levels apply, to include procedures To include all services incident to 25

26 Medicare RHC Covered Services E & M services Procedures Professional Component of diagnostic tests Injections Dressings CMS Manual Chapter 13 Section 50 26

27 RHC Covered Services Physician services NP, PA & CNM services Services & Supplies incident to provider service Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals not separately billable for RHCs but indirectly paid Visiting nurse services in non HHA area Clinical psychologist & clinical social worker CP & CSW supplies & services incident to 27

28 NonCovered as RHC Services (Covered if Billed to Correct Payer) Hospital patient services Lab tests (except venipuncture is part of Visit) Part D Drugs & Self administrable drugs DME Ambulance services Technical components of diagnostic tests i.e. xrays & EKG, Holter Monitoring Technical components of screening services i.e. screening paps/pelvic, PSA Prosthetic devices Braces CMS Pub Ch 13, Sec 60 &

29 Medicare Covered But Nonbillable Services Nurse service w/o face-to-face visit or incident to visit I.e. allergy injection, hormone injection, dressing change, venipuncture Provider MUST be in clinic to have incident to CMS Manual Chapter 13 Section Telephone services CMS Manual Chapter 13 Section 100 & 120 Prescription services CMS Manual Chapter 13 Section 100 &

30 30 o Routine INR visit for lab o Simple suture removal o Dressing change o Results of normal tests o Blood pressure monitoring o B12 injection o Allergy Injection o Prescription service only

31 ACCURATE CODING Compliance Policy Required if practice receives Medicare dollars Levels coded accurately = correct reimbursement Reimbursement difference from a level 3 and 4 of an established patient is approximately 50% more than the lower level charged As an RHC this is important due to the 20% copay based on the actual charge billed for Medicare 31

32 Better documentation does not mean MORE documentation checklists are not always a good practice just because a system is checked it doesnt mean it was examined If it isnt documented, it didnt happen if audited, the record must stand alone - Many times work is done, but no documentation Providers tend to undercode their cognitive services Levels coded accurately = correct reimbursement 32

33 Definitions: New Patient Patient who has not had any professional services from that provider or any provider in the same specialty who are part of the same group practice within the past 3 years. If seen in the hospital and then in the clinic and if billed under a different tax ID number, then the patient is considered new; if same tax ID number patient is considered established. Established Patient Patient who has received professional services from the provider or any other provider in the same group within the past 3 years. 33

34 Definitions: Preventive CPT codes CPT codes for physical exams based on age Use when patient has no significant complaints or follow up of ailments Medicare does not pay for Preventive physical CPT codes with the exception of the Introduction to Medicare Physical, paps, pelvic, annual wellness visit, PSA, etc. (those listed in the Medicare beneficiary booklet) 34

35 Definitions: Time Used to determine E & M Level when counseling and/or coordination of care is >50% Outpatient time is face-to-face time Inpatient time is unit/floor time Must document total time spent in minutes document what the counseling was about and/or what coordination of care was provided State Counseling or Coordination of care greater than 50% Counseling can be visiting about ailments, teaching, planning for treatments, etc. 35

36 Definitions: Concurrent Care Similar services i.e. inpatient subsequent care, to the same patient by different providers of different specialties on the same day but must be for different problems. Example: Orthopedist seeing patient after knee surgery; family physician seeing patient in hospital for diabetes. As long as different ICD 9 Diagnosis codes, both are allowed when different specialties. 36

37 Significant, separately identifiable E/M service by same provider on the same day of a procedure or other service. Append to E/M code, I.e ( in system only) Use Modifier 25 when one of the following criteria is met: Visit for a problem unrelated to the procedure Visit for a new problem or a problem that has changed significantly and requires re-evaluation before performing the procedure. Visit for the same problem in different sites; one treated surgically and one treated medically. 37

38 Visit for a problem unrelated to the procedure or service Preventive Care Visit = patient seen for annual physical E/M service = Patient also c/o leg pain, swelling and hot spot. Evaluated for phlebitis Supporting Documentation E/M documentation identifiably distinct from procedure documentation Must meet ALL requirements for E/M visit along with documentation of procedure. 38

39 Medicare Part A Billing RHC Services UB 04 form or 837i electronic format Bill Type 711 Revenue Codes (NO CPT CODES ON CLAIM) Exception when billing preventive services Sent to Fiscal Intermediary Claims for all RHC visits Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident Actual charges billed 39

40 Medicare Part A Revenue Codes 521Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All drugs & supplies, are bundled with the visit code charges in the Revenue Codes shown above 40

41 Timely Filing MEDICARE: Must file claims within one year from date of serviceseffective 3/23/10. I.e. August 1, 2012 must be filed by July 31, 2013 MEDICAID: Must file claims within 6 months from date of serviceeffective 9/1/13 PB I.e. Sept 1, 2013 must be filed by Feb 28,

42 42 Medicare RHC Provider Number RHC office visit services Excludes all labs, x-ray TC & EKG Tracing, any TC Includes venipuncture effective 1/1/14 Billed to the FI, UB04 Form or electronic Paid on the clinics all inclusive rate All Medicare coverage rules apply Reasonable & necessary Allowed preventive is covered, I.e. pap, PSA

43 Medicare Part B Provider Number (IRHC) All labs, x-ray TC, EKG tracing, any technical components (venipuncture is part of the office visit bundled service) All hospital services (IP, OP, ER, OBS) Billed to WPS/MAC, HCFA 1500 Form Paid on the Medicare Pt B fee schedule 43

44 Medicare Part B Provider Number (PBRHC) All hospital services (IP, OP, ER, OBS) * Billed to WPS MAC, HCFA 1500 Form Paid on the Medicare existing fee schedule * The only exception is if the CAH is Method II reimbursement; then the OP, ER & OBS professional component is part of the hospitals claim. 44

45 PBRHC - Hospital OP Provider Number ALL Laboratory performed in the RHC, including 6 basic tests (venipuncture is part of the office visit bundled service) Billed using 141 bill type for PPS Hospitals CAH 851 bill type For any facility owned by CAH or CAH employee performing Technical Component X-ray EKG Holter Monitor All TCs Billed using 131 bill type for PPS Hosp All TCs Billed using 851 bill type for CAH Paid on the Medicare Pt B Fee Schedule 45

46 PBRHC - Hospital OP Provider Number CAH Method II Hospital bills for both the professional and technical component when performed in the hospital setting: X-ray EKG Holter Monitor ER OP/OBS/ASC Must have separate line item for the prof service Paid on the Medicare Pt B Fee Schedule + 15% 46

47 State Medicaid RHC/nonRHC Billing Each State Medicaid is specific as to their State requirements50 states, 50 plans May use either the 1500 or UB04 Managed Care Plans have choice as well Coverage is specific to each state Most States require both RHC and nonRHC Medicaid provider numbers Paid on the RHC rate or a PPS rate NE has transitioned to Managed Care Payers 47

48 NE Medicaid Each Managed Care Payer (MCP) can require either/bothUB04 or 1500 All Services for the Managed Care patients are sent to the MCPnothing sent to DHHS MCP can determine how to bill and how to pay claims MCPs are given RHCs facility specific payment rates to assure MCP is paying the most current rateRHC Medicaid year is 7/1 through 6/30 each year 48

49 NE Medicaid Must have RHC and nonRHC number Form for each is per the Managed Care Payer Ailments are RHC services Preventive services are nonRHC services IRHCs receive 100% of their Medicaid PPS rate PB of <50 bed hosp receive 100% of their actual charges PB of >50 bed hosp receive 100% of MCD PPS rate Must send in a copy of your Medicare CR annually as is a Federal Requirement With PPS payments there are no cost report settlements 49

50 NE Medicaid IRHC RHC services = bundled servicesUB04 or 1500 Lab, X-ray TC and EKG tracings are billed on the nonRHC # X-ray PC and EKG interp is part of visit and bundled on the RHC Provider # All preventive, IP, OP, ER, OBS are nonRHC services, billed with nonRHC Provider # OB is global with exception of first visit If only visits, then nonRHC# and list visit dates All surgeries at the hospital have 2 wk global 50

51 NE Medicaid PBRHC RHC services = bundled servicesUB04 Lab, X-ray TC, EKG tracing billed with Hosp OP # Professional components are part of the visit All preventive, IP, OP, ER, OBS are nonRHC services, billed with the nonRHC # OB is global with exception of first visit If only OB visits, bill nonRHC# and list visit dates All surgeries at the hospital have 2 wk global 51

52 NE Medicaid Incident to services without a face-to-face visit are billed on the nonRHC # i.e. injection only Must have both the administration CPT code and the NDC of the drug administered If VFC is used, only the administration CPT is billed on the nonRHC # NO V-codes as primary nonRHC services paid using the fee schedule and not your RHC rates 52

53 Private Pay or Private Insurance Billed as in fee-for-service clinic No changes in reimbursement Must not discount charges no cash discounts at time of service payment no professional discounts given All discounts given should be based on finances of patients i.e. sliding fee scales can be developed to as high as 400% of poverty guidelines per Federal Regulations 53

54 Medicare Advantage (MA) Two types of plans PFFS – Private Fee for Service Send Claims on UB04 with Medicare Rate letter Regional/PPO Plans Must provide service to the entire region per CMS Send Claims on UB04; you negotiate payment When patients switch to MA, they are on your Private section of your visit counts You may want to keep them separate as they will count as Medicare patients if you need to figure the % of Medicare utilization. 54

55 55 MEDICARE INJECTIONS Injections with an Office Visit Charge All CPT codes in system Bundle all charges and submit claim to RHC MCR If it is a Pt D drug, it must be sent to Pt D plan or Patient Injections onlynurse service Charge in system Either DO NOT bill (write off) as there is no f-t-f visit OR can be bundled with a visit within 30 days pre or post nursing service and submitted with that f-t-f visit If injectable is a Part D drug it MUST not be a part of the RHC claim as it is only billable to the patient or to Part D

56 PART D - INJECTIONS Injectable/Vaccine as a Part D drug – 1/1/08 The injectable/vaccine is payable only through Pt D If injectable/vaccine is obtained at the clinic level, then the patient is to pay for the injectable/vaccine and the administration privately and then they have to submit that claim to their Part D company to be reimbursed for the services. Clinics can link to: and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount. 56

57 MEDICAID INJECTIONS Injections with an Office Visit Add charges to the E/M code and submit claim Injections onlynurse service Send on nonRHC Provider number Submit the CPT code for administration and the second line the NDC of the drug If no NDC is listed, no payment for drug will be made 57

58 Part B Drugs cannot be obtained from a Pharmacy and then a physician service be charged in the clinic for the administration effective with DOS 10/1/11. The clinic would be required to obtain the drug from the pharmacy and pay the pharmacy, and clinic would submit claim for all Pt B services to the patient or insurance for payment. MM CR 7397 revised & Transmittal R2437CP 58

59 How Do We Bill: Injections, i.e. Gardasil, Zostavax, Varivax, Tetanus (as immunization update), DTAP Medicare: Pt D drugs require billing to Pt D or the Patient can pay for these services and send to their Pt D plan and be reimbursed OR submit claim to a company such as EDispense Medicaid: If patient is eligible and has a visit, bill with the visit on the RHC number. Private/Commercial: Bill as did in FFS clinic These drugs are not to be on your RHC claim as they are not a Part B benefit for the patient 59

60 Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous Intravenous infusion, for therapy, prophylasis or diagnosis; initial up to 1 hr Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, including pump set-up Add charges to the E/M code and submit claim (Medicare) 60

61 All coded with the accurate CPT code Dont forget to charge the venepuncture in OV now 1/1/14 part of the office bundled service If more than one of the same test is done on the same day, a -91 modifier is added to the CPT code All Labs, to include the required basic 6 tests, are payable through Medicare Part B OR If PBRHC, they are payable through the Hospital OP provider number. No more than one 851 TOB can be submitted each day 61

62 All coded with the accurate CPT code for each the technical component and the professional component if provider interprets Chest x-ray = TC Two views frontal & lateral; x-ray interpretation Interpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Technical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number NE Medicaid follows Medicare guidelines Medicare reg on prof component billing: CMS Internet-Only Manual, Publication , Ch 13, Sec

63 Coded using the tracing only for the TC & the interpretation only if provider interprets. EKG Tracing only = EKG Interpretation and report = Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Tracing only is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number NE Medicaid follows Medicare guidelines w/CPTs 63

64 Incident to Services Bundled with a face-to-face encounter within a 30-day period Direct supervision by provider required Must be in clinic, not in same room being in the hosp when attached to clinic is NOT incident to Part of providers services previously ordered integral, though incidental covered as part of an otherwise billable encounter I.e. dressing change, injection, suture removal, blood pressure monitoring Medicare (Medicaid if State requires)services should be billed under the provider that performed the service 64

65 65 Incident to Services Direct supervision by provider required Must be in clinic, not in same room being in the hosp when attached to clinic is NOT incident to Part of providers services previously ordered integral, though incidental covered as part of an otherwise billable encounter I.e. dressing change, injection, suture removal, etc. When added, the added reimb is the 20% copay Otherwise, if not on a claim, all costs are part of your cost report and are included in your rate CMS , Ch 13, Sec 110; Sec 130; Sec 150

66 66 Services Rendered on non-visit days Incident To Services Can be combined on claim with a visit incident to service for plan of treatment NEVER considered a separate visit Visit should be within 30-days pre or post List only the date of the visit as DOS Charges should reflect all services bundled Adjustments OK717 Type of Bill; CC=D1; remarks changes in charges Otherwise, the costs are shown on your cost report and claimed indirectly

67 OV, Lab, EKG How Do We Bill: OV, Lab, EKG Medicare: Bill OV and EKG interp (if provider does the interp) to RHC Medicare on UB 04 (one line item, no CPT codes); Bill EKG tracing to MCR Pt B for IRHCs & PBRHCs bill with 131 or 851 TOB with Hosp OP # on UB04 Bill lab for IRHC to MCR Pt B & PBRHC bill with 141 or 851 TOB with Hosp OP # on UB04 Medicaid: Follows Medicare guidelines w/CPT Private/Commercial: Bill as in FFS clinic 67

68 How Do We Bill: Procedures w/OV I.e. Lesion removal, joint injection, wound closure, AND E & M code Medicare: Charge the OV level w/-25, the procedure codes, any med usedbill as collapsed into the 521 rev code (no CPTs on claim) Medicaid: Charge the OV level w/-25, the procedure codes, any med usedon UB, bill as collapsed into the 521 rev code (with E & M CPT on claim) Private/Commercial: Bill as in FFS clinic 68

69 69

70 How Do We Bill: OV & Hospital Admit same day for same ailment Medicare: Cahaba & WPS (depends on medical necessity)– but generally, if for same ailment, are not allowing both services to be billed; thus bill the Admit (services must take place in the hospital) Medicaid: Bill the hospital admit and not the clinic visit. Private/Commercial: Bill the hospital admit For all payers make sure you are accumulating all services to set the level of admit. 70

71 No global charges for Medicare in the RHC Each visit in the clinic is a billable visitif it wasnt your provider that did procedure, verify they billed with the -54 modifier Code the surgical procedure with -54 (surgical procedure only) and bill to Part B Bill the pre and post visits as RHC visits as it is the RHC facility billing the services, not a specific provider NE Medicaid has a 2 week global for procedures in the hospital setting 71

72 Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous Intravenous infusion, for therapy, prophylaxis or diagnosis; initial up to 1 hr Intravenous infusion each addtl hour Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, incl pump set-up Subcu. infusion each addtl hour Add charges to the E/M code and submit claim (Medicare & Medicaid) 72

73 73 Maternity Care in the RHC Visits would be medically reasonable and necessary and billed as an RHC visit with 711 TOB and 521 revenue code. Delivery only would be billed as a hospital nonRHC service; each post partum visit is a billable visit

74 More Than One Visit Per Day Only allowed if a different illness or injury WPS wants 1 st claim processed, then send 2 nd claim If same diagnosis, accumulate to set E & M level If seen by physician and then the mental health provider both are billable2 visits If have IPPE and an ailment visit, it is 2 visits If IPPE, ailment and mental health visit, it is 3 visits billed If seen in clinic, then admitted (MAC determines) If only one billed, bill hospital admission 74

75 Behavioral Health Services Clinical Psychologist (PhD) Doctoral level of education Clinical Social Worker (CSW) Masters level with at least 2 years experience Use 900 revenue code to bill therapeutic behavioral health The first visit to determine services by a physician/PA/NP is an RHC visit, then behavioral health services apply Reimbursement in 2014 is 80/20 75

76 Flu & Pneumonia Injections Keep a log of injections, or have your computer track Medicare paid on your Medicare Cost Report Flu payable once per season; pneumo once lifetime Medicaid is paid only if in your State benefits at time of service Keep track of vaccine and supply costs Determine average nursing hours per week Determine average provider hours per week Generally allow 10 minutes per injection on Cost Report, but do a time study NO Medicare Advantage on log LOGS MUST BE LEGIBLE 76

77 Preventive Services Preventive Services Quick Reference Guide: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Do wnloads/MPS_QuickReferenceChart_1.pdf IPPE Quick Reference Guide: Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf Annual Wellness Visit Quick Reference Guide: Network-MLN/MLNProducts/downloads/AWV_Chart_ ICN pdf 77

78 Preventive Services Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04 Technical Components, labs, EKG tracing are billed on the nonRHC side, either through the Hospital OP provider number (PBRHC) or to MCR Pt B (IRHC) use correct G-codes Each preventive service MUST be on a separate line on the UB with the G-code 78

79 How Do We Bill: Preventive physical Medicare: Does not pay for physicals, except for the Introduction to Medicare Physical. If the visit is only for a physical and not for the ailments, then bill the patient. Effective 1/1/11, Medicare will pay for an annual wellness visit per year; This IS NOT a physical Medicaid: Covered for kids and billed on the nonRHC Medicaid provider number Private/Commercial: Bill as in FFS clinic 79

80 HOW TO BILL: WELL WOMAN EXAM How does a RHC bill for a "Well Woman Exam"? Medicare does not have a "Well Woman Exam" as a covered preventive service. Each component of the "Well Woman Exam" would have to be looked at and billed separately. For instance, the Annual Wellness Visit is covered yearly and billed with either G0438 for the initial exam (covered once in a lifetime) or G0439 if it is a subsequent visit (covered annually). Both Screening Pap Tests and Screening Pelvic Examinations are covered every 24 months for low risk women and billed with Q0091 and G0101 respectively. Each of these tests, if the beneficiary is eligible, would be billed on a separate 052x revenue code line. For more information on Medicare's Preventive Services, please see the Medicare Preventive Services Quick Reference ChartMedicare Preventive Services Quick Reference Chart 80

81 HOW TO BILL: PREVENTIVE EXAM If a patient comes in for a preventive exam which is not a covered exam, who do we bill? Since it is not a covered service, you will bill the beneficiary. (This includes DOT physical) For any preventive service that has a frequency limitation, it is encouraged to get an ABN just in case the service is done at the incorrect timing, if no ABN, the clinic cannot charge if Medicare does not pay. As of 9/1/12 the UB claim is allowed to have the GA modifier along with the HCPCS code with the Occurrence Code of 32 with the date the ABN was signed. 81

82 Coding of NF/SNF Services For NF/SNF/SW Bed visits Code/Bill If Prolonged Services apply Code also or Effective with DOS 7/1/08 Can use Prolonged Service codes for NF/SNF services , 99307–99310 & but if codes are set for counseling, must be at highest level to code the prolonged service code MM5968, CR5968, Effective 7/1/08 82

83 Services to a Hospice Patient When seen for the hospice condition Is not payable to the clinic and must be coordinated with the Hospice Entity Any TC is billed to the Hospice Co, if required When seen for a condition other than the reason for being on hospice Bill the MAC/FI as an RHC visit, RC 52X Use Condition Code 07 Use diagnosis for ailment not the hospice DX Medicare Benefits Policy Manual 13, Sec

84 Telehealth Site Fee Services Bill to RHC FI Revenue Code 780 Does not require a Face-to-Face visit same day Q3014 code is paid separately from all- inclusive rate at the Medicare Phys Fee Schedule Bill for transmission fee REQUIRED to put the Q code on the claim RHCs are not allowed to be the provider 84

85 BILLING NONCOVERED CHARGES How do you bill noncovered charges? If all charges are noncovered, send 710 TOB with all charges as noncovered and condition code 21. If only some of the charges are noncovered, per CMS Internet-Only Manual, Publication , Chapter 1,Adobe Portable Document Format Section This section of the manual states, "... all of a bundled service must be billed as noncovered, or none of it. Therefore, as long as part of a bundled service is certain to be covered or medically necessary, billing the entire bundled service as covered is appropriate."Publication , Chapter 1,Adobe Portable Document Format 85

86 MEDICARE SECONDARY BILLING Medicare is secondary and we've billed an office visit, a joint injection and a drug, and the primary pays on all three lines. We then need to bill to Medicare for secondary payment. Do we add charges into one line? If Medicare was primary, we would roll everything into one line. How do we bill if the primary pays each line separately? When billing the claim to Medicare, you will roll everything into one line. Even though the primary may pay each line item separately, you still need to send the claim to Medicare according to Medicare billing regulations. 86

87 MEDICARE SECONDARY BILLING Do we only indicate what was paid, or do we send the allowed amount? You would bill the charges as you normally would if Medicare was primary. If you have a contractual obligation with the other insurance and if they paid less than the contractual amount and less than the total charges of the claim, you would use the 44 value code to indicate the contractual amount. Your other value code indicates what type of policy the primary is and what they actually paid. 87

88 MEDICARE SECONDARY- PRIMARY BENEFITS EXHAUSTED If I bill a liability policy as primary, and it is denied for benefits exhaust, how do we bill Medicare? If you have a denial from a primary insurance, you would bill the claim as a conditional payment. If it is a liability policy, the 47 value code will have $0.00. You need to enter the 24 occurrence code with the date of the denial from the primary insurance, and in remarks enter why the claim was denied. In this case the primary benefits were exhausted. 88

89 E-PRESCRIBING Because RHCs are not paid based on the Medicare Physician Fee Schedule, they are not included in the eRx program. Thus, there are no penalties for any RHC services when the clinic does not participate in eRx. If the clinic does a significant amount of nonRHC services, the clinic may be required to participate in eRx in order to not be penalized. 89

90 Incorrect WPS interpretation WPS had an educational training for RHCs and stated that the professional component of a diagnostic test constituted a face-to-face visit. THIS IS NOT CORRECT. There must be a face-to-face between the patient and the provider in order to have a billable service. 90

91 Adjustments TOB 717 Claim must be in finalized status Adjustment will appear as a debit or credit on future remittance advice Encourage submitting electronically exceptionsdenied charges & claims rejected as MSP Do not send another 711 claim as will error as a duplicate Examples of Adjustments: Revenue code changes, Service unit decrease or increase, Total charges changed, Primary payer incorrect 91

92 92 Maternity Care in the RHC Visits would be medically reasonable and necessary and billed as an RHC visit with 711 TOB and 521 revenue code. Delivery only would be billed as a hospital nonRHC service; each post partum visit is a billable visit

93 RHC CHART REVIEW Documentation !!! Must use either 1995 or 1997 documentation guidelines Develop policies as to which guidelines used Develop billing policies and assure claims are sent correctly Develop Collection policies and assure RHC is following policy when determine RHC bad debt Support Billing? Are lab tests warranted by diagnoses? If not, do we have an ABN signed? Does the Chart, Claim and Encounter form match for services and level of care? Have we asked the MSP questions? Required at time of each visit 93

94 Statistics needed within the RHC Number of RHC encounters by each Physician, NP or PA by payer class Number of nonRHC (hospital services) encounters by Physician, NP or PA Log of all Flu and Pneumonia injections to include: date, patient name, HIC#, charge Staffing schedules TIME STUDIES! 94

95 Medicare Bad Debt Expense Must keep patient name, date of service, HIC#, if a Medicaid patient or not, is it co-insurance or deductible and dates billed Exhibit 5 of the CMS 339 Form If send to collections, this is not considered written off as bad debt, cannot put on log until it is totally written off and no chance of payment. RHC Medicare Bad Debt to be reduced 95

96 Medicare Corporate Compliance All practices that accept Medicare & Medicaid dollars are required to have a Clinic Corporate Compliance Policy Hosp/Clinic Corporate Compliance Policy HIPAA Policies in place Do we have consents signed? Are we getting ABNs (Advanced Beneficiary Notices) when appropriate (must be CMS-R /11) Keep copy of ABN Are we asking the MSP (Medicare Secondary Payer) questions? 96

97 NE Medicaid Websites Health_and_Human_Services_System/Title-471/Chapter- 34.pdf NE Medicaid RHC Provider Information Chapter 34 NE Medicaid Billing Instructions for RHCs 97

98 98 ds/MPS_QuickReferenceChart_1.pdf - Network-MLN/MLNProducts/downloads//MPS_QRI_ IPPE001a.pdf Network-MLN/MLNProducts/downloads/ /AWV_Chart_ICN pdf Make sure you are a part of your MAC listserve for updated info!

99 Internet Websites of Interest (NRHA) (NeRHA) Downloads/bp102c13.pdf (new RHC/FQHC Regulations 3/13) /Manuals/ Downloads/clm104c09.pdf (RHC CMS Claims Manual) Rural Health Development Website & my 99

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