4 RHC STAFFING 30.1 - RHC Staffing MUST employ NP or PA (W-2 or owner)NP, PA or CNM at least 50% of clinic hoursA Locum Tenens NP or PA would not meet regIt has been proposed to allow contract services to meet this regulation, however, it has not be approved
5 RHC UPDATED REGULATIONS 40.1 – RHC Visit LocationClinic, Home, ALF, NF, SNFAny location exceptIP or OP hospital or CAHMedicare IP Rehab Fac; Hospice FacilityIn a location other than the RHC if:Practitioner is compensated by the RHCCost of service is included in the RHC cost reportRHC is required to post hours of operationsAll services during scheduled hrs are RHC servicesIt was discussed to have clear schedulesCannot rotate from clinic to hosp during RHC hrs
6 Medicare Part A Revenue Codes 521 Office visit in clinic522 Home visit524 Visit to a Part A SNF or SW patientOnly 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, ALPatient not on a Part A SNF Stay527 Visiting Nurse Service in a HHA shortage528 Visit at other site, I.e. scene of accidentTelehealth site fee900 Mental Health ServicesAll services and CPT codes, I.e. drugs, supplies, are bundled with the visit code charges, your system will have itemized
7 RHC UPDATED REGULATIONS 40.3 – Multiple Visits Same Day, Payable ifPatient has second visit for additional DXA medical visit and a mental health visit same dayIPPE and Medical Visit and Mental Health Visit (up to 3)AWV and a Mental Health VisitClinic visit and Hosp admit is per your MACWPS & Cahaba will allow if medically necessary
8 RHC UPDATED REGULATIONS 40.4 – Global BillingAll procedures in the RHC are not subject to GlobalsIf RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 modIf RHC prov performs hosp proc, bill w/54 mod, and then bill each visit at clinic level as not in globalServices never included in global surgical packageInitial visit to determine surgery requiredVisits unrelated to DX for surgical procedureTreatment for underlying condition or an added course of treatment which is not part of normal recovery40.5 – 3-Day Payment WindowRHC services are not subject
10 Medicare RHC Covered Services E & M servicesProceduresProfessional Component of diagnostic testsInjectionsDressingsDiabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionalsnot separately billable for RHCs but indirectly paidCMS Manual Chapter 13 Section 50
11 GLOBAL BILLING 40.4 – Global Billing All procedures in the RHC are not subject to GlobalsIf RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 modIf RHC prov performs hosp proc, bill w/54 mod, and then bill each visit at clinic level as not in globalServices never included in global surgical packageInitial consultationVisits unrelated to DX for surgical procedureTreatment for underlying condition or an added course of treatment which is not part of normal recovery
12 RHC UPDATED REGULATIONS 50.3 – Emergency ServicesNeither IRHCs or PBRHCs are subject to EMTALAMust have drugs & biologicals commonly used in life-saving proceduresNon RHC ServicesMCR excluded services, i.e. dental, hearing & eye testsTechnical component of an RHC serviceLaboratory ServicesDME, Prosthetic devices, BracesAmbulance ServicesHospital Services, ASC, MCORFTelehealth distant-site servicesHospice Services (if for DX of hospice)Auxiliary Services, i.e. language interp, transp, security
13 RHC UPDATED REGULATIONS 80.1 – Charges & WaiversMust charge all patients the same ratesMay 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 ScaleNot required, but may haveMust be applied to all patientsPolicy must be postedIf based on income, must document that info from ptCopies of wage statements or income tax return no requiredSelf-attestations are acceptable
14 RHC UPDATED REGULATIONS 90 – ComminglingSharing 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 servicesMay 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 operationIf 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 paidDoes not prohibit provider going to hosp for emergenciesMust follow schedules for hospital and RHC time
15 PHYSICIAN SUPERVISION At least one supervisory visit every 2 weeks onsiteCMS 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.
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 paidIf 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.
17 RHC UPDATED REGULATIONS 210 – Preventive Health ServicesOnly the professional services are billed as RHCTCs are billed as nonRHCMust use the appropriate G-codesFlu and Pneumo VaccinesHepatitis VaccinesMany preventive services have no copay or deductibleDiabetes Counseling and Medical Nutrition ServicesNot separately billable but “incident to” serviceCosts allowed on the cost report
18 2014 Medicare Rates Patient Deductible = $147 per year IRHC Rate = $79.80/visitPBRHC PPS Hospital Rate = $79.80/visitPBRHC <50 bed hospitals = No limit
19 Forms & Paperwork Required Consent to be treatedAuthorization to BillHIPAA Privacy notificationMedicare Secondary Payer Questions asked (keep 10 yrs)Pub Chapter 3, section 20Required each time the patient presents to the clinicABN issued if applicableGiven when service does not meet medical necessityRoutine services contractually non-covered do not require an ABN, I.e. physical, can use the NEMB formSurgical ConsentCoordination of Benefits Customer Service for CWFam–8 pm EST TDDBeneficiaries, providers, attorneys, third party payers
20 Patient RecordSAll billable services must be documented in the patient record to support billing of procedures and E & MsEach service must be specificCBC is only a CBC, not CBC with differentialInjection given must be ordered in chart and also noted as given by the nurseLesions must be noted as to size, number, method of removal, closure methodFollow-up or plan with patient instructions must be documentedIf more than one visit per day, document date and timeIf counseling is reason for visit, then time in and out can be used to determine E & M Level
21 PATIENT RECORDSAll pages of the Medical Record must have patient identifierAll Reports must be reviewed and signed off with patient receiving results that is documentedAll documentation must be authenticatedSignatureElectronic signature – affirmation and password protected—DO NOT leave screen on when leave roomStamped signature is not allowed (CR5971, SE0829)with the exception for a provider that is disabled and cannot sign his/her name
22 Coding Levels of Care DOES IT MATTER HOW WE CODE A VISIT? Patient payment is affectedMedicare considers OVER CODING as a violation of the fraud and abuse regulations because of the additional reimbursementMedicare considers UNDER CODING as a violation of the fraud and abuse regulations because it encourages patients to overuse the clinic
23 CPT Procedure CodesAll Procedure Codes that are normally performed in a physician’s clinic are applicable in the RHCIf your coder is also your biller, the knowledge of what service to bill to which payer is imperativeSome CPT codes will have to be “split” billed, i.e. EKG, xray prof & tech comp
24 Productivity Standards PhysicianFTE (Full Time Equivalent = 40 hrs/wk, 52 wks/yr or 2080 hrs year)4,200 visits per each FTEPA, NP, CNM2,100 visits per each FTEVISITS OF ALL PAYER CLASSES ARE COUNTED TO DETERMINE PRODUCTIVITY STANDARD
25 What is a Visit? Face-to-Face with the Provider Medically necessary Physician, PA, NP, CNMClinical Social Worker or Clinical PsychologistMedically necessaryDoes it require the skills of a Provider?Payer ClassAll payer classes are counted in the total visit countPlace of ServiceClinic, Home, NH, SNF/SW B, Scene of AccidentLevel of ServiceAll levels apply, to include proceduresTo include all services “incident to”
26 Medicare RHC Covered Services E & M servicesProceduresProfessional Component of diagnostic testsInjectionsDressingsCMS Manual Chapter 13 Section 50
27 RHC Covered Services Physician services NP, PA & CNM services Services & Supplies incident to provider serviceDiabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionalsnot separately billable for RHCs but indirectly paidVisiting nurse services in non HHA areaClinical psychologist & clinical social workerCP & CSW supplies & services “incident to”
28 NonCovered as RHC Services (Covered if Billed to Correct Payer) Hospital patient servicesLab tests (except venipuncture is part of Visit)Part D Drugs & Self administrable drugsDMEAmbulance servicesTechnical components of diagnostic testsi.e. xrays & EKG, Holter MonitoringTechnical components of screening servicesi.e. screening paps/pelvic, PSAProsthetic devicesBracesCMS Pub Ch 13, Sec 60 & 60.1
29 Medicare Covered But Nonbillable Services Nurse service w/o face-to-face visit or “incident to” visitI.e. allergy injection, hormone injection, dressing change, venipunctureProvider MUST be in clinic to have “incident to”CMS Manual Chapter 13 Section 110.2Telephone servicesCMS Manual Chapter 13 Section 100 & 120Prescription services
30 Examples of no medical necessity Routine INR visit for labSimple suture removalDressing changeResults of normal testsBlood pressure monitoringB12 injectionAllergy InjectionPrescription service only
31 ACCURATE CODING Compliance Policy Required if practice receives Medicare dollarsLevels coded accurately = correct reimbursementReimbursement difference from a level 3 and 4 of an established patient is approximately 50% more than the lower level chargedAs an RHC this is important due to the 20% copay based on the actual charge billed for Medicare
32 Accurate Coding Better documentation does not mean MORE documentation checklists are not always a good practicejust because a system is checked it doesn’t mean it was examinedIf it isn’t documented, it didn’t happenif audited, the record must stand alone - Many times work is done, but no documentationProviders tend to undercode their cognitive servicesLevels coded accurately = correct reimbursement
33 E & M Coding Definitions: New Patient Established 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 PatientPatient who has received professional services from the provider or any other provider in the same group within the past 3 years.
34 E & M Coding Definitions: Preventive CPT codes CPT codes for physical exams based on ageUse when patient has no significant complaints or follow up of ailmentsMedicare 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)
35 E & M Coding Definitions: Time Outpatient time is face-to-face time Used to determine E & M Level when counseling and/or coordination of care is >50%Outpatient time is face-to-face timeInpatient time is unit/floor timeMust document total time spent in minutesdocument what the counseling was about and/or what coordination of care was providedState “Counseling or Coordination of care greater than 50%”Counseling can be visiting about ailments, teaching, planning for treatments, etc.
36 E & M Coding 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.
37 MODIFIER -25Significant, 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 procedureVisit 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.
38 EXAMPLES OF MODIFIER -25Visit for a problem unrelated to the procedure or servicePreventive Care Visit = patient seen for annual physicalE/M service = Patient also c/o leg pain, swelling and hot spot. Evaluated for phlebitisSupporting DocumentationE/M documentation identifiably distinct from procedure documentationMust meet ALL requirements for E/M visit along with documentation of procedure.
39 Medicare Part A Billing RHC Services UB 04 form or 837i electronic formatBill Type 711Revenue Codes (NO CPT CODES ON CLAIM)Exception when billing preventive servicesSent to Fiscal IntermediaryClaims for all RHC visitsOffice, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accidentActual charges billed
40 Medicare Part A Revenue Codes 521 Office visit in clinic522 Home visit524 Visit to a Part A SNF or SW patientOnly 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, ALPatient not on a Part A SNF Stay527 Visiting Nurse Service in a HHA shortage528 Visit at other site, I.e. scene of accidentTelehealth site fee900 Mental Health ServicesAll drugs & supplies, are bundled with the visit code charges in the Revenue Codes shown above
41 Timely Filing MEDICARE: Must file claims within one year from date of services—effective 3/23/10.I.e. August 1, 2012 must be filed by July 31, 2013MEDICAID:Must file claims within 6 months from date of service—effective 9/1/13 PB 13-50I.e. Sept 1, 2013 must be filed by Feb 28, 2014
42 Medicare RHC Provider Number RHC office visit servicesExcludes all labs, x-ray TC & EKG Tracing, any TCIncludes venipuncture effective 1/1/14Billed to the FI, UB04 Form or electronicPaid on the clinic’s “all inclusive rate”All Medicare coverage rules applyReasonable & necessaryAllowed 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 FormPaid on the Medicare Pt B fee schedule
44 Medicare Part B Provider Number (PBRHC) All hospital services (IP, OP, ER, OBS)*Billed to WPS MAC, HCFA 1500 FormPaid 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 hospital’s claim.
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 HospitalsCAH 851 bill typeFor any facility owned by CAH or CAH employee performingTechnical ComponentX-rayEKGHolter MonitorAll TC’s Billed using 131 bill type for PPS HospAll TC’s Billed using 851 bill type for CAHPaid on the Medicare Pt B Fee Schedule
46 PBRHC - Hospital OP Provider Number CAH Method IIHospital bills for both the professional and technical component when performed in the hospital setting:X-rayEKGHolter MonitorEROP/OBS/ASCMust have separate line item for the prof servicePaid on the Medicare Pt B Fee Schedule + 15%
47 State Medicaid RHC/nonRHC Billing Each State Medicaid is specific as to their State requirements—50 states, 50 plansMay use either the 1500 or UB04Managed Care Plans have choice as wellCoverage is specific to each stateMost States require both RHC and nonRHC Medicaid provider numbersPaid on the RHC rate or a PPS rateNE has transitioned to Managed Care Payers
48 NE MedicaidEach Managed Care Payer (MCP) can require either/both—UB04 or 1500All Services for the Managed Care patients are sent to the MCP—nothing sent to DHHSMCP can determine how to bill and how to pay claimsMCPs are given RHCs facility specific payment rates to assure MCP is paying the most current rate—RHC Medicaid year is 7/1 through 6/30 each year
49 NE Medicaid Must have RHC and nonRHC number Form for each is per the Managed Care PayerAilments are RHC servicesPreventive services are nonRHC servicesIRHCs receive 100% of their Medicaid PPS ratePB of <50 bed hosp receive 100% of their actual chargesPB of >50 bed hosp receive 100% of MCD PPS rateMust send in a copy of your Medicare CR annually as is a Federal RequirementWith PPS payments there are no cost report settlements
50 NE Medicaid IRHC RHC services = bundled services—UB04 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 visitIf only visits, then nonRHC# and list visit datesAll surgeries at the hospital have 2 wk global
51 NE Medicaid PBRHC RHC services = bundled services—UB04 Lab, X-ray TC, EKG tracing billed with Hosp OP #Professional components are part of the visitAll preventive, IP, OP, ER, OBS are nonRHC services, billed with the nonRHC #OB is global with exception of first visitIf only OB visits, bill nonRHC# and list visit datesAll surgeries at the hospital have 2 wk global
52 NE Medicaid“Incident to” services without a face-to-face visit are billed on the nonRHC # i.e. injection onlyMust have both the administration CPT code and the NDC of the drug administeredIf VFC is used, only the administration CPT is billed on the nonRHC #NO V-codes as primarynonRHC services paid using the fee schedule and not your RHC rates
53 Private Pay or Private Insurance Billed as in fee-for-service clinicNo changes in reimbursementMust not discount chargesno cash discounts at time of service paymentno professional discounts givenAll discounts given should be based on finances of patientsi.e. sliding fee scales can be developed to as high as 400% of poverty guidelines per Federal Regulations
54 Medicare Advantage (MA) Two types of plansPFFS – Private Fee for ServiceSend Claims on UB04 with Medicare Rate letterRegional/PPO PlansMust provide service to the entire region per CMSSend Claims on UB04; you negotiate paymentWhen patients switch to MA, they are on your “Private” section of your visit countsYou may want to keep them separate as they will count as Medicare patients if you need to figure the % of Medicare utilization.
55 MEDICARE INJECTIONS Injections with an Office Visit Charge All CPT codes in systemBundle all charges and submit claim to RHC MCRIf it is a Pt D drug, it must be sent to Pt D plan or PatientInjections only—nurse serviceCharge in systemEither DO NOT bill (write off) as there is no f-t-f visitOR can be bundled with a visit within 30 days pre or post nursing service and submitted with that f-t-f visitIf 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 DIf 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.
57 MEDICAID INJECTIONS Injections with an Office Visit Add charges to the E/M code and submit claimInjections only—nurse serviceSend on nonRHC Provider numberSubmit the CPT code for administration and the second line the NDC of the drugIf no NDC is listed, no payment for drug will be made
58 Part B DrugsPart 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 revised & Transmittal R2437CP
59 How Do We Bill:Injections, i.e. Gardasil, Zostavax, Varivax, Tetanus (as immunization update), DTAPMedicare: 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 EDispenseMedicaid: If patient is eligible and has a visit, bill with the visit on the RHC number.Private/Commercial: Bill as did in FFS clinicThese drugs are not to be on your RHC claim as they are not a Part B benefit for the patient
60 INFUSION THERAPY Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous96365 Intravenous infusion, for therapy, prophylasis or diagnosis; initial up to 1 hr.96369 Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, including pump set-upAdd charges to the E/M code and submit claim (Medicare)
61 Laboratory Services All coded with the accurate CPT code Don’t forget to charge the venepuncture in OVnow 1/1/14 part of the office bundled serviceIf more than one of the same test is done on the same day, a -91 modifier is added to the CPT codeAll Labs, to include the required basic 6 tests, are payable through Medicare Part B ORIf PBRHC, they are payable through the Hospital OP provider number. No more than one 851 TOB can be submitted each day
62 Radiology ServicesAll coded with the accurate CPT code for each the technical component and the professional component if provider interpretsChest x-ray = TC Two views frontal & lateral; x-ray interpretationInterpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural HealthTechnical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider numberNE Medicaid follows Medicare guidelinesMedicare reg on “prof component” billing:CMS Internet-Only Manual, Publication , Ch 13, Sec 30.3.
63 EKG ServicesCoded using the tracing only for the TC & the interpretation only if provider interprets.EKG Tracing only =EKG Interpretation and report = 93010Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural HealthTracing only is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider numberNE Medicaid follows Medicare guidelines w/CPTs
64 “Incident to” Services Bundled with a face-to-face encounter within a day periodDirect supervision by provider requiredMust be in clinic, not in same roombeing in the hosp when attached to clinic is NOT “incident to”Part of provider’s services previously orderedintegral, though incidentalcovered as part of an otherwise billable encounterI.e. dressing change, injection, suture removal, blood pressure monitoringMedicare (Medicaid if State requires)services should be billed under the provider that performed the service
65 “Incident to” Services Direct supervision by provider requiredMust be in clinic, not in same roombeing in the hosp when attached to clinic is NOT “incident to”Part of provider’s services previously orderedintegral, though incidentalcovered as part of an otherwise billable encounterI.e. dressing change, injection, suture removal, etc.When added, the added reimb is the 20% copayOtherwise, if not on a claim, all costs are part of your cost report and are included in your rateCMS , Ch 13, Sec 110; Sec 130; Sec 150
66 Services Rendered on non-visit days—“Incident To” Services Can be combined on claim with a visit“incident to” service for plan of treatmentNEVER considered a separate visitVisit should be within 30-days pre or postList only the date of the visit as DOSCharges should reflect all services bundledAdjustments OK—717 Type of Bill; CC=D1; remarks “changes in charges”Otherwise, the costs are shown on your cost report and claimed indirectly
67 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 toMCR Pt B for IRHCs & PBRHCs bill with 131 or 851 TOB with Hosp OP # on UB04Bill lab for IRHC to MCR Pt B & PBRHC bill with 141 or 851 TOB with Hosp OP # on UB04Medicaid: Follows Medicare guidelines w/CPTPrivate/Commercial: Bill as in FFS clinic
68 How Do We Bill: Procedures w/OV I.e. Lesion removal, joint injection, wound closure, AND E & M codeMedicare: Charge the OV level w/-25, the procedure codes, any med used—bill as collapsed into the 521 rev code (no CPTs on claim)Medicaid: Charge the OV level w/-25, the procedure codes, any med used—on UB, bill as collapsed into the 521 rev code (with E & M CPT on claim)Private/Commercial: Bill as in FFS clinic
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 admitFor all payers make sure you are “accumulating” all services to set the level of admit.
71 Hospital Procedures No global charges for Medicare in the RHC Each visit in the clinic is a billable visit—if it wasn’t your provider that did procedure, verify they billed with the -54 modifierCode the surgical procedure with -54 (surgical procedure only) and bill to Part BBill the pre and post visits as RHC visits as it is the RHC facility billing the services, not a specific providerNE Medicaid has a 2 week global for procedures in the hospital setting
72 INFUSION THERAPY Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous96365 Intravenous infusion, for therapy, prophylaxis or diagnosis; initial up to 1 hr.96366 Intravenous infusion each addt’l hour96369 Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, incl pump set-up96370 Subcu. infusion each addt’l hourAdd charges to the E/M code and submit claim (Medicare & Medicaid)
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 injuryWPS wants 1st claim processed, then send 2nd claimIf same diagnosis, accumulate to set E & M levelIf seen by physician and then the mental health provider both are billable—2 visitsIf have IPPE and an ailment visit, it is 2 visitsIf IPPE, ailment and mental health visit, it is 3 visits billedIf seen in clinic, then admitted (MAC determines)If only one billed, bill hospital admission
75 Behavioral Health Services Clinical Psychologist (PhD)Doctoral level of educationClinical Social Worker (CSW)Masters level with at least 2 years experienceUse 900 revenue code to bill therapeutic behavioral healthThe first visit to determine services by a physician/PA/NP is an RHC visit, then behavioral health services applyReimbursement in 2014 is 80/20
76 Flu & Pneumonia Injections Keep a log of injections, or have your computer trackMedicare paid on your Medicare Cost ReportFlu payable once per season; pneumo once lifetimeMedicaid is paid only if in your State benefits at time of serviceKeep track of vaccine and supply costsDetermine average nursing hours per weekDetermine average provider hours per weekGenerally allow 10 minutes per injection on Cost Report, but do a time studyNO Medicare Advantage on logLOGS MUST BE LEGIBLE
78 Preventive ServicesAllowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04Technical 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-codesEach preventive service MUST be on a separate line on the UB with the G-code
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 physicalMedicaid: Covered for kids and billed on the nonRHC Medicaid provider numberPrivate/Commercial: Bill as in FFS clinic
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 Chart
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.
82 Coding of NF/SNF Services For NF/SNF/SW Bed visitsCode/BillIf Prolonged Services applyCode also or 99357Effective with DOS 7/1/08Can 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 codeMM5968, CR5968, Effective 7/1/08
83 Services to a Hospice Patient When seen for the hospice conditionIs not payable to the clinic and must be coordinated with the Hospice EntityAny TC is billed to the Hospice Co, if requiredWhen seen for a condition other than the reason for being on hospiceBill the MAC/FI as an RHC visit, RC 52XUse Condition Code 07Use diagnosis for ailment not the hospice DXMedicare Benefits Policy Manual 13, Sec. 200
84 Telehealth Site Fee Services Bill to RHC FIRevenue Code 780Does not require a Face-to-Face visit same dayQ3014 code is paid separately from all- inclusive rate at the Medicare Phys Fee ScheduleBill for transmission feeREQUIRED to put the Q code on the claimRHCs are not allowed to be the provider
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."
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.
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.
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.
89 E-PRESCRIBINGBecause 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.
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.
91 Adjustments TOB 717 Claim must be in finalized status Adjustment will appear as a debit or credit on future remittance adviceEncourage submitting electronicallyexceptions—denied charges & claims rejected as MSPDo not send another 711 claim as will error as a duplicateExamples of Adjustments:Revenue code changes, Service unit decrease or increase, Total charges changed, Primary payer incorrect
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 guidelinesDevelop policies as to which guidelines usedDevelop billing policies and assure claims are sent correctlyDevelop Collection policies and assure RHC is following policy when determine RHC bad debtSupport 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
94 Statistics needed within the RHC Number of RHC encounters by each Physician, NP or PA by payer classNumber of nonRHC (hospital services) encounters by Physician, NP or PALog of all Flu and Pneumonia injections to include: date, patient name, HIC#, chargeStaffing schedulesTIME STUDIES!
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 billedExhibit 5 of the CMS 339 FormIf 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
96 Medicare Corporate Compliance All practices that accept Medicare & Medicaid dollars are required to have a Clinic Corporate Compliance PolicyHosp/Clinic Corporate Compliance PolicyHIPAA Policies in placeDo we have consents signed?Are we getting ABNs (Advanced Beneficiary Notices) when appropriate (must be CMS-R /11)Keep copy of ABNAre we asking the MSP (Medicare Secondary Payer) questions?
97 NE Medicaid WebsitesHealth_and_Human_Services_System/Title-471/Chapter- 34.pdfNE Medicaid RHC Provider Information Chapter 34NE Medicaid Billing Instructions for RHCs
98 Internet Websites of Interest ds/MPS_QuickReferenceChart_1.pdf- Network-MLN/MLNProducts/downloads//MPS_QRI_ IPPE001a.pdfNetwork-MLN/MLNProducts/downloads/ /AWV_Chart_ICN pdfMake 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