1. RHC HCPCS Reporting CG Modifier RHC TA Call December 22, 2016

2. Reporting Services
Beginning on April 1, 2016, RHCs are required to report the appropriate HCPCS code for each service line along with a revenue code on their Medicare claims. RHC qualifying medical visits are typically Evaluation and Management (E/M) type of services or screenings for certain preventive services.

3. HCPCS Reporting – Medicare Only!
HCPCS Reporting, QVL, CG Modifiers and all of the RHC billing requirements which changed on April 1, 2016…Only Affects Medicare RHC Claims! This does not affect commercial or State Medicaid RHC billing requirements!

4. Revenue Codes
The qualifying visit line must include the total charges for all the services provided during the encounter/visit. RHCs can report incident to services using all valid revenue codes except 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x- 088x, 093x, or 096x-310x. RHCs should report the most appropriate revenue code for the services being performed. (MLN 9269)

5. Revenue Codes
The following revenue codes are used on UB04 claims: Clinic Visit at RHC by RHC provider Home visit by RHC provider Part A SNF bed by RHC provider Non-SNF bed, NF or other residential facility (non-Part A) by RHC Provider Visiting Nurse service in Home Health Shortage Area Visit by RHC provider to other non-RHC site (scene of an accident)

6. Additional Revenue Codes – 4.1.2016
0250 – Pharmacy (Does not need the HCPCS)
0300 – Venipuncture
0636 – Injection/Immunization
0780 – Telehealth
0900 – Behavioral Health

7. 10/01/16 requirements
“…beginning on October 1, 2016, RHCs shall add modifier CG (policy criteria applied) to the line with all the charges subject to coinsurance and deductible.” (Med Learn Matters SE1611)

8. CG Modifier April 1, 2016 October 1, 2016
Line-Item Billing/HCPCS reporting Implemented with QVL.
The original QVL lacked various types of procedure codes.
The CG Modifier was announced in place of continually updated QVLs.
October 1, 2016
The CG modifier was effective
The CG modifier is required for all claims submitted after
CG Modifier affects claims for dates of service retroactively to

9. CG Modifier
RHCs should report modifier CG on one line with a medical and/or mental health HCPCS code that represents the primary reason for the medically necessary face-to-face visit.
The Qualifying Visit List can be used as a guideline to determine which HCPCS codes constitute RHC encounters.

10. CG Modifier - FAQ
Rural Health Clinics (RHCs) Reporting Requirements Frequently Asked Questions (FAQs) (Revised )

11. Total Qualifying Visit Line
Medicare does not adjudicate RHC claims based on the 0001 Total Charge amount.
Medicare adjudicates RHC claims using the Qualifying Visit Line.
The qualifying visit line should be the sum of all RHC charges subtracted by any preventive services.

12. Line Item Messages CO97 - Contractual obligation. No CG Modifier
CARC 97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
RARC M15 - Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

13. Billing Example #1
An established patient is seen and a qualifying visit of for $100 is generated. The CG modifier is applied to the qualifying visit HCPCS code. The applicable coinsurance and/or deductible shall be based upon $ Medicare will pay the encounter at 80% of the AIR. The patient will be responsible for $20.00 in co-insurance.

14. Service Detail
Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR.

15. Billing Example #2 – Alternative Method Medical Visit plus Ancillary
The Injection charge amount ($30.00) plus $.01 for the line item is bundled with the $100 charge on the qualifying visit line. The CG modifier is used on the qualifying visit code (99213) to determine the total charge and calculate co-insurance.

16. CG Modifier – Preventive Services
“If only preventive services are furnished during the visit, the RHC should report modifier CG with the preventive HCPCS code that represents the primary reason for the medically necessary face-to-face visit and the bundled charges.”

17. Billing Example #3 Preventative Services
An established patient is seen and a qualifying visit of for $100 is generated. A breast/pelvic exam was performed for $ A venipuncture was performed for $20.00.
The charge for the pelvic exam should NOT be bundled in the line since there will be no co-insurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the charge for $

18. Bundled Services – Different Dates
“The RHC can combine incident to services furnished on a different date of service on one claim as long as they are furnished in a medically appropriate period and are incident to the service being billed. Incident to services should not be reported with modifier CG.”

19. Billing Example #4 Bundled Injection/Different Dates
The charge amount for the Allergy Injection ($15.00) will be added to the ($100) for a qualifying visit line of $ The total charge line is overstated.

20. Billing Example #4a Bundled Injection/Different Dates
The Allergy injection charge amount ($15.00) plus $.01 for the line item is bundled with the $100 charge on the qualifying visit line. Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.

21. Claim Example #5: Behavioral Services
Mental Health Services RHCs shall report one service line per mental health encounter/visit with revenue code 0900 and a qualifying mental health visit from the RHC Qualifying Visit List.

22. Claim Example #6: Medical and Behavioral Health Services
Modifier CG should be reported once per day for a qualified medical visit (revenue code 052x) and/or once per day for a qualified mental health visit (revenue code 0900).

23. Medicare Stand Alone Encounters
Medicare Preventive Service
HCPCS Code/ Short Description
AIR?
Same Day?
Coins/Ded
Annual Wellness Visit – Initial
G0438/ AWV - I
Yes No
Waived
Annual Wellness Visit – Subsq
G0439/ AWV-S
Screening Pelvic Exam
G0101/ Pelvic-breast Exam
Prostate Cancer Screening
G0102/ Prostate Screening
Not Waived
Glaucoma Screening
G0117 Glaucoma
G0118 Glaucoma
Screening Pap Test
Q0091 Obtaining Pap Smear
Alcohol Screening /Behavioral Counseling
G0442 Alcohol Screen 15 min
G0443 Brief alcohol misuse counseling
Screening for Depression
G0444 Depression screen annual

24. Medicare Stand Alone Encounters
Medicare Preventive Service
HCPCS Code/ Short Description
AIR?
Same Day?
Coins/Ded
Screening for Sexually Transmitted Infections
G0445/ STD 30 Minutes
Yes No
Waived
Intensive Behavioral Therapy for Cardiovascular Disease
G0446/ Cardio-disease
Intensive Behavioral Therapy for Obesity
G0447/ Obesity 15 minutes
Smoking and Tobacco Cessation Counseling
994061/Smoking 3-10 minutes
994071/Smoking > 10 Minutes
Lung Cancer Screening With Low Dose Computed Tomography
G0296/ Lung Cancer LDCT
1 HCPCS code G0436 and G0437 will be discontinued effective 10/1/2016. CPT codes and 99407
are the remaining codes for tobacco cessation counseling.

25. Billing Example #7 – Multiple Preventive Stand Alone Encounters
A breast and pelvic exam (G0101) and a pap collection (Q0091) were performed on the same day. Both services are “stand-alone” preventive services. Report one of these with the CG modifier. No co-insurance or deductible amount should be applied.

26. Billing Example #8 Procedure only (Red QVL) – October 1, 2016
A minor surgical procedure which is on the Qualifying Visit List can be billed alone as an encounter. The appropriate HCPCS code for the procedure should be amended with the CG modifier.

27. Billing Example #9 IPPE Only
“Modifier CG does not need to be reported with the IPPE HCPCS code whether it is billed alone or with other payable services on a claim.” RHC FAQ
The IPPE was the only service performed. The G0402 does NOT need a CG modifier when billed. **Make sure and report preventive charges on your Cost Report!!

28. Billing Example #10 IPPE and a Medical Visit
“RHC/FQHC can receive a separate payment for an encounter in addition to the payment for the [certain preventive services] when they are performed on the same day.” RHC Reporting FAQ

29. Billing Example #11: Well Woman Exam
Medicare does not pay a well-woman exams ( ). Each component will be billed instead. An annual or subsequent wellness visit (G0438/G0439) is reported for the examination, plus the breast/pelvic exam (G0101), and the pap smear (Q0091).

30. Corrected Claims – CG Modifier
FL4 TOB: 717
FL18 Condition Code: D9
FL44: Add the CG Modifier
FL64: Include ICN number from CO97
FL80: “Added the CG Modifier”

31. Modifier 59 – Modifier 25
“…the RHC should report modifier 25 or modifier 59 on the line with the medical service that represents the primary reason for the subsequent visit and has the bundled charges for all services for the subsequent visit. Modifier 59 or modifier 25 should be reported with a medical service using revenue code 052x.”

32. Modifier-59 Example
The CG Modifier will amend the initial visit. The 59 modifier will amend the subsequent visit laceration repair. The CG modifier should NOT accompany the subsequent visit code.

33. Presenters
Shannon Chambers, CPC, CRCA South Carolina Office of Rural Health Director of Provider Solutions
Charles A. James, Jr. North American Healthcare Management Services President and CEO