ron l. nelson, pa president 2 east main street fremont, michigan 49412 ph: 231-924-0244 fx:...

RON L. NELSON, PAPRESIDENT

2 East Main StreetFremont, Michigan 49412

Ph: 231-924-0244Fx: 231-924-4882

Health Services Associates, Inc.

Website: www.hsagroup.net

Email: nelson@hsagroup.net

Understanding Billing Issues

•RHC/FQHC Services

•Part B Services

•Provider Based vs. Independent

RHC Services

•Physician Services

•PA/NP/CNM

•Psychologist

•Clinical Social Worker

•Services and Supplies “Incident-To” to the above Services

Part B Services

• Inpatient – Professional Component

•Lab – Technical

•X Ray – Technical

•Diagnostic – Technical

•Radiologist Fees (four walls test applies)

Billing for PA/NP/CNM

•Obtain UPIN’s for PA’s, NP’s and/or CNM’s

•Medicare Advantage – review how PA, NP, CNM are covered

•Medicaid – review participation agreements

VaccinesVaccines

•Flu

•Pneumococcal

What information do I need to capture?

Billing for Procedures

•Endoscopies

•Biopsies

•Surgical Procedures (office based)

•Commingling – defined

How can we correctly carve out procedures?

MEDICAID – What is Covered?

•Core Services

•Other Services

•Managed Care

How to analyze its impact

Behavioral Health Services Health Services

•Clinical Psychologist (PhD)

•Clinical Social Worker (CSW)

• Initial Diagnostic Visit Paid at 100%

•Four walls test applies

Telehealth

•Bill to RHC/FQHC Program

•Q3014 code is paid separately from all all-inclusive rate

•Bill for $20, transmission fee

•Real Time Audio/Video Transmission

•Separate service not subject to fee schedule restrictions

SNF, Swing Bed Visits

• January 1, 2005 - bill all to RHC FI

•The requirements for visits are every 30 days (not less than 21 days)

•Medical necessity allows acute visits

Billing for Procedures

•Endoscopies

•Biopsies

•Surgical Procedures (office based)

Billing Billing Crossovers

•Problems with EOB with EOB

• How to get PaidHow to get Paid

• How to Remain CompliantHow to Remain Compliant

Provider-Based Issues

•Only Visits Billed to Intermediary

•Ancillaries Billed Under Hospital Fee Schedule Hospital provider type

•Exceptions – CAH – offsite clinics

What constitutes a visit

•Face to face encounter a patient and a physician, physician assistant, nurse practitioner, nurse-midwife, or visiting nurse.

•Encounters with more than one health professional and/or multiple encounters with the same health profession that take place on the same day at a single location constitutes a single visit.

Pap/Pelvic

Bill Professional component to FI under revenue code 521Bill Technical component to the Part B CarrierSee Medi 913-01

Colorectal Screening/Bone Mass/Prostate Cancer Screening

Bill Professional component to FI under revenue code 521Bill Technical component to the Part B CarrierSee Medi 799-00

Diabetic Outpatient Self-Management Training Services

Not reimbursed by Medicare at this time for services rendered by RHC.

SERVICES RENDERED ON NON-VISIT

DAYSCan be combined with claims with visits

Recommend they be within 30 days

List only the date of the visit

Show charges for all services

Adjustments OK

Otherwise, handle thru cost report

LIST ACTUAL CHARGES

The RHC should list their actual charge for each service.

Do not automatically default to listing the all-inclusive rate amount only.

SIGNATURESMEDICAL RECORDS- ACCEPTABLE- HANDWRITTEN ELECTRONIC STAMPED + HANDWRITTEN

UNACCEPTABLE- STAMPED STAMPED + INITIALS

CLAIMS- ACCEPTABLE - HANDWRITTEN ELECTRONIC STAMPED “SIGNATURE ON FILE”

Medicare Reimbursement

ONE VISIT PER PATIENT PER DAY WITH FEW EXCEPTIONS

SECOND ENCOUNTER ON SAME DAY MAY BE BILLED IF UNRELATED (SORE THROAT AND BROKEN HAND)

MAY BILL FOR A PART A VISIT AND A PART B non-RHC/FQHC VISIT (HOSPITAL VISIT) ON SAME DAY

Medicare Reimbursement (continued)

Pneumonia and Influenza immunizations

Medicare will pay cost at the end of the year on the cost report.

Cost based reimbursement is two to three times standard payment levels

Do not bill Medicare. The clinic is only required to maintain a log

Medicare Reimbursement (continued)

Pneumonia and Influenza logs required

Must include all patients

Separate log for pneumonia and for influenza

Information needed:

Date of service

Patient name

Patient Medicare number, if Medicare patient

Bonus Payment Non RHC/FQHC Part B ServicesHealth Professional Shortage Area:

HPSA Geographic10%

Physician Scarcity Areas:PSA 5%

Specialty Physician Scarcity Area:SPSA 5%

www.cms.hhs.gov/providers/bonuspayment

Apply to physician services – not services provided by non physicians.