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Rural Health Clinic
D i v i s i o n o f M e d i c a i d I m p o r t a n t I n f o r m a t i o n
2013
O f f i c e o f t h e G o v e r n o r | M i s s i s s i p p i D i v i s i o n o f M e d i c a i d
RHC BASICSKimberley Funchess – Facilities and Transportation Programs
O F F I C E O F T H E G O V E R N O R | M I S S I S S I P P I D I V I S I O N O F M E D I C A I D 2
Rural Health Clinics
• Governing Document: Administrative Code Title 23, Part 212– Found on Division of Medicaid’s Website:
www.medicaid.ms.gov
• Reimbursement for RHC Services: Funded by Medicare and Medicaid
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Rural Health Clinics
Provide to Mississippians:• Primary healthcare– including specialty practice (OB/GYN, pediatric, etc.)
• Six specified lab tests required on-site – urine, HGB/HCT, blood glucose, stool, pregnancy,
cultures
• Supportive services not mandated
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Hospital Services
• Services provided in an inpatient or outpatient hospital setting are NOT eligible for reimbursement by an RHC provider– These services must be billed by a qualified, eligible provider
using his/her Medicaid provider number– Claims billed by an RHC provider with the following places of
service will be denied:
POS 21 POS 22 POS 23
• Providers employed by an RHC may render services in an inpatient or outpatient hospital, but the services must be billed by the provider, not the RHC
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Service Limits
• All service limits are applicable– Physician visits– Dental– Vision– Mental Health
• Additional benefits are available for beneficiaries who qualify for Expanded EPSDT services.
• COE limits apply – COE 029, 031, 051, 54, 045, 088
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Prior Authorization
• All prior authorization requirements are applicable:– Dental– Expanded EPSDT– Pharmacy– Vision
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Documentation
• Provider documentation must:– Include complete patient records– Verify appropriate services provided – Include date of service, presenting complaint, findings, treatment rendered, provider
signature– Include details such as drug dosages, lab values, radiology reports, etc.
• Documentation may be audited by DOM or a contracted entity at any time
• Services not documented may be subject to recoupment or further investigation by Program Integrity
• Providers referred to a regulatory body may be prosecuted for fraud or suffer monetary penalties
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Co-mingling
• Definition:– Simultaneous operation of an RHC and another
physician practice, thereby mixing the two practices (share hours of operation, space, staff, equipment, supplies, and other resources).
• Physicians and non-physician practitioners may not operate private Medicare and Medicaid practice during RHC hours of operation using clinic resources.
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RHC REIMBURSEMENTKEY POINTS
Marilyn Dickerson, CPC – Coding Specialist
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RHC Reimbursement
• Paid based upon encounter rates– Encounter rates are set for individual providers– One encounter rate per face-to-face visit allowed– Provider must bill encounter code to receive
reimbursement– Codes other than encounter codes will reimburse at a
rate of zero
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Multiple Encounters Same Day
• Up to four encounters may be reimbursed for the same date of service– Limited to one encounter for each visit type• Medical• Dental• Vision/Eyeglass• Mental Health
– Additional medical encounters may be paid on the same date of service by submitting a paper claim with supporting documentation
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Encounter CodesMedical
99201 – 99215 99341 – 99350 H0023
99241 – 99245 99381 – 99397 H1002
999304 – 99310 99401 S9127
99315 59425 – 59426 S9445
99318 59430 T1017
99324 – 99337 T1023
Dental
D0000 – D9999
Vision/Eyeglass
92002 – 92014
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Mental Health Encounter Code Changes
Valid for dates of service beginning 1/1/2013
90785 90845 – 90847 96101
90791 – 90792 90849 96110
90832 – 90834 90853 96111
90836 – 90838 90870 96118
No longer valid after 12/31/2012
90801 – 90802 90821 – 90824 90865
90804 – 90815 90857 90876
90816 – 90819 90862 90899
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Obstetrical Billing
Antepartum Visits– CPT codes 99201 – 99215, 59425 and 59426
• Visit 1, 2, or 3 one per visit in 99201 – 99215 range• Visit 4, 5, or 6 use 59425• Visit 7 or more use 59426
Postpartum visits• When clinic physician is not the delivering physician use
59430
Modifiers • Include modifier -TH with all antepartum, delivery and
postpartum codes
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Billing Reminders
• RHC should not be listed as the servicing provider on the claim
• Non-covered and invalid procedure or diagnosis codes will deny if billed
• $3.00 copay applies, unless exempted by policy
• National Correct Coding Initiative Edits (NCCI) do not apply
• 5% assessment does not apply
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Additional Billing Informationwww.medicaid.ms.gov/publications.aspx
Provider Reference GuidePart 212 – Rural Health Clinics
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EPSDT PROGRAMShanda Boarden, RN – EPSDT Program
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Mississippi Cool KidsEarly and Periodic Screening, Diagnosis and
Treatment (EPSDT)
Secondary Facility Location Requirements
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Enrollment Requirements for Secondary Locations
• Contact the Bureau of Provider Enrollment at (601) 359-6133 and request to link a secondary location to the primary location’s provider facility group number.
• The Bureau of Provider Enrollment will notify the requestor that the secondary location has been linked. It is the responsibility of the requestor to contact the Bureau of Medical Services at (601) 359-5565 to request the MS Cool Kids Secondary Location Form. After receipt and approval the requestor will be notified.
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EPSDT Servicing Providers
The EPSDT Servicing Provider must be one of the following provider types:
• Physician
• Nurse Practitioner
• Physician Assistant
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Equipment, Supplies, and Other Requirements
• Pediatric Scales (Balanced)• Adult Scales (Balanced)• Equipment to measure height• Equipment to measure infant
length and head circumference• Audioscope or Audiometer,
(calibrated annually)• Snellen Eye Chart or Titmus
Machine• Plus Lens• Pediatric Blood Pressure Cuff
• Anemia testing machine (HCT/HGB)
• HCT/HGB equipment calibration log
• Ophthalmoscope• Otoscope• Disposable gloves and Sharps
container• Urine dipstick for glucose and
protein (Expiration Date)• Containers for urine specimen
collection
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Equipment, Supplies, and Other Requirements continued
• Developmental Assessment Tool (Denver Kit or Alternative Supplies)• Gown and Drapes available• Supplies available to obtain necessary lab (Lead, RPR)• Private Medical Record Filing System (HIPPA complaint)• Private Exam Area• Waiting room adequate for isolation of well and sick child• Bathroom and hand washing facilities• Exit doors clearly marked• Handicap Ramp or access• Fire extinguisher• Disaster/Fire plan posted• Administrative Policies, procedure manual, job descriptions
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