Rural Health Clinic Billing & Coding

Janet Lytton, Director of ReimbursementRural Health Development

308-647-6455 janet.lytton@rhdconsult.com

Kearney, NE September 2014

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Overview of RHC Regulations & changes Elements of RHC Billing & “how to’s” The following areas will be discussed:

The RHC Encounters and Medical Necessity

Rural Health Services Non-RHC Services Preventive Services Basic claim submission requirements Online RHC Resources

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From the NARHC website: http://narhc.org/resources/rhc-rules-and-guidelines/

Interpretative Guidelines are also given Link of General rules redirects to:

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID= bd5ea765b228085fc1b9f5a7366f85a0&n=42y2.0.1.2.5.15&r=SUBPART&ty=HTML

Current as of 8/1/14

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Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 173 issued 11/22/13, effective 1/1/14

MM8504 issued 11/22/13 updates effective 1/1/14 Federal Register of 5/2/14 updated RHC regs

effective 7/11/14 CMS clarification of stand-alone preventive

services 8/14/14

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• RHC must be located in a healthcare shortage area

• Health Professional Shortage Area (HPSA)• Medically Underserved Area (MUA)

• Medically Underserved Population does not meet the shortage area designations (MUP)

• Governor’s list of Healthcare Shortage Areas• Check website:

•http://www.hrsa.gov/shortage/find.html•Search to find your area as either a HPSA or MUA

• Check the State website for governor’s list of shortage areas

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30.1 - RHC Staffing MUST employ 1 NP or PA (W-2 or owner)

Others can be contract providers NP, PA or CNM at least 50% of clinic hours

Contract services for “some” NPs/PAs effective 7/11/14

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40.2 - RHC is required to post hours of operations

All services during scheduled hours are RHC services

Have clear schedules Cannot rotate from clinic to hospital during

RHC hours

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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 (2 visits) IPPE and Medical Visit and Mental

Health Visit (3 visits) AWV and a Mental Health Visit (2 visits) Clinic visit and Hospital admit is per your

MAC WPS & Cahaba will allow if medically

necessary Patient must have face-to-face contact in

hospital10

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

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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

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50.3 – Emergency Services Neither IRHCs or PBRHCs are subject to EMTALA Must have drugs & biologicals commonly used in life-

saving procedures 60.1 - Non RHC Services

MCR excluded services, i.e. dental, hearing & eye tests

Technical component of an RHC service Laboratory Services (does not include venipuncture) 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,

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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 not required Self-attestations are acceptable

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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.

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90 – Commingling (con’t) 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

If a RHC practitioner furnishes a RHC service at the RHC during RHC hours, the service must be billed as a RHC service. The service cannot be carved out of the cost report and billed to Part B.

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120.2 – Physician Supervision Effective 7/11/14, supervision of NP, PA, and

CNM is per your State Regulations

Nebraska: ARNP: The collaborating physician is responsible for supervision through ready availability for consultation and direction of the activities of the ARNP within the ARNP’s defined scope of practice to ensure the quality of health care provided to patients. (NE Regulations 172 NAC 100)

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Nebraska: PA: Supervision of a physician assistant by a supervising physician shall be continuous but shall not require the physical presence of the supervising physician at the time and place that the services are rendered.A supervising physician may supervise no more than four physician assistants at any one time. The board may consider an application for waiver of this limit and may waive the limit upon a showing that the supervising physician meets the minimum requirements for the waiver. (NE Statutes 38-2050)

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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.

Providers should coordinate care with the Hospice Co.

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Medicare beneficiaries who elect the Medicare hospice benefit may choose either an individual physician or NP to serve as their attending practitioner (Section 1861(dd) of the Act). RHCs are not authorized under the statute to be hospice attending practitioners. However, a physician or NP who works for a RHC may provide hospice attending services during a time when he/she is not working for the RHC (unless prohibited by their RHC contract or employment agreement). These services would not be considered RHC services, since they are not being provided by a RHC practitioner during RHC hours.

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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

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Patient Deductible = $147 per year

IRHC Rate = $79.80/visit

PBRHC PPS Hospital Rate = $79.80/visit

PBRHC <50 bed hospitals = No limit

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• Consent to be treated• Authorization to Bill• HIPAA Privacy notification• Medicare Secondary Payer Questions asked (keep 10 yrs)

• Pub 100-5 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

• 1-800-999-1118 8 am–8 pm EST TDD 800-318-8782• Beneficiaries, providers, attorneys, third party payers

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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

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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

protected—DO 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

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All Procedure Codes that are normally performed in a physician’s 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

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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

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• 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”

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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”

CMS Manual 100-02 Chapter 13 Section 50 30

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. 100-02. Ch 13, Sec 60 & 60.1

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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 100-02 Chapter 13 Section 110.2

Telephone services CMS Manual 100-02 Chapter 13 Section 100 & 120

Prescription services CMS Manual 100-02 Chapter 13 Section 100 & 120

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o Routine INR visit for labo Simple suture removalo Dressing changeo Results of normal testso Blood pressure monitoringo B12 injectiono Allergy Injectiono Prescription service only

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

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Compliance Policy Required if practice receives Medicare dollars

Levels coded accurately = correct reimbursement All ancillary services must have an order Reimbursement 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 35

Better documentation does not mean MORE documentation

checklists are not always a good practice just because a system is checked it doesn’t mean it was examined If it isn’t documented, it didn’t 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

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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.

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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)

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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.39

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.

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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. 99214-25 (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.

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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.

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• 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

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521 Office 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

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MEDICARE:Must file claims within one year from date

of services—effective 3/23/10.I.e. August 1, 2013 must be filed by July

31, 2014

MEDICAID:Must file claims within 6 months from

date of service—effective 9/1/13 PB 13-50

I.e. March 1, 2014 must be filed by Aug 31, 2014 45

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• 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 clinic’s “all inclusive rate”• All Medicare coverage rules apply

• Reasonable & necessary• Allowed preventive is covered, I.e. pap, PSA

• 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

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• 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 hospital’s claim.

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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

MLN SE1412, December 27, 2013 CAH 851 bill type

For any facility owned by CAH or CAH employee performing

Technical Component X-ray EKG Holter Monitor All TC’s Billed using 131 bill type for PPS Hosp All TC’s Billed using 851 bill type for CAH

Paid on the Medicare Pt B Fee Schedule49

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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%

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Each State Medicaid is specific as to their State requirements—50 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

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Each Managed Care Payer (MCP) can require either/both—UB04 or 1500 All Services for the Managed Care patients are sent to the MCP—nothing 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 rate—RHC Medicaid year is 7/1 through 6/30 each year

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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

settlements54

RHC services = bundled services—UB04 or 1500 Lab, X-ray TC and EKG tracings are billed on the nonRHC provider # 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

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RHC services = bundled services—UB04 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

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“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

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• 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

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Two types of plansPFFS – 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.

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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 only—nurse 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

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: www.mytrnsactrx.com and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount. 61

Injections with an Office Visit Add charges to the E/M code and submit claim

Injections only—nurse 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

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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

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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

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Preventive Services Quick Reference Guide:https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdfIPPE Quick Reference Guide:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdfAnnual Wellness Visit Quick Reference Guide:www.cms.gov/Outreach-and-Education/Medicare-Learning-Net work-MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdfMore Preventive Service info:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /Downloads/clm104c09.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /Downloads/clm104c18.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals /Downloads/bp102c13.pdf

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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 clinicThese drugs are not to be on your RHC claim as they are not a Part B benefit for the patient

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Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion

subcutaneous or intravenous 96365 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-up

Add charges to the E/M code and submit claim (Medicare)

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• All coded with the accurate CPT code• Don’t forget to charge the venepuncture in OV

• effective 1/1/14 is part of the office bundled services• 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

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• All coded with the accurate CPT code for each the technical component and the professional

component if provider interprets• Chest x-ray = 71020-TC Two views frontal & lateral; 71020-26 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 100-02, Ch 13, Sec 30.3.

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• Coded using the tracing only for the TC & the interpretation only if provider interprets.

• EKG Tracing only = 93005• EKG Interpretation and report = 93010

• 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

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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 provider’s 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

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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 provider’s services previously ordered integral, though incidental covered as part of an otherwise billable encounter I.e. dressing change, injection, suture removal, etc.

Can be bundled with a face-to-face encounter within a 30-day period 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 100-02, Ch 13, Sec 110; Sec 130; Sec 150

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• Can be combined on claim with a visit within 30-days pre or post • “incident to” service for plan of treatment• NEVER considered a separate visit• List only the date of the visit as date of service• Charges should reflect all services bundled• When added, the added reimb is the 20% copay• Adjustments OK—717 Type of Bill; CC=D1; remarks “changes in charges”• Otherwise, the costs are shown on your cost report and claimed indirectly

CMS 100-02, Ch 13, Sec 110; Sec 130; Sec 150

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

UB04Medicaid: Follows Medicare guidelines w/CPTPrivate/Commercial: Bill as in FFS clinic

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I.e. Lesion removal, joint injection, wound closure, AND E & M code Medicare: 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

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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.

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• 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 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

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Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for

Infusion med, CPT for Infusion subcutaneous or intravenous

96365 Intravenous infusion, for therapy, prophylaxis or diagnosis; initial up to 1 hr.

96366 Intravenous infusion each addt’l hour 96369 Subcutaneous infusion for therapy or

prophylaxis, initial up to 1 hr, incl pump set-up

96370 Subcu. infusion each addt’l hour Add charges to the E/M code and submit claim

(Medicare & Medicaid)

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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

• Only allowed if a different illness or injury• WPS wants 1st claim processed, then send 2nd claim• If same diagnosis, accumulate to set E & M level

• If seen by physician and then the mental health provider both are billable—2

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

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• 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 86

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

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• Suggest inputting into system with the G0008-flu administration, and G0009-pneumo administration• Create a report that will list Medicare flu and pneumo injections

• Patient Name• Date of Service• Patient Medicare number

• Log is sent with your RHC Cost Report for payment through your cost report. NEVER send a claim for a Medicare flu or pneumo injection to either Medicare Rural Health or Pt B

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

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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

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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.

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• For NF/SNF/SW Bed visits• Code/Bill 99304 - 99318

• If Prolonged Services apply• Code also 99356 or 99357 • Effective with DOS 7/1/08 • Can use Prolonged Service codes for NF/SNF services 99304-99306, 99307–99310 & 99318 but if codes are set for counseling, must be at highest level to code the prolonged service code

MM5968, CR5968, Effective 7/1/08

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• 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. 200

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• 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

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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 100-04, Chapter 1,Adobe Portable Document Format Section 60.1.1.1. 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."

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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.

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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.

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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.

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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.

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• TOB 717• Claim must be in finalized status• Adjustment will appear as a debit or credit on future remittance advice• Encourage submitting electronically

• exceptions—denied 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

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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 101

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!

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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

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Q.RE: CHOW - If a RHC is in a county that is no longer designated as a HPSA and then sells its practice to another entity (CHOW), would the clinic lose its RHC status since the clinic is no longer in a HPSA?

A. As long as the new owner accepts assignment of the Medicare agreement and does not relocate the clinic, it would remain an RHC (unless and until CMS adopts new regulations implementing the 1997 Balance Budget Act “essential provider” provision).  Conversion from independent to provider-based would not affect its status, either.

CAUTION: If the clinic submits the CMS 29 form as part of the application, the clinic will may lose its status because it will come back as denied due to lack of a HPSA designation.  The key is not to submit the CMS 29 form but many of the state licensing offices require it as part of the CHOW application.  You will need to explain to the local licensing office that the CMS 29 form is not part of the CHOW.

Table of ContentsA.Overview of the Rural Health ClinicB.Disclosure of OwnershipC.Listing of Physicians and Midlevel ProvidersD.Definitions used in the reportE.Review of Clinic RecordsF.Review of Encounters by TypeG.CPT Code Analysis by ProviderH.Cost AnalysisI.Statement of Scope of PracticeJ.Review of Policy and Procedure ManualK.Listing of Individuals on the Annual Evaluation Review CommitteeL.Signatures of Annual Evaluation Review Committee accepting the Annual ReportM.Mock InspectionN.Timeline for Recommended Changes/ImprovementsO.Confirmation of Changes/Improvements MadeP.Minutes From Annual Evaluation Review Committee Meeting 105

• 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- 131 03/11)• Keep copy of ABN• Are we asking the MSP (Medicare Secondary

Payer) questions?

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Information Needed to Complete

the RHC Cost ReportCMS 222-92 (05/2013)

Provider based – owned, operated by Hospital, SNF, HHA (Schedule M)

Independent – (Freestanding) – may be MD/DO owned, privately owned or owned by other health professionals (CMS 222)

Method to reconcile and verify payments to allowable costs

Allowable RHC Costs/RHC Visits = RHC Cost Per Visit = RHC rate; not to exceed the maximum allowable reimbursement rate for current period. ($79.80 2014)

Determines future reimbursement rates

Cost reports are due five months after FYE

Must obtain (PS&R) Provider Summary Report 90 days after FYE through the IACS internet system

Cost reports must be submitted in electronic format (ECR File) on CMS approved software

Vendor list on the CMS website Many use HFS software

Financial Statements

Visits by payer class—Medicare, Medicaid, Medicare Advantage, All other

Clinic Hours of Operation

FTE Calculations—Time studies are strongly encouraged

Total number of nursing staff hours worked during the cost report period.

Staff of RHC (Worksheet 5)

Vaccine Information (Worksheet 6 and Sample Vaccine Logs)

Payments received

Depreciation Schedule

Medicare Bad Debt (Exhibit 5 of CMS 339)

Laboratory Costs (From time study & financials)

Non-RHC X-ray Costs (From time study & financials)

Broken down by provider and by insurance type for all health care providers

Count only face-to-face encounters Do not include visits for hospital, non

covered services, non qualified providers or injections

If computer print out, assure accuracy If manual, total for each provider

RHC Hours Non-RHC Hours (if applicable) – must have

reasonable methodology for carve out (i.e. average time spent, visits, space, clinical hours)

Do Time Studies for provider services, lab services, x-ray, flu and pneumo administration Time studies are required for providers to be 1 week

a month, different weeks each month Service time studies are a study of the time it takes

to perform each type of service (usually =>10 services)

BASED ON TIME STUDIES PERFORMED Average hours worked per week for each health

care provider at the RHC: Average administrative hours worked per

week (used to reclassify wages of provider) Average patient care hours worked per week

(used to calculate the FTE input on the cost report for the provider)

Average inpatient care hours worked per week (used to adjust wages of provider to hospital services)

Total number of nursing staff hours worked per year (for use in calculating the staff time ratio of time available for giving vaccines).

RN

LPN

MA

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Job Titles

Gross Wages

Fringe benefits and payroll taxes of all providers and clinical staff

Staff performing lab duties

Allocate % of time for non-RHC carve out for staff performing non-RHC lab/x-ray duties vs. RHC duties

Time studies of staff to support the allocated carve out

Balance Sheet

Profit and Loss Statement

Trial Balance

All accounting in the accrual method of accounting

Date Asset Purchased Description of Asset Cost of Asset Life of Asset All depreciation is based on straight-line

method with CMS healthcare lives

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Influenza and Pneumovax

Total vaccines given of each to all payer types

Total Medicare vaccines given of each (log must accompany cost report – sample log attached)

Cost per dose of each from invoices Must submit copies of invoices with cost

report

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Medicare bad debt form must accompany cost report of total bad debt being claimed.

Medicare bad debt is claimed on the cost report based on which fiscal year the bad debt was written off in, not date of service.

All Bad Debts must have been written off “after” at least 120 days of statements sent (4)

Accounts cannot be sent to collection and claimed as bad debt

RHC must request the PS&R at approx. 90 days after FYE using the IACS internet system

Compare PS&R total to your Medicare visit count. Is this accurate? If not, determine why and if this is a common issue that occurred when pulling all insurance visit type information

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http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/ Health_and_Human_Services_System/Title-471/Chapter-34.pdf

NE Medicaid RHC Provider Information Chapter 34

http://dhhs.ne.gov/medicaid/Documents/471-000-77.pdf

NE Medicaid Billing Instructions for RHCs

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www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickReferenceChart_1.pdf

www.cms.gov/Outreach-and-Education/Medicare-Learning -Network-MLN/MLNProducts/downloads//MPS_QRI_ IPPE001a.pdf

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ /AWV_Chart_ICN905706.pdf

www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf

Make sure you are a part of your MAC listserve for updated info!

www.ruralhealthweb.org (NRHA)

www.nebraskaruralhealth.org (NeRHA)

www.cms.gov

www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/bp102c13.pdf (new RHC/FQHC Regulations 11/13)

www.cms.gov/Regulations-and-Guidance/Guidance /Manuals/ Downloads/clm104c09.pdf (RHC CMS Claims Manual)www.wpsmedicare.com

www.cahabagba.com

www.narhc.org

Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com

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