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Some common allowed Revenue codes may be:052X, 0250, 0300, 0636, 0780, 0900 (this is not an all

inclusive list)All HCPCS codes must match Rev code used; 0250 should

not have a CPT code on the line itemCurrently, QVC list is not updated and RHCs are

allowed to bill for a service that is deemed as a provider service

If providing a service on the QVC list, suggest using that code as the one that has the CG modifier

QVC List https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

* References are CMS CR9269 and SE1611

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MEDICARE:Must file claims within one year from date-of-services—

effective 3/23/10.I.e. January 1, 2018 must be filed by Dec 31, 2018

NE MEDICAID: Must file claims within 180 days from date-of-service

I.e. January 1, 2018 must be filed by Jun 29, 2018Any adjustment must be completed w/I 90 daysMCD MCOs may have longer timely filing; Heritage

Health began 1/1/17*If any Xover payments are not received, these can be put

on your Medicare Bad Debt log for your cost report

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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 MAC, 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, AWV

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• All labs, x-ray TC, EKG tracing, any

technical components (venipuncture is

part of the office visit bundled services)

• All hospital services (IP, OP, ER, OBS)

• Billed to MAC, HCFA 1500 Form

• Paid on the Medicare Pt B fee schedule

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• All hospital services (IP, OP, ER, OBS)*

• Billed to WPS MAC, HCFA 1500 Format

• 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 as would have been if provided at the hospitalTechnical Component

X-rayEKGHolter Monitor placementAll TC’s Billed as would have been if provided at the hospital

Paid on the Medicare Pt B Fee Schedule

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CAH Method II• Hospital bills for both the professional and technical component when performed in the hospitalsetting:

• 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 UB04Managed Care Plans have choice as well

Coverage 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

Heritage Health began 1/1/17http://dhhs.ne.gov/medicaid/Pages/med_medcontracts.aspx

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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

Nebraska Total CareUnitedHealthcare Community Plan of NebraskaWellCare of Nebraska

MCP 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

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Must have RHC and nonRHC numberForm for each is per the Managed Care Payer

NE Plans use the UB04 for RHC servicesUse the 1500 for the nonRHC services

Ailments 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

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RHC services—UB04Detailed line items on UB04 w/RHC Provider #Lab, X-ray TC and EKG tracings (nonRHC) are

billed on the nonRHC provider # on the 1500All preventive, IP, OP, ER, OBS are nonRHC

services, billed with nonRHC Provider # on1500OB is global with exception of first visit (1500)If only visits, then nonRHC# and list visit datesGlobal Period will depend on the MCO—anywhere

from 2 weeks (Wellcare) or more

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RHC services —UB04Detailed line items on UB04 with RHC Provider #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 # on 1500OB is global with exception of first visit (1500)If only OB visits, bill nonRHC# and list visit datesGlobal Period will depend on the MCO—anywhere

from 2 weeks (Wellcare) or more

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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, Vaccine CPT is billed on the nonRHC # with charge of $19 and SL modifier

nonRHC services paid using the fee schedule and not your RHC rates

Are allowed to have an RHC visit at the same time as a nonRHC visit, i.e. ailment and preventive

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• Billed as in fee-for-service clinic• No changes in reimbursement• Must not discount charges at time of service

• RHC rule that all patients be charged the same fees• no cash discounts• 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 Regulations4

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Two types of plansPFFS – Private Fee for Service

Send Claims on UB04 with Medicare Rate letterRegional/PPO Plans

Must provide service to the entire region per CMSSend Claims on UB04; you negotiate payment

When 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.

The RHC Encounters and Medical NecessityRural Health ServicesNon-RHC ServicesPreventive Services“Incident to” ServicesTransitional Care ManagementChronic Care ManagementAdvance Care PlanningBasic claim submission requirementsCost Reporting Basics and why we need the info

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Injections with an Office VisitCharge All CPT codes in systemBundle all charges with the QVC; list the 0250 w/no CPT

code, or 0636 Rev Code with the J-code & submit claim to RHC MCR

If it is a Pt D drug, it must be sent to Pt D plan or PatientInjections only—nurse service (Incident to service)

Charge 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 visit If injectable is a Part D drug it MUST not be a part of an

RHC claim as it is only billable to the patient or to Part D

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Injectable/Vaccine as a Part D drug – 1/1/08The 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.mytransactrx.com and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount. (an electronic system for the clinic to bill is suggested by CMS)

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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• After 10/1/16 will require a CG modifier on the bundled line item

• The first visit to determine services by a Physician/PA/NP is an RHC visit, then behavioral health services apply

• Reimbursement in 2014> changed to 80/20 • Can be only service on claim or can also have 521 rev code

• If both the 900 and 521 rev codes on claim, both will have the CG mod.

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QVC required; AIR paid with copay and deductible applied.900 Rev code is for Behavior Health Providers

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• Only allowed if a different unplanned illness or injury• If same diagnosis, accumulate to set E & M level• 1st visit must have a CG modifier; 2nd visit is to be billed with a -59

modifier; or after 10/1/16 also can use -25• Visit by physician and then the mental health provider both are

billable—2 visits—Each bundled 521 and 900 will have a CG modifier effective 10/1/16

• IPPE and an ailment visit—is 2 visits, only ailment visit requires CG modifier

• IPPE, ailment and mental health visit—is 3 visits, ailment visit and mental health visit require CG modifiers

• Visit in clinic, then hospital admit (MAC determines); generally both not billable

• Visits by two different specialties on same day—is 1 visit

CMS Manual 100-02 Chapter 13 Section 40.3

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Effective 10/1/16, the -25 or -59 will only be attached to the RC line item that is the second visit on the same date-of-service for an unplanned different ailment of the patient. 2 AIRs paid

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Example of claim after 10/1/16, with both 521, 900 and preventive services on the claim. Note the CG modifier is attached to the “bundled” 521 line, and to the “bundled” 900 line with the 521 preventive service charges not included in either of those lines. (2 AIRs). Since the Preventive service is AWV, there is not additional payment.

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Example of claim effective 10/1/16, with a Medical Visit 521, 900 Mental Health Visit and IPPE on same DOS. Note the CGmodifier is attached to the “bundled” 521 line, and to the “bundled” 900 line. (3 AIRs pd); the Preventive service is NOTincluded in the bundle.

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Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04

Preventive TCs, labs, EKG tracing are billed on the nonRHC side, either through the Hospital OP provider number (PBRHC) or to MCR Pt B (IRHC) assure using correct G-codes

Each preventive service MUST be on a separate line on the UB with the G-code

If all services are preventive, 1 must have CG mod

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Medicare Preventive Services that can be “stand alone” services and the RHC will receive their AIR;

IPPE is paid in addition to any other services billedCMS 100-02, Ch 13, Sec 220

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73

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The CG modifier must be attached to the main preventive service with all the other services listed on subsequent lines. 1 AIR is paid, unless there was an IPPE (G0402), then 2 AIRs are paid; no lines are bundled.

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Preventive Services Quick Reference Guide (interactive tool):https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.htmlIPPE Quick Reference Guide:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/mps_qri_ippe001a.pdfAnnual Wellness Visit Quick Reference Guide:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV-Chart-ICN905706TextOnly.pdfBeneficiary Preventive Services Coveragehttps://www.medicare.gov/coverage/preventive-and-screening-services.htmlNoncovered ICD-10 codes for Labshttp://www.healthnetworklabs.com/pdf/icd10/4NONCOVEREDICD10CMCODESFORALLLABNCDS.pdf

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Medicare: Does not pay for annual physicals, does pay for the Introduction to Medicare Exam (IPPE) or Annual Wellness Visit (AWV). If not an IPPE or AWV, and visit is for a physical and not for the ailments, then bill the patient.

If patient has no ailments and all services are noncovered by Medicare, then if requested by patient, RHC is required to send a “no-pay” claim (710 TOB) to Medicare for denial.

No ABN is required but suggest giving one for PR reasons. ABN used is CMS-R-31 Exp. 3/2020

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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 can use:

Modifier GY = noncovered by Medicare Statute or Modifier GX = ABN Issued, Beneficiary liable.Can use one or both on Medicare claim but the charge for the item must be shown as noncovered and will not be bundled in the CG line.

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79Claim when only partially noncovered

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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, CPT codes 99381-99387. Each component of the "Well Woman Exam" billed on separate line items.

i.e. G0438 for the initial Annual Wellness Visit (covered once in a lifetime) orG0439 if it is a subsequent Annual Wellness Visit (covered annually). Screening Pap Tests Q0091 and Screening Pelvic Examinations G0101 covered every 24 months for low risk.Each of these Codes, if the beneficiary is eligible, would be billed on a separate 052x revenue code line.billed on

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Only Veni & OV bundled, all others separate charges; 1 AIR pd, copay on CG line amount = $30; copay on preventive services is in settlement on your annual cost report

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Injections, i.e. Gardasil, Zostavax, Varivax, Tetanus (as immunization update), DTAP (90697 check your MCR payer as it may have a LCD to be under Pt B; WPS allows to be Pt B for an injury, effective 1/1/16 LCD L34596)

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 MyTransactRX (CMS encourages clinics to do this for patients)

Medicaid: If patient is eligible and has a visit, bill with the visit on the nonRHC number on the 1500

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

Infusion with an Office VisitIn 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 bundled to the E/M code and line item entry of each bundled service (Medicare)

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

• effective 1/1/14 is part of the office RHC services• If more than one of the same test is done on the same day,

a -91 modifier is added to the CPT code• IRHCs—All Labs, to include the required basic 6 tests,

are payable through Medicare Part B• PBRHCs—All labs, to include the required basic 6 tests,

both Medicare & Medicaid are payable through the Hospital OP provider number

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• All coded with the accurate CPT code for each the technical component (TC) and the professional component(PC) if provider interprets

• Effective 1/1/18, some x-ray codes are both the TC and PC but no list given as yet, i.e. Chest x-ray = 71046 Two views frontal & lateral has no splits

• Interpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health; then listed separately

• Technical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number

Medicare reg on nonRHC service billing, TCs & EKG tracing:CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.

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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 (521 rev code)

• Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health, then listed on separate line

• Tracing only is billed to Medicare Pt B for IRHC or PBRHC bills using the hospital OP provider number

Medicare reg on nonRHC service billing, TCs & EKG tracing:CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.

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Note xray reading is -26 modifier and CPT for EKG interp; all bundled with the OV on the CG line; 1 AIR pd, $36 copay

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Direct supervision by provider requiredMust be in clinic, not in same roombeing in the hosp when attached to clinic is NOT

“incident to”Exception is the Chronic Care Management services

Part of provider’s services previously orderedintegral, though incidental covered as part of an otherwise billable encounterI.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—NE Medicaid does require

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• Can be combined on claim with a visit within 30days 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 (CG line)

• Added charges will be on subsequent lines of UB• When added, the added reimb is the 20% copay• Adjustments OK—717 Type of Bill; CC=D1; ICN#

in FL 64, remarks “changes in charges”• Otherwise, the costs are shown on your cost report

and claimed indirectlyCMS 100-02, Ch 13, Sec 120

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Medicare: Bill OV, EKG interp, xray read (if provider does the interp/read) to RHC Medicare on UB 04 (use E & M with bundled charges w/CG and subsequent lines of the 71046-26 & 93010 with charge); Bill labs, EKG tracing & Xray TC to MCR Pt B for IRHCs & PBRHCs bill with Hosp OP # on UB04 NE Medicaid: IRHC follows Medicare guidelines w/CPT; PBRHC list all line items and paid total charges.

Private/Commercial: Bill as in FFS clinic