rural health clinic division of medicaid important information 2013 office of the governor |...

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

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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


http://www.medicaid.ms.gov/

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


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


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


Prior Authorization

• All prior authorization requirements are applicable:– Dental– Expanded EPSDT– Pharmacy– Vision


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


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.


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


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


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


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


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


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


Additional Billing Informationwww.medicaid.ms.gov/publications.aspx

Provider Reference GuidePart 212 – Rural Health Clinics


http://www.medicaid.ms.gov/publiscations.aspx

EPSDT PROGRAMShanda Boarden, RN – EPSDT Program


Mississippi Cool KidsEarly and Periodic Screening, Diagnosis and

Treatment (EPSDT)

Secondary Facility Location Requirements


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


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


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


rural health clinic division of medicaid important information 2013 office of the governor |...

Documents

rhc office

medicaid office

rhc services

rhc provider

mandated office

postpartum codes office

hospital services services

division of medicaids