Face-to-Face with the Provider Physician, PA, NP, CNM Clinical Social Worker or Clinical Psychologist Medically necessary Does it require the skills

Transcription

1 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 41

2 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 tracing and interp, xray prof & tech comp 42

3 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 Chapter 13 Section Telephone services CMS Manual Chapter 13 Section 100 & 120 Prescription services CMS Manual Chapter 13 Section 100 &

4 o o o o o o o o Routine INR visit for lab Simple suture removal Dressing change Results of normal tests Blood pressure monitoring B12 injection Allergy Injection Prescription service only 44

5 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 and only pays the alloweable G or Q-codes to include: IPPE, paps, breast & pelvic exam, annual wellness visit, PSA, etc. (those listed in the Medicare beneficiary booklet) 45

6 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 (in system only) Use Modifier 25 when: 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. (DO NOT use -25 on claim as it means there was a separate visit on the same day for unrelated diagnosis, effective 10/1/16) 46

7 Visit for a problem unrelated to the procedure or service Preventive AWV = patient seen for annual wellness visit 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. 47

8 UB 04 form or 837i electronic format Bill Type X and/or 900 Revenue Code(s) with CPT code of face-to-face visit with CG modifier and the bundled charges minus any preventive service charges All other revenue codes listed on separate lines with CPTs of the bundled charge line items Charges on subsequent lines must be $.01 or > Sent to MAC Claims for all RHC visits Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident 48

9 Office visit in clinic Home visit 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. Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay Visiting Nurse Service in a HHA shortage Visit at other site, I.e. scene of accident Mental Health Services 49

10 052X and/or 0900 with Qualifying Visit code noted with the CG modifier, HCPCS of QVC, total bundled charges of all service lines except preventive codes; separate line for each bundled service with charge > $.01, list each preventive service with HCPCS code and charge. IPPE requires CG modifier as always a separate payment; any stand alone preventive service requires CG modifier Detail of all Revenue codes except the following are allowed: 002X-024X, 029X, 045X, 054X, 056X, 060X, 065X, 067X-072X, 080X-088X, 093X, 096X-310X Some common allowed Revenue codes may be: 052X, 0250, 0300, 0420, 0430, 0440, 0636, 0780, 0900 (this is not an all inclusive list) All HCPCS codes must match Revenue codes used; 0250 does not require any CPT code * References are CMS CR9269 and SE

11 The 0521 RC is a total of the services of the day with the other RCs showing what additional services were performed, copay and deductible will be determined from the 0521 line; 1 AIR paid; if preventive services, these are not bundled, each on as a line item. 51

12 Effective10/1/16, the CG modifier will be attached to the 521 RC and/or the 900 RC line item that is the bundled amount of services. Copay and deductible will be determined from the CG line(s), not the total at the bottom of the claim 1 AIR paid; if both 521 & 900 RC have CG then 2 AIRs pd; if preventive services performed, these are not bundled, each service is a separate line item. ( Per CMS SE 1611) 52

13 Example of claim effective10/1/16, with both 521, 900 and preventive services on the claim. Note the CG modifier is attached to 1 of the 521 lines and 1 of the 900 lines with the 521 preventive services not included in either of those lines. 53

14 Effective10/1/16, the -25 or -59 will only be attached to the RC line item with the CG modifier that is the second visit on the same date of service for an unplanned different ailment of the patient. DO NOT use the -25 on your E & M code on claim if there is also a procedure performed. When billing with the -25 or -59, RHC will receive 2 AIRs. 54

15 MEDICARE: Must file claims within one year from date of services effective 3/23/10. I.e. January 1, 2016 must be filed by Dec 31, 2016 NE MEDICAID: Must file claims within 6 months from date of service I.e. January 1, 2016 must be filed by Jul 31, 2016 Any adjustment must be completed w/i 90 days MCD MCOs may have longer timely filing; Heritage Health will begin 1/1/17 55

16 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 56

17 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 MAC, HCFA 1500 Form Paid on the Medicare Pt B fee schedule 57

18 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. 58

19 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 hospital Technical Component X-ray EKG Holter Monitor All TC s Billed as would have been if provided at the hospital Paid on the Medicare Pt B Fee Schedule 59

20 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% 60

21 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 Heritage Health to begin 1/1/17 61

22 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 62

23 Must have RHC and nonrhc number Form for each is per the Managed Care Payer NE Plans use the UB04 for RHCs 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 settlements 63

24 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 64

25 RHC services UB04 Detailed line items 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 65

26 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, administration CPT is billed on the nonrhc # with charge; CPT of vaccine given with 0 charge and SL modifier on claim (DHHS PB 1549) nonrhc services paid using the fee schedule and not your RHC rates 66

27 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 67

28 Two types of plans PFFS 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. 68

29 The RHC Encounters and Medical Necessity Rural Health Services Non-RHC Services Preventive Services Incident to Services Transitional Care Management Chronic Care Management Basic claim submission requirements Cost Reporting Basics and why we need the info 69

30 Injections with an Office Visit Charge All CPT codes in system Bundle all charges with the QVC; list the 0250 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 Patient Injections only nurse service (Incident to 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 an RHC claim as it is only billable to the patient or to Part D 70

31 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 71

32 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: and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount. 72

33 Only allowed if a different unplanned illness or injury If same diagnosis, accumulate to set E & M level Is to be billed with a -59 modifier; or after 10/1 also can use -25 Visit by physician and then the mental health provider both are billable 2 visits Each bundled 521 or 900 will have a CG modifier effective 10/1/16 IPPE and an ailment visit is 2 visits IPPE, ailment and mental health visit is 3 visits Visit in clinic, then hospital admit (MAC determines); generally not both billable Visits by two different specialties on same day is 1 visit CMS Manual Chapter 13 Section

34 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> is 80/20 Can be only service on claim or can also have 521 rev code 74

35 QVC required; AIR paid with copay and deductible applied, after 10/1/16 the CG modifier required 75

36 As shown, 2 per diems; does not require the 521 for BH to be paid, after10/1/16, CG modifier on both line items required 76

37 RC 521 IPPE is an AIR, no copay/ded; plus other is an AIR, copay/ded applied; other RCs for info only and no copay/ded applied, after 10/1/16, & G0402 require CG modifier 77

38 As shown, 3 per diems; IPPE, Office Visit, Behavior Health Visit, after 10/1/16, all lines on this claim require the CG Mod. 78

39 2 visits in one day, different diagnoses & episodes; must have modifier 59 (per CR 9269) (10/1/16 either -25 or -59 can be used along with the CG modifier; caution DO NOT USE traditional use of -25 on claims) 79

40 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 80