RHC Basics and Beginning Billing 03/19/2018. Dedicated to improving access to quality healthcare in rural communities

Transcription

1 RHC Basics and Beginning Billing 03/19/2018 Dedicated to improving access to quality healthcare in rural communities

2 RHC Services An RHC Encounter is defined as a medicallynecessary, face-to face (one-on-one) medical or mental health visit, or a qualified preventative health visit, with a RHC practitioner during which time one or more RHC services are rendered. Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

3 RHC Providers Physicians Nurse Practitioners Physician Assistants Certified Nurse Midwifes (CNM) Clinical Psychologists Clinical Social Workers (CSW or LCSW)

4 What about Specialists? Condition of Coverage: Provision of Services- Providing Rural Health Clinic Services: o A facility may provide services in addition to RHC services, usually, related health care services such as the other ambulatory services Must be 51% Primary Care Services Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf

5 Medicare Part A Only If the patient only has Part A then they aren t covered under RHC services

6 Medicare Advantage Plans Billed the same as regular Medicare.

7 RHC Billing Requirements Beginning October 1, 2016, RHCs shall add modifier CG to the line with all the charges subject to coinsurance and deductible. (SE1611) **Exception is the Initial Preventative physical Exam (IPPE)** RHCs are required to bill the appropriate HCPCS code for each line along with the correct revenue code on each line.

8 Revenue Codes Clinic Visit Home Visit Part A SNF Visit SNF, NF or Residential facility (Non Part A) Visit Scene of an Accident Telehealth Mental Health Service

9 Claim Examples When a claim is for an office visit only then you would have the 0521 revenue code, with a CG modifier placed at the end of the procedure code

10 Claim Example 0521 Office Visit 99213CG (175.00) 0521 Procedure

11 Bill Types RHC claims typically have 4 types of bills: o710- Non payment/ Zero Claim o711- Original Claim o717- Adjustment Claim (Replacement of prior claim) o 718- Cancelled Claim (Void/Cancel Prior claim)

12 Non RHC Services Hospital Visits- Billed to Part B DME- Must have a DME Provider number Part D Drugs-

13 ABNs

14 EKGs: vs 93005, (93005 should be billed to Part B Independent and Hospital numbers of Provider based and should be billed to Part A) X-rays (Technical goes to Part B, Professional Part A)

15 Claim Example 0521 Office Visit 99213CG $ ($175.00) 0521 EKG $50.00

16 Preventive Services Preventive services can be stand alone visits or billed with another visit. Service-Payment/FQHCPPS/Downloads/RHC- Preventive-Services.pdf

17 Deductible/Coins Waived

18 Initial Preventive Exam Procedure Code Description Paid at the AIR Eligible for Same Day Billing Coins/Deductible Applied G0402 Initial Preventive Exam Yes Yes Waived

19 Annual Wellness Visit Procedure Code Description Paid at the AIR Eligible for Same Day Billing Coins/Deductible Applied G0438 Initial Visit Yes No Waived G0439 Subsequent Yes No Waived

20 Screenings Procedure Code Description Paid at the AIR Eligible for Same Day Coins/Deduct Applied G0101 Q0091 CA Screening. Pelvic/Brea st Obtaining Pap Yes No Waived Yes No Waived

21 Claim Examples Preventative services with an Office visit.

22 Two Visits on the Same Day MLN/MLNMattersArticles/Downloads/SE1611.pdf

23 Claim Example 0521 Office Visit 99213CG25 or Office visit 99215CG

24 Influenza and Pneumonia Vaccines Should be put on your Shot Log and submitted as part of your cost report. Do not submit on a claim. Patient Name Health Insurance Number Date of Service Donald Duck A 10/15/2017 Daisy Duck A 10/15/2017

25 Advanced Care Planning Stand alone service or billed with Annual Wellness Visit. Explanation and discussion of Advanced Directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional.

26 Advanced Care Planning for the first 30 minutes for additional 30 minutes Deductible/Coins Applied Deductible/Coins Not Applied AWV and ACP ACP Sick Visit and ACP XX XX XX

27 Telehealth Services RHCs may only serve as the originating site Billable as the only service or as an additional service with another visit RHCs cannot be the consulting/distant site Billed with 0780 Revenue Code with Q3014

28 Hospice Services Can treat a patient for Non-Hospice Diagnosis If treating for Non-Hospice Diagnosis then 07 condition code must be applied to the claim If provider is treating for Hospice related diagnosis then claim should be billed to hospice company or adjusted. Claim cannot be billed to Part B.

29 Lab Charges Must be able to furnish these 6 tests onsite o Blood Sugar o Pregnancy Tests o Primary Culturing for transmittal to a certified lab o Hemoglobin or hematocrit o Exam of stool specimen for occult blood o Chemical exam of urine by stick or tablet or both

30 RHC Type RHC Service Lab Performed in RHC Technical Components Independent Part A (UB-04) Part B (1500) Part B (1500) Provider Based Part A (UB-04) Billed to Medicare Contractor by Parent Hospital. Billed to Medicare Contractor by Parent Hospital.

31 Resources Rural Health Information Hub Medicare Claims Processing Manual Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 581KB] National Association of Rural Health Clinics

32 Questions??

33 Contact Information 107 Saluda Pointe Dr Lexington, SC Phone: Fax: