RHC Billing for Provider-Based RHCs. Charles A. James, Jr. President and CEO North American Healthcare Management Services

Transcription

1 RHC Billing for Provider-Based RHCs Charles A. James, Jr. President and CEO North American Healthcare Management Services

2 Presentation Objectives Provider-Based Requirements Provider-based Enrollment Issues PBRHC Department of the Hospital? Review RHC Billing Parameters RHC Locations and Providers RHC Services vs. Non-RHC Services Billing Examples Medicare Preventive Services

3 Provider-Based RHC Compliance Components Licensure Clinical Services Financial Integration Public Awareness Obligations of hospital outpatient deptartments Joint Ventures

4 Provider-Based RHC Enrollment All RHC Enrollment begins with the Medicare 855A. All Provider-Based RHCs must be enrolled under their parent hospital EIN number. Advise getting RHC NPI (261QR1300X Taxonomy). Enroll RHC as additional service site under the Hospital PTAN.

5 Commercial Payers Only ONE EIN can be billed out of a Provider-based RHC during RHC hours. All commercial claims during RHC hours must be billed under the hospital EIN NOT under a separate medical group EIN. All commercial payers should be approached to add outpatient professional services to provider contracts to enable compliant billing.

6 Provider Numbers Provider Number RHC PTAN Hospital PTAN Medicare Part B Group Medicare Part B Individual Description Six Digit (XX-XXXX) P-Tan RHC Site/Address Specific Enrolled using Medicare 855A Application Hospital Provider Number (tied to Hospital NPI/EIN) Fee-For-Service (1500) Medicare Group Enrollment Enrolled using Medicare 855B Application Fee-for-Service (1500) Individual Medicare Enrollment Enrolled using Medicare 855I and reassigned to Medicare Group via (855R) NPI Number National Provider Identifier Universal Number for individual providers and facilities One or more taxonomy codes is attached to NPI numbers indicating specialty or facility type.

7 42 ecfr (a)(2) Requirements for a determination that a facility or an organization has provider-based status. For purposes of this part, the term department of a provider does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC.

8 Outpatient PPS 2017 A key proposal in 2017 is to implement Section 603 of the Bipartisan Budget Act of 2015, which will affect how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider (hereinafter referenced as off-campus provider-based departments (PBDs)).

9 Places of Service Codes Danger!! Rural Health Clinics are NOT Hospital Outpatient Departments (PBD). Place of Service Codes 72 or 11 are only ones relevant for RHC claims. Outpatient Hospital Places of Service are hereby those which shall not be named! Place of Service Codes 72 Rural Health Clinic (Yay Money!) 11 - Office (Meh It ll work) 19 Satellite Outpatient Department (Boo!) Shall No Longer Be Named 22 Outpatient Hospital (Hiss!) Shall No Longer Be Named

10 RHC Claims - Medicare Part A RHC Services are submitted on a CMS-UB04 claim form. The formal electronic format is ANSI837-Institutional. Rural Health Clinic claims are administered by Medicare Part A. It is a Part B (Physician Service) benefit, using the structure of Medicare Part A. This is why we deal with UB04, Cost Reports, Revenue Codes, etc.

11 Types of Bill The following rules apply specifically to all RHC claims: The third digit of TOBs 71x provides additional information regarding the individual claim. When the third digits, called frequency codes, are used on RHC claims the TOBs are: 710 = non-payment/zero claim (a claim with only noncovered charges) 711 = Admit through discharge (original claim) 717 = Replacement of prior claim (adjustment) 718 =Void/cancel prior claim (cancellation) CMS Medicare Claims Processing Manual Chapter 9

12 Revenue Codes The qualifying visit line must include the total charges for all the services provided during the encounter/visit. RHCs can report incident to services using all valid revenue codes except 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x- 088x, 093x, or 096x-310x. RHCs should report the most appropriate revenue code for the services being performed. (MLN 9269)

13 Revenue Codes Encounter Revenue Codes Non-Encounter Revenue Codes Clinic visit 0250 Pharmacy (i.e. compound) Home visit by RHC provider 0636 Injection/Immunization Part A SNF Visit by RHC provider 0780 Telehealth Non-SNF Visit by RHC Provider 0900 Behavioral Health 0527 Visiting Nurse in HH shortage area 0528 Non-RHC Site by RHC (scene of an accident)

14 RHC Locations An RHC or FQHC visit may take place in the RHC or FQHC, the patient s residence, an assisted living facility, a Medicare-covered Part A SNF, the scene of an accident (Medicare Benefit Policy Manual. Chapter 13. Section 40.1)

15 Qualified RHC Providers An RHC encounter can be billed for the following providers: Physicians (MD, or DO) Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives Clinical Psychologists (PhD) Clinical Social Workers (CSW or LCSW)

16 Rural Health Services Physicians' services, as described in section 100; Services and supplies incident to a physician s services, as described in section 110; Services of NPs, PAs, and CNMs, as described in section 120; Services and supplies incident to the services of NPs, PAs, and CNMs, as described in section 130; (Medicare Benefit Policy Manual Chapter 13)

17 Rural Health Services (Continued) CP and CSW services, as described in section 140; Services and supplies incident to the services of CPs and CSWs, as described in section 150; and Visiting nurse services to the homebound as described in section 180. (Medicare Benefit Policy Manual Chapter 13)

18 The RHC Encounter is: A RHC or FQHC visit is defined as a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more RHC or FQHC services are rendered. A Transitional Care Management (TCM) service can also be a RHC or FQHC visit. (Medicare Benefit Policy Manual. Chapter 13. Section 40.)

19 Physician Services Physician services are professional services furnished by a physician to an RHC or FQHC patient and include diagnosis, therapy, surgery, and consultation. The physician must either examine the patient in person or be able to visualize directly some aspect of the patient s condition without the interposition of a third person s judgment. Direct visualization includes review of the patient s X-rays, EKGs, tissue samples, etc. (Medicare Benefit Policy Manual. Chapter 13. Section 100.)

20 Incident-to Services Defined Incident-to services are considered covered and paid under the RHC. They must be bundled with the RHC encounter. They are not separately billable or payable. Services that do not occur on the same date as the encounter can be bundled if they occur 30 days before or after. The effect on payment is an increase in the charge, and therefore in the co-insurance. The cost for these services are included in the cost report, but are not separately payable on claims.

21 Provision of Incident-to Services Services and supplies furnished incident to physician s services are limited to situations in which there is direct physician supervision of the person performing the service. Direct supervision does not mean that the physician must be present in the same room the physician must be in the RHC or FQHC and immediately available. (Medicare Benefit Policy Manual. Chapter 13. Section 110.1)

22 Examples of incident-to services NP/PA billed under the physician Injections Suture Removal Dressing Changes Prescription Services Blood Pressure Monitoring

23 Non-Rural Health Services Non-Rural Health Services can be billed to the fee-for-service carrier (or hospital FI). These services include: Diagnostic testing - X-Ray, EKG, etc. Laboratory services except Venipuncture! Professional services rendered in the hospital

24 Venipuncture Although RHCs and FQHCs are required to furnish certain laboratory services laboratory services are not within the scope of the RHC or FQHC benefit. When clinics and centers separately bill laboratory services, the cost of associated space, equipment, supplies, facility overhead and personnel for these services must be adjusted out of the RHC or FQHC cost report. This does not include venipuncture, which is included in the allinclusive rate when furnished in the RHC or FQHC by an RHC or FQHC practitioner and as part of an RHC or FQHC visit. (MLN Matters MM8504)

25 Diagnostic Testing and Lab: Provider-Based The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter. The technical components for X-Ray, EKG, ultrasounds, etc. are billed to the FI using the parent entity s billing number. Lab services are also billed to the FI using the parent entity s billing number.

26 Provider-based Lab Claims PBRHC owned by CAH: Billed using parent s outpatient provider number. TOB 851/Rev Code 300/UB04 CPT and DOS on each line. Payment based on parent cost report.

27 Provider-based Radiology-TC Claims PBRHC owned by CAH: Billed using parent s outpatient provider number. TOB 851/Rev Code 320/UB04 CPT and DOS on each line. Payment based on parent cost report.

28 Provider-based EKG-TC Claims PBRHC owned by CAH: Billed using parent s outpatient provider number. TOB 851/Rev Code 730/UB04 CPT and DOS on each line. Payment is cost-based.

29 PBRHC owned by PPS Billed using parent s outpatient provider number. Lab: TOB 141/Rev Code 300/UB04 Rad-TC: TOB 131/Rev Code 320/UB04 EKG-TC: TOB 131/Rev Code 730/UB04 Payment is on Medicare Fee Schedule.

30 Reporting Services Beginning on April 1, 2016, RHCs are required to report the appropriate HCPCS code for each service line along with a revenue code on their Medicare claims. RHC qualifying medical visits are typically Evaluation and Management (E/M) type of services or screenings for certain preventive services.

31 Qualifying Visits Medical Services Medical Services RHCs shall report one service line per encounter/visit with revenue code 052X and a qualifying medical visit from the RHC Qualifying Visit List and the CG Modifier. Payment and applicable coinsurance and/or deductible shall be based upon the qualifying medical visit line with the CG modifier attached.

32 Total Qualifying Visit Line Medicare does not adjudicate RHC claims based on the 0001 Total Charge amount. Medicare adjudicates RHC claims using the Qualifying Visit Line with the CG-Modifier. The qualifying visit line should be the sum of all RHC charges subtracted by any preventive services.

33 CG Modifier Requirement RHCs should report modifier CG on one line with a medical and/or mental health HCPCS code that represents the primary reason for the medically necessary face-to-face visit. Rural Health Clinics (RHCs) Reporting Requirements Frequently Asked Questions (FAQs) (Revised )

34 Claim Example #1 Office Visit Only FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 Office Visit Est III 99213CG 4/2/ $ Total Charge $ An established patient is seen and a qualifying visit of for $100 is generated. The applicable coinsurance and/or deductible shall be based upon $100. Medicare will pay the encounter at 80% of the AIR. The patient will be responsible for $20.00 in co-insurance.

35 Claim Example #2: Medical Services Plus Ancillary A Medicare beneficiary is seen for for a charge of $100. A Toradol injection (J1885) for $30 was performed. Service Charge $ $20.00 J1885 $30.00 Total Charges $150.00

36 Billing Example #2 UB Fields Medical Visit plus Ancillary FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est CG 4/2/ $ Injection Admin /2/ $ Toradol J1885 4/2/ $ Total Charge $ The charge amount for Toradol ($30.00) and the administration ($20.00) will be added to the ($100) for a qualifying visit line of $ The total charge line is inaccurate.

37 Service Detail Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR.

38 Claim Example #2 Alternative Medical Visit plus Ancillary FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est CG 4/2/ $ Injection Admin /2/ $ Toradol J1885 4/2/ $ Total Charge $ The Toradol charge amount ($30.00) plus $.01, the injection administration (20.00) plus $.01 are bundled with the $100 charge on the qualifying visit line. Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.

39 Bundled Services Different Dates The RHC can combine incident to services furnished on a different date of service on one claim as long as they are furnished in a medically appropriate period and are incident to the service being billed. Incident to services should not be reported with modifier CG.

40 Claim Example #3 UB Fields Bundled Injection/Different Dates FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est CG 4/2/ $ Allergy Injection /2/ $ Total Charge $ The charge amount for the allergy Injection ($20.00) plus $.01 will be added to the ($100) for a qualifying visit line of $

41 Claim Example #4: Medical Services Plus EKG A Medicare beneficiary is seen for for a charge of $100. A EKG (93005/93010) for $75/$30. Service Charge $ EKG-TC $ EKG-PC $30.00 Total Charges $175.00

42 Claim Example #4: Medical Visit plus EKG FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 521 OV Est CG 4/2/ $ EKG-PC /2/ $ Total Charge $ The charge for the EKG-PC ($30.00) is bundled with the charge ($100.00) on the RHC claim. The EKG-PC is reported as a $.01 line item. A will be billed to Medicare Part B/FFS under the physician/group (IRHC) or Hospital P-TAN (PBRHC).

43 Claim Example #5: Behavioral Health Services FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0900 Psytx Pt Family 30 Min CG 4/2/ $ Total Charge $ Behavioral Health Services RHCs shall report one service line per mental health encounter/visit with revenue code 0900 and a qualifying mental health visit from the RHC Qualifying Visit List.

44 Claim Example #6: Sick Visit and Behavioral Health Services FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 Office Visit Est III 99213CG 4/2/ $ Rx Management 90832CG 4/2/ $ Total Charge $ Modifier CG should be reported once per day for a qualified medical visit (revenue code 052x) and/or once per day for a qualified behavioral health visit (revenue code 0900).

45 Preventive Services Cost Reporting Track Medicare Preventive Services (MPS) charge amounts. These are to be entered on the cost report.

46 No Co-Ins/Deductible for RHC Preventive Health Services When one or more qualified preventive service is provided as part of a RHC visit, charges for these services must be deducted from the total charge for purposes of calculating beneficiary copayment and deductible. (Section 210.2: Claims Processing Manual)

47 Medicare Preventive Services (MPS) RHCs are paid an all-inclusive rate (AIR) per visit for qualified primary and preventive health services If an IPPE visit occurs on the same day as another billable visit, two visits may be billed. Except for DSMT/MNT, all of the preventive services may be billed as a stand-alone visit if no other service is furnished on the same day. CMS Preventive Service Quick Reference Chart

48 Diabetes Counseling and Medical Nutrition Services Diabetes counseling or medical nutrition services provided by a registered dietician or nutritional professional at a RHC are considered incident to a visit with a RHC practitioner provided all applicable conditions are met.

49 CG Modifier Preventive Services If only preventive services are furnished during the visit, the RHC should report modifier CG with the preventive HCPCS code that represents the primary reason for the medically necessary face-to-face visit and the bundled charges.

50 Same Day Billing RHC/FQHC can receive a separate payment for an encounter in addition to the payment for the [Certain Preventive Services] when they are performed on the same day. Technical Note: These are services the United States Preventive Services Task Force (USPSTF) has given grade A or B. (MLN SE1039) The IPPE (G0402) is the only Medicare Preventive Service eligible for sameday billing.

51 Stand Alone Encounter Billing If a Stand Alone encounter is the only service rendered on a particular date of service, then it will be paid at the AIR. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible may be waived, depending on the service rendered.

52 Stand-Alone Encounters Annual Wellness Visit (AWV) and Personalized Prevention Plan Services (PPPS) Subsequent Annual Wellness Visit Advanced Care Planning Medicare Preventive Screenings

53 Stand Alone Encounters - Not Eligible for Same Day Billing MPS Code Description Alcohol Screening and Behavioral Counseling G0442, G0443 Annual alcohol misuse screening, 15 minute Screening for Depression G0444 Annual depression screening, 15 minutes Screening for Sexually Transmitted Infections and High Intensity Behavioral Counseling G0445 High intensity behavioral counseling to prevent sexually transmitted infection; face to-face, individual Intensive Behavioral Therapy for Cardiovascular Disease G0446 Annual, face-to face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

54 Stand Alone Encounters Not Eligible for Same Day Billing MPS Code Description Intensive Behavioral Therapy for Obesity G0447 Face-to-face behavioral counseling for obesity, 15 minutes Smoking and Tobacco Cessation Counseling G0436 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes Smoking and Tobacco Cessation Counseling G0437 greater than 10 minutes

55 Stand Alone Encounters Codes Code Description G0101 CA Screen/Pelvic G0102* Prostate screening G0117* Glaucoma Screen G0118* Glaucoma Screen - Supervised G0296 Visit to determine LDCT Eligibility (Lung Cancer) G0436 Tobacco-use counsel 3-10 min G0437 Tobacco-use counsel >10 G0442 Annual alcohol screen 15 min G0443 Brief alcohol misuse counsel * Co-Insurance and Deductible apply

56 Billing Example #5 Preventive/Ancillary An established patient is seen and a qualifying visit of for $100 is generated. A breast/pelvic exam was performed for $ A venipuncture was taken for $ FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est CG 4/2/ $ Breast/Pelvic G0101 4/2/ $ Venipuncture /2/ $ Total Charge $ The charge for the pelvic exam should NOT be bundled in the line since there will be no coinsurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the charge for $

57 Billing Example #6: Medical Services Plus Procedure A Medicare beneficiary is seen for for a charge of $100. A minor surgical procedure (11100) for $150 was performed. Service Charge $ $ Total Charges $250.00

58 Billing Example #6 Alternative Medical Visit plus Procedure FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est CG 4/2/ $ Procedure /2/ $ Total Charge $ Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.

59 Procedure only Procedures on the Qualifying Visit list can be billed by themselves, at the total charge for the service, with a CG modifier. FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 Procedure CG 4/2/ $ Total Charge $

60 Billing Example #7: IPPE Only An established patient is seen for the Welcome to Medicare Visit or IPPE. (G0402) is the only service performed. Modifier CG does not need to be reported with the IPPE HCPCS code whether it is billed alone or with other payable services on a claim. RHC Reporting Requirement FAQ Service Charge G0402 $ Total Charges $200.00

61 Billing Example #7: IPPE Only The IPPE was the only service performed. The G0402 does NOT need a CG modifier when billed. FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 IPPE G0402 4/2/ $ Total Charge $ **Make sure and report preventive charges on your Cost Report!!

62 Billing Example #8: IPPE plus a sick visit An established patient is seen for a COPD. The patient has just enrolled with Medicare and is eligible for the Welcome to Medicare Visit or IPPE (G0402). An established patient visit is billed treating the COPD in addition to the IPPE. Service Charge G0402 $ $ Total Charges $300.00

63 Billing Example #8: IPPE and a sick visit Modifier CG does not need to be reported with the IPPE HCPCS code whether it is billed alone or with other payable services on a claim. When IPPE is furnished with another medically necessary face-to-face service, modifier CG is reported with the HCPCS code for the other billable service. RHC Reporting FAQ FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 Est Patient III 99213CG 4/2/ $ IPPE G0402 4/2/ $ Total Charge $

64 Billing Example #9: Multiple Preventive Services/Well Woman Exam An established patient is seen for a well woman exam. Medicare does not recognize A subsequent annual wellness visit (G0439) is performed for $175, in addition to a breast/pelvic exam (G0101) for $ A pap spear (Q0091) for $50.00 is also rendered. Service Charge G0439 $ G0101 $75.00 Q0091 $50.00 Total Charges $300.00

65 Billing Example #9: Multiple Preventive Services/Well Woman Exam Medicare does not pay a well-woman exams ( ). Each component will be billed instead. An annual or subsequent wellness visit (G0438/G0439) is reported for the examination, plus the breast/pelvic exam (G0101), and the pap smear (Q0091). Each charge is listed individually. The patient is not responsible for any co-insurance or deductible for these Medicare Preventive Services. Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 Subsq AWV G0439 CG 4/2/ $ Breast/Pelvic G0101 4/2/ $ Pap Smear Q0091 4/2/ $ Total Charge $

66 Multiple Encounters are allowed when: The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day (2 visits), or The patient has a medical visit and a mental health visit on the same day (2 visits), or The patient has his/her IPPE and a separate medical and/or mental health visit on the same day (2 or 3 visits). (Medicare Benefit Policy Manual. Chapter 13. Section 40.3)

67 Multiple Encounters are allowed when: The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day (2 visits), or; The patient has a medical visit and a mental health visit on the same day (2 visits), or; The patient has his/her IPPE and a separate medical and/or mental health visit on the same day (2 or 3 visits). (Medicare Benefit Policy Manual. Chapter 13. Section 40.3)

68 Subsequent Illness or Injury Which Gets CG? Modifier-CG is ONLY reported on the initial, medically necessary visit. ONLY Modifier-59 is reported on the subsequent visit. Both are paid as encounters.

69 Initial Sick Visit/ Subsequent Illness or Injury Modifier-59 Example FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 OV Est Level CG 4/2/ $ Laceration /2/ $ Total Charge $

70 CMS Resources Medicare Claims Processing Manual UB04 Completion Medicare Claims Processing Manual Chapter 9 RHC/FQHC Coverage Issues Medicare Benefit Policy Manual Chapter 13 RHC/FQHC Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

71 Medicare Preventive Reference MPS Chart: ReferenceChart_1.pdf CMS Preventive Services Center: MLN/MLNProducts/PreventiveServices.html

72 Chronic Care Management Changes Federal Register: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY A Rule by the Centers for Medicare & Medicaid Services on 11/15/2016

73 Contact Information Charles A. James, Jr. North American Healthcare Management Services President and CEO