RHC Advanced Billing Janet Lytton RHIT, NHA Director of Reimbursement Rural Health Development
Learn how to bill preventive care, nonrhc & Incident to services & what Revenue code to use Learn how to handle Pt D drugs Learn how to bill for TCM, CCM, ACP 97
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 PBRHC through the Hospital OP provider number IRHC to MCR Pt B Each preventive service MUST be on a separate line on the UB G-code on main preventive service when all services are preventive ARE NOT bundled Some claims may have more than one G-code 98
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Medicare Does not pay for physicals Exception for the Introduction to Medicare Physical (IPPE) If visit is for a physical, not ailments = bill the patient Does not require an Advance Beneficiary Notice (ABN) If patient requested by patient, RHC required to send a no-pay claim to Medicare for denial 710 TOB with all charges noncovered and CC 21 100
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 - initial Annual Wellness Visit (covered once in a lifetime) G0439 - subsequent Annual Wellness Visit (covered annually). Screening Pap Tests Q0091 and Screening Breast and Pelvic Examinations G0101 covered every 24 months for low risk. Each Code billed separately, if the beneficiary is eligible, with 052x rev code If ailments are addressed, then appropriate to assign E&M 101
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Injections with Office Visit Charge All CPT codes in system Bundle all charges with the QVC; list the RC 0250 w/no CPT code, or RC 0636 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 a medically appropriate time generally 30 days pre or post nursing service and submitted with the f-t-f visit If injectable is a Part D drug it MUST not be on RHC claim; only billable to the patient or to Part D 103
Injectable/Vaccine as a Part D drug 1/1/08 The injectable/vaccine is payable only through Pt D Exception is flu and pneumonia is payable through the RHC cost report; Hepatitis B is Pt B covered if indicated Pt high risk 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 the system will let you know the copay amount. (an electronic system for the clinic to bill is suggested by CMS) 104
MCR excluded services, i.e. dental, hearing & eye tests = Patient payable Lab Services; Technical components of an RHC service = Billable to Pt B for IRHCs; PBRHC billed by parent hospital DME, Prosthetic devices, Braces = Must have DME provider # to bill items Ambulance Services = Ambulance company bills Hospital Services ER, OP, IP, ASC, MCORF = Billed to Pt B; if CAH Method II, ER, OP, ASC billed by CAH Telehealth distant-site services = Billed on the RHC claim with 780 RC with Q3014 and charge Hospice Services (if for DX of hospice); Auxiliary Services, i.e. language interpretation, transportation, security = not billable to anyone 105
All coded with the accurate CPT code Don t forget to charge the venipuncture with OV Part of the office RHC services (0300 RC) IRHCs All Labs, to include the required basic 6 tests, are payable through Medicare Part B (1500 form) PBRHCs All labs, to include the required basic 6 tests, are payable through the Hospital OP provider number 106
All coded with CPT code for each the technical component and the professional component if provider interprets Chest x-ray = 71020-TC; 71020-26 x-ray interpretation Interpretation billed with office visit and bundled Submitted on RHC claim a separate line item with 0521 RC & charge Technical Component Billed to Medicare Pt B for IRHC Billed using the hospital OP provider number for PBRHC Medicare reg on nonrhc service billing, TCs & EKG tracing: CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90. 107
RHC must split bill for EKGs EKG Tracing only = Technical Component = nonrhc service = 93005 EKG Interpretation and report = RHC service = 93010 Interp, 93010, is billed with OV (if performed in the RHC) Included in bundled line item of RHC claim And listed on separate line w/0521 RC, CPT and charge Tracing, 93005, is the nonrhc portion IRHC bills to Medicare Pt B under Provider NPI PBRHC billed through 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. 108
Telehealth Site Service with Office Visit Same Day Revenue Code HCPCS Service Units Service Date Total Charges Payment Coinsurance/ Deductible Applied 52X 99213CG 1 1/25/2018 $XX.XX AIR Yes 780 Q3014 1 1/25/2018 $XX.XX 80% of $26 Approx Yes Any service date after 10/1/16 Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line) Telehealth Site Service only Revenue Code HCPCS Service Units Service Date Total Charges 780 Q3014 1 1/25/2018 $XX.XX Any service date after 10/1/16 Payment 80% of $26 Approx Coinsurance/ Deductible Applied Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line) Yes 109
Hospice Claim for ailment other than hospice diagnosis 110
Direct supervision by a provider is required Must be in clinic, not in same room being in the hospital when attached to clinic is NOT incident to Part of provider s services previously ordered integral, though incidental covered as part of an otherwise billable encounter I.e. BP check, dressing change, injection, suture removal, etc. CMS Internet Manual 100-02, Ch 13, Sec 120, 140, 160 RHC claims should reflect the Provider of services, not the supervising Phys for the PA, NP or CNM 111
Can be combined on claim with a visit within a medically appropriate timeframe (30 days pre/post) NEVER considered a separate visit or sent to Part B List only the date of the FTF visit as date-of-service Charges should reflect all services bundled (CG line) Added charges will be on subsequent lines of UB04 When added, additional reimb is the 20% copay Adjustments OK 717 Type of Bill; CC=D1; remarks changes in charges Otherwise, the costs are included on the cost report and claimed indirectly CMS Internet Manual 100-02, Ch 13, Sec 120 112
TOB 717 Claim must be in finalized status Adjustment will appear as a debit or credit on future remittance advice Encourage submitting electronically exceptions denied charges & claims rejected as MSP Do not send another 711 claim as will error as a duplicate Examples of Adjustments: Revenue code changes, Service unit decrease or increase, Total charges changed, Primary payer incorrect 113
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Transitional Care Management (TCM) General Chronic Care Management (CCM) General Behavioral Health Integration (BHI) Psychiatric Collaborative Care Model (CoCM) https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/ Downloads/FQHC-RHC-FAQs.pdf 115
30-day transitional period of next 29 days after discharge from: Inpatient Acute Care Hospital Inpatient Psychiatric Hospital Long Term Care Hospital Skilled Nursing Facility Inpatient Rehabilitation Facility Hospital outpatient observation or partial hospitalization Partial hospitalization at a Community Mental Health Center Discharge to: His or her home His or her domiciliary A rest home Assisted living MLN ICN 908628 116
Face-to-face visit 99495 moderate medical decision complexity w/i 14 days 99496 high medical decision complexity w/i 7 days Only 1 health care professional may report TCM Report once per beneficiary during TCM For RHC, Date of service used is the F-T-F visit day RHC paid their RHC all-inclusive rate TCM cannot be billed during a global period Documentation required: Date of discharge Date of interactive contact with bene and/or caregiver Date of face-to-face visit Complexity of Medical Decision making MLN ICN 908628 117
Reimbursed as nonrhc service G0511 General Care Management = $62.28 Services for primary care conditions G0511 Behavioral Health Integration = $62.28 Services for primary care and/or mental or behavior health conditions Patient must have been seen in the last year or initiate CCM at an AWV or a physician visit Billed under: Physicians, NPs, PA s, CNMs, and CNMs General supervision allowed; allows for offsite management MM10175 118
At least 20 minutes of clinical staff time per calendar month to address ailments that include: Option A General Care Management Pt with multiple (2 or more) chronic conditions to last at least 12 mo with significant risk of death, acute exacerbation/ decompensation, or functional decline Option B BHI Pt with any behavioral health or psychiatric condition being treated by an RHC provider that is determined to warrant BHI services Must have Pt verbal or written consent with method to opt out Must develop a comprehensive care plan with patient receiving a copy 24/7 Access to Care access to physicians or other qualified health care professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week (Can use secure email or phone calls) Must use EHR; Allows transmission of the care plan by fax MM10175 119
Billed on the RHC/FQHC UB-04 to Medicare Part A Revenue code 521 Can be billed with other services or billed alone Will receive the payment alone or in addition to your visit rate Payment allowance Made under the Physician Fee Schedule Non-Facility Rate No geographic adjustment Average of the comparable CPT codes (99490, 99487 & 99484) 2018 allowance: $62.28 Coinsurance/deductible are applicable 120
CCM Furnished as a Stand-alone Billable Visit Revenue Code HCPCS Service Units Service Date Total Charges 52X G0511 1 1/31/2018 $XX.XX Any service date after 1/1/18 Enter your charge (coinsurance will be based upon your charge) Coinsurance /Deductible Payment Applied 80% of $62.28 Yes CCM Billed with another Face-to-face Visit Revenue Code HCPCS Service Units Service Date Total Charges Payment Coinsurance /Deductible Applied 52X 99213CG 1 1/25/2018 $XX.XX AIR Yes 52X G0511 1 1/25/2018 $XX.XX 80% of $62.28 Yes Any service date after 1/1/18 Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line) 121
G0512 CoCM = $145.08 Paid at national non-facility avg 99492 & 99493 Patient must have been seen in the last year or initiate CCM at an AWV or a physician visit Billed under: Physicians, NPs, PA s, CNMs, and CNMs General supervision allowed; allows for offsite management Must have Pt verbal or written consent with method to opt out 70 minutes or more of initial psychiatric CoCM services; 60 minutes or more of subsequent psychiatric CoCM services Initial assessment by a behavioral health manager Primary care practitioner determines if the patient is eligible for psychiatric CoCM Psychiatric consultant Participates in regular reviews of the clinical status of the patient Advises the medical care provider MM 10175 122
CoCM Furnished as a Stand-alone Billable Visit Revenue Code HCPCS Service Units Service Date Total Charges 52X G0512 1 1/31/2018 $XX.XX Any service date after 1/1/18 Enter your charge (coinsurance will be based upon your charge) Coinsurance /Deductible Payment Applied 80% of $145.08 Yes CoCM Billed with another Face-to-face Visit Revenue Code HCPCS Service Units Service Date Total Charges Payment Coinsurance /Deductible Applied 52X 99213CG 1 1/25/2018 $XX.XX AIR Yes 52X G0512 1 1/25/2018 $XX.XX 80% of $145.08 Yes Any service date after 1/1/18 Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line) 123
Advance care planning including the explanation and discussion of advance directives such as standard forms first 30 minutes (but does not have to have forms completed) Can be a stand alone service and paid as a visit Or, is an add-on element of the AWV No frequency limits, but if performed again there should be a change in status or change in end-of-life wishes documented FTF with patient, family member(s), and/or surrogate No deductible or copay when with the AWV Deductible and copay applies when billed otherwise 99498 can be billed for each additional 30 minutes No specific diagnosis required ICN 909289 June 2018 124
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Medicare Benefit Policy Manual Ch 13 RHC and FQHC Services Rev 220 issued 1/09/18 https://www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/bp102c13.pdf RHC CMS Claims Manual Ch 9 Rev 3434 issues 12/31/15 https://www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/clm104c09.pdf CMS clarification of stand-alone preventive services 8/10/16 https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf CMS Rural Health Clinics Center https://www.cms.gov/center/provider-type/rural-health-clinics-center.html 126
https://www.cms.gov/medicare/prevention/prevntiongeninfo/medicare-preventiveservices/mps-quickreferencechart-1.html (interactive preventive service web tool) https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf https://www.cms.gov/mlnproducts/downloads/mlncatalog.pdf https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/ som107ap_g_rhc.pdf (CMS State Operations Manual updated 1/26/18) www.narhc.org (National Association of RHCs) Make sure you are subscribed to your MAC listserve for updated info! Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com 127
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