Claim to RHC Medicare; 1 AIR pd, copay $41 IRHC claim to Mcr Pt B per the fee schedule PBRHC Hospital would submit UB04 claim with OP prov. #s 91
I.e. Lesion removal, joint injection, wound closure, AND E & M code (multiple procedure services) Medicare: Bundle the OV, the procedure codes, any med used bill as bundled into the 521 rev code; w/cg (OV CPT on claim, with subsequent lines of proc code(s) and med used) Medicaid: IRHC: Bundle all charges on 1 line; PBRHC: Charge the OV level w/-25, the procedure codes, any med used w/j-code & NDC on UB Private/Commercial: Bill as in FFS clinic 92
NOTE: For Medicare will allow the -25 modifier on the E & M code when billed with a procedure and will not result in a double payment. (info recently acquired), 1 AIR pd, $140 copay 93
Medicare: MACs say it depends on medical necessity but generally, if for same ailment, are not allowing both services to be billed; thus bill the Admit (services must be a face-to-face in the hospital) Medicaid: Bill the hospital admit and not the clinic visit. Private/Commercial: Bill the hospital admit For all payers make sure you are accumulating all services to set the level of admit. 94
No global charges for Medicare in the RHC Each visit in the clinic for a covered service is a billable visit If visit is following a hospital procedure, must verify the procedure was billed with the -54 modifier If not, then the visit cannot be billed Bill the pre and post visits as RHC visits as it is the RHC facility billing the services, not a specific provider NE Medicaid has a 2 week global for procedures in the hospital setting 95
Medicare: Visits would be medically reasonable and necessary and billed as an RHC visit with 711 TOB and 521 revenue code. Delivery only would be billed as a hospital nonrhc service; each post partum visit is a billable visit Medicare DOES NOT pay for birth control devices, their Pt D plans will pay for birth control pills Medicaid: NE pays global for OB services unless provider transfers for delivery, then bill number of visits with dates as nonrhc services on the 1500 96
Keep a log of injections, or have your computer track Medicare paid on your Medicare Cost Report Flu payable once per season; pneumo initial must be at least 11 months before second of different vaccine (eff 1/1/15) Prevnar injections do go on the log. Medicaid is paid only if in your State benefits at time of service Keep track of vaccine and supply costs (invoices) Determine average nursing hours per week Determine average provider hours per week Generally allow 10 minutes per injection on Cost Report, but must do a time study to verify length of time admin NO Medicare Advantage on log LOGS MUST BE LEGIBLE 97
For NF/SNF/SW Bed visits Code/Bill 99304-99318 524 Rev Code for Skilled patient; 525 for NH patient If Prolonged Services apply Code also 99356 or 99357 Effective with DOS 7/1/08 Can use Prolonged Service codes for NF/SNF services 99304-99306, 99307 99310 & 99318 but if codes are set for counseling, must be at highest level of counseling E & M to code the prolonged service code MM5968, CR5968, Effective 7/1/08 98
Claim for a Resident on a Pt A Skilled Stay Claim for a regular Nursing Home Resident 99
Transitional Care Management (TCM) General Chronic Care Management (CCM) General Behavioral Health Integration (BHI) Psychiatric Collaborative Care Mode. (CoCM) https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/ Downloads/FQHC-RHC-FAQs.pdf 100
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 101
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 102
Claim is billed on the F-T-F visit date (MPFS is $156.07) Make sure your charges are set appropriately Claim is billed on F-T-F visit date (MPFS is $220.85) Assure the correct documentation is in the chart. CMS 100-02, Ch 13, Sec 230.1 MLN ICN 908628 103
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 Paid at national non-facility avg of 99490, 99487 & 99484 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 104
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/phone calls) Must use EHR; Allows transmission of the care plan by fax 105
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 106
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) 107
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 service 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 108
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) 109
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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-oflife 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 111
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When seen for the hospice condition Is not payable to the clinic and must be coordinated with the Hospice Entity Any TC is billed to the Hospice Co, if required Coordinate all cares with the Hospice Company When seen for a condition other than the reason for being on hospice Bill the MAC as an RHC visit, RC 52X Use Condition Code 07 Use diagnosis for ailment not the hospice DX Medicare Benefits Policy Manual 13, Sec. 210 113
Hospice Claim for ailment other than hospice diagnosis 114
Bill to RHC FI Revenue Code 780 Does not require a Face-to-Face visit same day Q3014 code is paid separately from allinclusive rate at the Medicare Phys Fee Schedule Bill for transmission fee REQUIRED to put the Q code on the claim RHCs are not allowed to be the service provider 115
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 Payment 80% of $26 Approx Coinsurance/ Deductible Applied 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) Yes 116
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 117
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Must keep patient name, date of service, HIC#, if a Medicaid patient or not, is it co-insurance or deductible and dates billed Exhibit 5 of the CMS 339 Form If send to collections, this is not considered written off as bad debt, cannot put on log until it is totally written off and no chance of payment. RHC Medicare Bad Debt paid at 65% More Medicare Bad Debt due to Qualified Medicare Beneficiary (QMB) 119
Medicare bad debt form must accompany cost report of total bad debt being claimed. Medicare bad debt is claimed on the cost report based on which fiscal year the bad debt was written off in, not date of service. All Bad Debts must have been written off after at least 120 days of statements sent (4), unless was for a QMB patient or Medicaid or indigent Accounts cannot be sent to collection and claimed as bad debt, must be totally written off 120
With QMB(Qualified Medicare Bene) and the policy of NE MCD, there will be significantly more Medicare allowed Bad Debt; don t miss out! 121
RHC services are not looked at when determining if Threshold of $90,000 in Pt B services or 200 Medicare Pts Must chose at least 1 quality measure to avoid a 4% payment adjustment Can report the measure on your Pt B claims instead of using a vendor to do the reporting Eligible clinicians can participate by their group or individually Info can be found at: https://qpp.cms.gov/about/small-underserved-rural-practices 122
All practices that accept Medicare & Medicaid dollars are required to have a Clinic Corporate Compliance Policy Are the OIG checks being made monthly? HIPAA Policies in place Do we have consents signed? Are we getting ABNs (Advanced Beneficiary Notices) when appropriate (must be CMS-R-131 3/2020) Keep copy of ABN Are we asking the MSP (Medicare Secondary Payer) questions? 123
https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/downloads/MLNCatalog.pdf https://www.cms.gov/regulations-and-guidance/guidance/manuals /downloads/som107ap_g_rhc.pdf (CMS State Operations Manual) https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf (CCM Services) Make sure you are a part of your MAC listserve for updated info! 124
www.nebraskaruralhealth.org (NeRHA) www.wpsmedicaregba.com www.palmettogba.com www.narhc.org (National Association of RHCs) www.cms.gov www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/bp102c13.pdf (RHC/FQHC Regs 01/18) Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com 125
Any? s 126