Nebraska Rural Health Association RHC Group

Presented on Behalf of Nebraska Rural Health Association RHC Group By Janet Lytton, Director of Reimbursement Rural Health Development 308-647-6455 janet.lytton@rhdconsult.com September 2015 1

RHC Billing Regulations CMS RHC Internet Only Claims Manual http://www.cms.gov/regulations-and-guidance/ Guidance/Manuals/Downloads/clm104c09.pdf 2

Medicare Benefit Policy Manual Ch 13 RHC and FQHC Services Rev 201 issued 12/12/14, effective 1/1/15 http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c 13.pdf CMS clarification of stand-alone preventive services http://www.cms.gov/medicare/medicare-fee-for- Service-Payment/FQHCPPS/Downloads/RHC- Preventive-Services.pdf 3

An RHC is a certification from CMS that allows physician practices to qualify for cost-based reimbursement from Medicare and Medicaid; Any service provided in a physician s clinic can be performed in an RHC 4,100 RHCs across the country out of 230,187 physician practices (1.7%) Who are the RHCs in your State? http://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/Downloads/ rhclistbyprovidername.pdf 4

Patient Deductible = $147 per year IRHC Rate = $80.44/visit PBRHC PPS Hospital Rate = $80.44/visit PBRHC <50 bed hospitals = No limit 5

Physician services NP, PA & CNM services Services & Supplies incident to provider service Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals not separately billable for RHCs but indirectly paid Visiting nurse services in non HHA area Clinical psychologist & clinical social worker CP & CSW supplies & services incident to CMS Manual 100-02 Ch 13 Sec 50 6

Hospital patient services Lab tests (except venipuncture is part of Visit) Part D Drugs & Self administrable drugs DME Ambulance services Technical components of diagnostic tests i.e. xrays & EKG, Holter Monitoring Technical components of screening services i.e. screening paps/pelvic, PSA Prosthetic devices Braces CMS Pub. 100-02. Ch 13, Sec 60 & 60.1 7

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 100-02 Chapter 13 Section 110.2 Telephone services CMS Manual 100-02 Chapter 13 Section 100 & 120 Prescription services CMS Manual 100-02 Chapter 13 Section 100 & 120 8

Multiple Visits Same Day, Payable if Patient has second visit for additional DX A medical visit and a mental health visit same day (2 visits) IPPE and Medical Visit and Mental Health Visit (3 visits) AWV and a Mental Health Visit (2 visits) Clinic visit and Hospital admit is per your MAC Generally allows based on medically necessary Patient must have face-to-face contact in hospital CMS Pub. 100-02. Ch 13, Sec 40.3 9

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 10

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. 99214-25 (in system only) Use Modifier 25 when one of the following criteria is met: 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. 11

Visit for a problem unrelated to the procedure or service Preventive Care Visit = patient seen for annual physical 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. 12

UB 04 form or 837i electronic format Bill Type 711 Revenue Codes (NO CPT CODES ON CLAIM) Exception when billing preventive services Sent to Fiscal Intermediary Claims for all RHC visits Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident Actual charges billed 13

521 522 524 525 527 528 780 900 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 Telehealth site fee Mental Health Services All drugs & supplies, are bundled with the visit code charges in the Revenue Codes shown above 14

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 15

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 16

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. 17

ALL Laboratory performed in the RHC, including 6 basic tests (venipuncture is part of the office visit bundled service) Billed using 141 bill type for PPS Hospitals MLN SE1412, December 27, 2013 CAH 851 bill type For any facility owned by CAH or CAH employee performing Technical Component X-ray EKG Holter Monitor All TC s Billed using 131 bill type for PPS Hosp All TC s Billed using 851 bill type for CAH Paid on the Medicare Pt B Fee Schedule 18

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% 19

Must have RHC and nonrhc number 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 either to or from the RHC 20

Each Managed Care Payer (MCP) can require either/both UB04 or 1500 Arbor Health United HealthCare Coventry Of which all questions presented in the Spring to all MCPs were not answered 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 21

RHC services = bundled services UB04 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 22

RHC services = bundled services UB04 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 23

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, only the administration CPT is paid on the nonrhc # NO V-codes as primary nonrhc services paid using the fee schedule and not your RHC rates 24

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 25

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. 26

Injections with an Office Visit Charge All CPT codes in system Bundle all charges and 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 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 the RHC claim as it is only billable to the patient or to Part D 27

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: www.mytransactrx.com and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount. 28

Injections: Pt D Drugs, i.e. Gardasil, Zostavax, Varivax, Tetanus (as immunization update), DTAP Medicare: Pt D drugs require billing to Pt D or the Patient can pay for these services and send to their Pt D plan and be reimbursed OR submit claim to a company such as MyTransactRX Medicaid: If patient is eligible and has an ailment visit, bill with the visit as an RHC visit; if no ailment visit bill on the nonrhc number on the 1500 form Private/Commercial: Bill as did in FFS clinic For Medicare, these drugs are not to be on your RHC claim as they are not a Part B benefit for the patient 29

All coded with the accurate CPT code Don t forget to charge the venepuncture in OV effective 1/1/14 is part of the office bundled services IRHCs All Labs, to include the required basic 6 tests, are payable through Medicare Part B; NE Medicaid labs are billed on the nonrhc prov # PBRHCs All labs, to include the required basic 6 tests, both Medicare & Medicaid are payable through the Hospital OP provider #, either 851 (CAH) or 141 type of bill (TOB) for other hospitals 30

All coded with the accurate CPT code for each the technical component and the professional component if provider interprets Chest x-ray = 71020-TC Two views frontal & lateral; 71020-26 x-ray interpretation Interpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Technical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider # NE Medicaid follows Medicare guidelines Medicare reg on prof component billing: CMS Internet-Only Manual, Publication 100-02, Ch 13, Sec 30.3. 31

Coded using the tracing only for the TC & the interpretation only if provider interprets. EKG Tracing only = 93005 EKG Interpretation and report = 93010 Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health Tracing only is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number NE Medicaid follows Medicare guidelines w/cpts 32

Direct supervision by provider required Must be in clinic, not in same room being in the hosp 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. dressing change, injection, suture removal, blood pressure monitoring Medicare & NE Medicaid services should be billed under the provider that performed the service 33

Can be combined on claim with a visit within 30- days pre or post incident to service for plan of treatment NEVER considered a separate visit List only the date of the visit as date of service Charges should reflect all services bundled When added, the added reimb is the 20% copay Adjustments OK 717 Type of Bill; CC=D1; remarks changes in charges Otherwise, the costs are shown on your cost report and claimed indirectly CMS 100-02, Ch 13, Sec 110; Sec 130; Sec 150 34

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 35

36

Medicare: Bill OV and EKG interp (if provider does the interp) to RHC Medicare on UB 04 (one line item, no CPT codes); Bill EKG tracing to MCR Pt B for IRHCs & PBRHCs bill with 131 or 851 TOB with Hosp OP # on UB04 Bill lab for IRHC to MCR Pt B & PBRHC bill with 141 or 851 TOB with Hosp OP # on UB04 Medicaid: Follows Medicare guidelines w/cpt Private/Commercial: Bill as in FFS clinic 37

I.e. Lesion removal, joint injection, or wound closure, AND E & M code Medicare: Charge the OV level w/-25, the procedure codes, any med used bill all collapsed into the 521 rev code (no CPTs on claim) Medicaid: Charge the OV level w/-25, the procedure codes, any med used on UB, bill all collapsed into the 521 rev code (with E & M CPT on claim) Private/Commercial: Bill as in FFS clinic 38

39

Medicare: Cahaba & WPS (depends on medical necessity) but generally, if for same ailment, are not allowing both services to be billed; thus bill the Admit (services must take place 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. 40

No global charges for Medicare in the RHC Each visit in the clinic is a billable visit if it wasn t your provider that did procedure, verify they billed with the -54 modifier Code the surgical procedure with -54 (surgical procedure only) and bill to Part B 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 41

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 Medicaid: NE pays global for OB services unless provider transfers for delivery, then bill number of visits with dates 42

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 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 43

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 CMS Pub. 100-02. Ch 13, Sec 210 44

45

46

47

48

49

50

Preventive Services Quick Reference Guide: https://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/mps _QuickReferenceChart_1.pdf IPPE Quick Reference Guide: http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf Annual Wellness Visit Quick Reference Guide: www.cms.gov/outreach-and-education/medicare-learning-net work- MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf More Preventive Service info: http://www.cms.gov/regulations-and-guidance/guidance/manuals /Downloads/clm104c09.pdf http://www.cms.gov/regulations-and-guidance/guidance/manuals /Downloads/clm104c18.pdf http://www.cms.gov/regulations-and-guidance/guidance/manuals /Downloads/bp102c13.pdf 51

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) 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 do a time study NO Medicare Advantage on log LOGS MUST BE LEGIBLE 52

Suggest inputting into system with the G0008-flu administration, and G0009-pneumo administration Create a report that will list Medicare flu and pneumo injections Patient Name Date of Service Patient Medicare number Log is sent with your RHC Cost Report for payment through your cost report. NEVER send a claim for a Medicare flu or pneumo injection to either Medicare Rural Health or Pt B 53

Medicare: Does not pay for physicals, except for the Introduction to Medicare Physical. If the visit is only for a physical and not for the ailments, then bill the patient. Effective 1/1/11, Medicare will pay for an annual wellness visit per year; This IS NOT a physical Medicaid: Covered for kids and billed on the nonrhc Medicaid provider number Private/Commercial: Bill as in FFS clinic 54

How does a RHC bill for a "Well Woman Exam"? Medicare does not have a "Well Woman Exam" as a covered preventive service. Each component of the "Well Woman Exam" would have to be looked at and billed separately. For instance, the Annual Wellness Visit is covered yearly and billed with either G0438 for the initial exam (covered once in a lifetime) or G0439 if it is a subsequent visit (covered annually). Both Screening Pap Tests and Screening Pelvic Examinations are covered every 24 months for low risk women and billed with Q0091 and G0101 respectively. Each of these tests, if the beneficiary is eligible, would be billed on a separate 052x revenue code line. For more information on Medicare's Preventive Services, please see the Medicare Preventive Services Quick Reference Chart 55

If a patient comes in for a preventive exam which is not a covered exam, who do we bill? Since it is not a covered service, you will bill the beneficiary. (This includes DOT physical) For any preventive service that has a frequency limitation, it is encouraged to get an ABN just in case the service is done at the incorrect timing, if no ABN, the clinic cannot charge if Medicare does not pay. As of 9/1/12 the UB claim is allowed to have the GA modifier along with the HCPCS code with the Occurrence Code of 32 with the date the ABN was signed. 56

57

58

59

60

61

For NF/SNF/SW Bed visits Code/Bill 99304-99318 524 Rev Code for Skilled patient; 525 Rev Code for NH patient NE Medicaid only, NH req d visits on the nonrhc# 62

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/FI as an RHC visit, RC 52X Use Condition Code 07 Use diagnosis for ailment not the hospice DX Medicare Benefits Policy Manual 13, Sec. 200 63

64

How do you bill noncovered charges? If all charges are noncovered, send 710 TOB with all charges as noncovered and condition code 21. If only some of the charges are noncovered, per CMS Internet-Only Manual, Publication 100-04, Chapter 1,Adobe Portable Document Format Section 60.1.1.1. This section of the manual states, "... all of a bundled service must be billed as noncovered, or none of it. Therefore, as long as part of a bundled service is certain to be covered or medically necessary, billing the entire bundled service as covered is appropriate." 65

66

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 provider 67

68

30-day transitional period after discharge from inpatient hospital and next 29 days Face-to-face visit within 14 days of discharge 99495 moderate medical decision complexity 99496 high medical decision complexity Only 1 health care professional may report TCM Report once per beneficiary during TCM Date of service used is the face-to-face DOS 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 69

At this time, this is nonreimbursable in the RHC Will be reimbursed to RHCs per MPFS beginning 1/1/16 Physicians, NPs, PAs, CNMs, CNSs Provider must bill IPPE, AWV or comp E & M prior Must use Electronic Health Record Must get consent from patient for this service At least 20 minutes of clinical staff time per calendar month to include: Multiple (2 or more) chronic conditions to last at least 12 mo or until death Significant risk of death, acute exacerbation/decompensation, or functional decline Comprehensive care plan established, implemented, revised, or monitored Examples: Alzheimers; arthritis; asthma; atrial fibrillation; autism spectrum disorders; cancer; COPD; depression; diabetes; heart failure; hypertension; ischemic heart disease; osteoporosis MLN ICN 909188 70

RHCs will be required to bill by line item, i.e office E & M, meds used, office procedure, each preventive service each a separate line with the CPT code listed instructions yet to be determined Chronic Care Management Services to be billable in the RHC; paid at the MPFS; billed on the UB either with another service or as only service on the claim PQRS will not apply to RHCs for either the RHC or the nonrhc services. PBRHC issue to be determined. 71

Because RHCs are not paid based on the Medicare Physician Fee Schedule, they are not included in the erx or PQRS program. PQRS is based on Tax ID. Currently, the PBRHCs with the hospital Tax ID, are not showing up as exempt. NARHC is in conference with CMS on how to fix this issue. Thus, there are no penalties for any services of an RHC, to include any nonrhc services. PBRHCs are encouraged to capture all PQRS data until CMS has a fix in their system. 72

All practices that accept Medicare & Medicaid dollars are required to have a Corporate Compliance Policy Hosp/Clinic Corporate Compliance Policy HIPAA Policies in place Do we have consents signed? Are we getting ABNs (Advanced Beneficiary Notices) when appropriate (must be CMS-R-131 03/11) Keep copy of ABN Are we asking the MSP (Medicare Secondary Payer) questions? Is our billing appropriate for the documentation in the chart? 73

www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/mps_qu ickreferencechart_1.pdf (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) Make sure you are a part of your MAC listserve for updated info! 74

www.nebraskaruralhealth.org (NeRHA) www.narhc.org (National Association of RHCs) www.cms.gov www.cms.gov/regulations-and-guidance/guidance/ Manuals/ Downloads/bp102c13.pdf (new RHC/FQHC Regulations 1/15) www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/clm104c09.pdf (RHC CMS Claims Manual) www.cahabagba.com www.wpsmedicare.com Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com 75

Any? s 76