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. When added, the added reimb is the 20% copay Otherwise, if not on a claim, all costs are part of your cost report and are included in your rate CMS 100-02, Ch 13, Sec 110.1 110.2 110.3 36
Can be combined on claim with a visit incident to service per plan of treatment NEVER considered a separate visit Visit should be within 30-days pre or post List only the date of the visit as DOS (< 4/1/16) Add charges to the bundled 52X line item (> 4/1/16) Rev codes & Charges should reflect service provided Adjustments OK 717 Type of Bill; CC=D1; remarks changes in charges Otherwise, the costs are shown on your cost report and claimed indirectly 37
UB 04 form or 837i electronic format Bill Type 711 Revenue Codes Must have Qualifying Visit Code on claim (QVC) Many Revenue codes allowed refer to CR 9269 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 38
521 522 524 525 527 528 900 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 Mental Health Services 39
052X and/or 0900 with Qualifying Visit code (QVC)*, HCPCS required, total charges of all service lines except preventive codes; separate line for each preventive services with HCPCS code. Detail of all Revenue codes except the following are allowed: 002X-024X, 029X, 045X, 054X, 056X, 060X, 065X, 067X-072X, 080X- 088X, 093X, 096X-310X Some common allowed Revenue codes will be: 052X, 0250, 0300, 0420, 0430, 0440, 0636, 0780, 0900 (this is not an all inclusive list) All HCPCS codes must match Revenue codes used, 0250 does not require any CPT code (per CR 9269) * https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf 40
The 0521 RC is a total of the services of the day with the other RCs showing what additional services were performed, copay and deductible will be determined from the 0521 line; 1 AIR paid; if preventive services, these are not bundled, each on as a line item. 41
Compliance Policy Required if practice receives Medicare dollars Levels coded accurately = correct reimbursement All ancillary services must have an order Reimbursement difference from a level 3 and 4 of an established patient is approximately 50% more than the lower level charged As an RHC this is important due to the 20% copay based on the actual charge billed for Medicare 42
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 43
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 44
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. 45
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 46
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% 47
Each State Medicaid is specific as to their State requirements 50 states, 50 plans May use either the 1500 or UB04 Managed Care Plans have choice as well Coverage is specific to each state Most States require both RHC and nonrhc Medicaid provider numbers Paid on the RHC rate or a PPS rate NE has transitioned to Managed Care Payers 48
Each Managed Care Payer (MCP) can require either/both UB04 or 1500 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 49
Must have RHC and nonrhc number Form for each is per the Managed Care Payer 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 50
RHC services = bundled services UB04 or 1500 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 51
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 52
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, administration CPT is billed on the nonrhc # with charge; CPT of vaccine given with 0 charge and SL modifier on claim (DHHS PB 1549) nonrhc services paid using the fee schedule and not your RHC rates 53
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 54
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 MA Company may have specific format for claims 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. 55
Injections with an Office Visit Charge All CPT codes in system Bundle all charges with the QVC; list the 0250 or 0636 Rev Code 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 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 an RHC claim as it is only billable to the patient or to Part D 56
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. 57
Only allowed if a different illness or injury If same diagnosis, accumulate to set E & M level If seen by physician and then the mental health provider both are billable 2 visits If have IPPE and an ailment visit, it is 2 visits If IPPE, ailment and mental health visit, is 3 visits If seen in clinic, then admitted (MAC determines) If seen by two different specialties, only 1 visit billable CMS Manual 100-02 Chapter 13 Section 40.3 58
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 Can be only service on claim or can also have 521 rev code 59
2 visits in one day, different diagnoses & episodes; must have modifier 59 (per CR 9269) 60
As shown, 2 per diems; does not require the 521 for BH to be paid 61
As shown, 3 per diems; IPPE, Office Visit, Behavior Health Visit 62
RC 521 IPPE is an AIR, no copay/ded; plus other 521 99213 is an AIR, copay/ded applied; other RCs for info only and no copay/ded applied 63
QVC required; AIR paid with copay and deductible applied 64
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 or Q-code shown Some claims may have more than one preventive code Many preventive codes can be stand alone services 65
This list of RHC preventive services can be found at: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf 66
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Preventive Services Quick Reference Guide: https://www.cms.gov/medicare/prevention/prevntiongeninfo/down loads/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- Network-MLN/MLNProducts/downloads/AWV_Chart_ ICN905706.pdf 69
Medicare: Does not pay for physicals, except for the Introduction to Medicare Physical (IPPE). If not an IPPE, and visit is for a physical and not for the ailments, then bill the patient. If patient has no ailments and all services are noncovered by Medicare, then if requested by patient, RHC required to send a no-pay claim to Medicare for denial. No ABN is required but suggest giving one for PR reasons. 70