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, Section 60.4.3. 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." https://www.cms.gov/regulations-and-guidance/ Guidance/Manuals/Downloads/clm104c01.pdf 71
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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 for the initial Annual Wellness Visit (covered once in a lifetime) or G0439 if it is a subsequent Annual Wellness Visit (covered annually). Screening Pap Tests Q0091and Screening Pelvic Examinations G0101 covered every 24 months for low risk. Each of these Codes, if the beneficiary is eligible, would be billed on a separate 052x revenue code line. 73
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Injections, 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 a visit, bill with the visit on the nonrhc number on the 1500 Private/Commercial: Bill as did in FFS clinic These drugs are not to be on your RHC claim as they are not a Part B benefit for the patient 75
Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous 96365 Intravenous infusion, for therapy, prophylasis or diagnosis; initial up to 1 hr. 96369 Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, including pump set-up Add charges to the E/M code and submit claim (Medicare) 76
All coded with the accurate CPT code Don t forget to charge the venepuncture with OV effective 1/1/14 is part of the office bundled services If more than one of the same test is done on the same day, a -91 modifier is added to the CPT code IRHCs All Labs, to include the required basic 6 tests, are payable through Medicare Part B or NE Medicaid 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 77
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 number NE Medicaid follows Medicare guidelines Medicare reg on prof component billing: CMS Internet-Only Manual, Publication 100-02, Ch 13, Sec 30.3. 78
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 79
I.e. Lesion removal, joint injection, wound closure, AND E & M code Medicare: Charge the OV level w/-25, the procedure codes, any med used on UB, bill as collapsed into the 521 rev code w/qvc; 2 nd line would be the procedure; 3 rd line the drug, etc. Medicaid: Charge the OV level w/-25, the procedure codes, any med used on UB, bill as collapsed into the 521 rev code (with E & M CPT on claim)?? Private/Commercial: Bill as in FFS clinic 80
Note: Drugs can be put to 0250 (without J-code) or 0636 with J-code All allowed modifiers can be used on the RHC Claim 81
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 (face-to-face 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. 82
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 83
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 Medicaid: NE pays global for OB services unless provider transfers for delivery, then bill number of visits with dates 84
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 85
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 86
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 RHC Date of service used is the visit day 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 87
Reimbursable in the RHC as of 1/1/16 Physicians, NPs, PAs, CNMs, and/or auxiliary staff services Provider must bill IPPE, AWV or comp E & M prior Must use HER Must have consent of patient At least 20 minutes of clinical staff time per calendar month: 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 88
CCM can be billed with a visit or without and will be paid per the National Medicare Physician Fee Schedule; patient owes 20% copay; in this example, the RHC would receive 80% of their rate for the QVC and 80% of the CCM both less the 2% sequestration and the patient owes 20% copay. 89
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 90
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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/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 92
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Assure MSP questions are asked at each visit Other Payer Possibilities include: Employer Group Health Insurance Accident Liability Insurance Claim ESRD Black Lung VA, Federal Program 94
Info at: http://www.cgsmedicare.com/hhh/education/materials/pdf/ms P_Billing.pdf 13 pg reference giving codes, definitions, and algorhythms Claim sent to primary payer on several lines and payments to each line, Medicare will require: Claim submitted in Medicare required format Value codes, Occurrence codes and Condition codes required Medicare will be the 2 nd payer line Effective 1/1/16, MSP can be sent through DDE or PCACE electronically, CMS CR 8486 95
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If I bill a liability policy as primary, and it is denied for benefits exhaust, how do we bill Medicare? If you have a denial from a primary insurance, you would bill the claim as a conditional payment. If it is a liability policy, the 47 value code will have $0.00. You need to enter the 24 occurrence code with the date of the denial from the primary insurance, and in remarks enter why the claim was denied. In this case the primary benefits were exhausted. 97
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TOB 717 Claim must be in finalized status Adjustment will appear as a debit or credit on future remittance advice Submit electronically exceptions denied charges & claims rejected as MSP Requires Condition Code & ICN # of claim adjusted 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 99
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Because RHCs are not paid based on the Medicare Physician Fee Schedule, they are not included in the erx or PQRS program. Thus, there are no penalties for any RHC services when the clinic does not participate in erx or PQRS. If the clinic does any nonrhc services, the clinic will be required to participate in erx and PQRS in order to not be penalized. 101
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! 102
www.narhc.org (National Association of RHCs) www.cms.gov (Centers for Medicare and Medicaid Services) www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/bp102c13.pdf (new RHC/FQHC Regulations 1/16) www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/clm104c09.pdf (RHC CMS Claims Manual) Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com 103
www.nebraskaruralhealth.org (NeRHA) www.wpsmedicare.com www.cahabagba.com 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 1/16) www.cms.gov/regulations-and-guidance/guidance/manuals/ Downloads/clm104c09.pdf (RHC CMS Claims Manual) Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com 104
Any? s 105