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Presented on Behalf of
Nebraska Rural Health Association RHC Group
By
Janet Lytton, Director of Reimbursement
Rural Health Development
308-647-6455 [email protected]
April 16, 2016
Difference between Independent vs Provider Based
Specialists in the RHC
RHC, nonRHC services and locations
Bundling of “incident to” services
Exceptions for more than 1 visit per day paid
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Understand how to bill: Mental Health (Behavioral Health) Billing
Preventive Services
Telehealth Services
Hospice Services
Medicare Secondary claims
Claim form Completion and revenue codes used
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Medicare Pt A = Hospital Service charges
Most Patients receive these benefits without additional premium
Medicare Pt B = Professional service charges
Patients have choice of participating in Medicare Pt B benefits
Additional premium for most of $104.60 (2016)
RHC Services are professional services paid using Medicare Pt B eligibility, but paid through Medicare Pt A Payer
Any DME supplies are only payable through DMERC
Any Medicare Pt D Drugs are payable through the patient’s Pt D plan
Medicare Pt C (Medicare Advantage) is outside the traditional Medicare coverages
Plans can set equal to or greater benefits for patients
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Patient Deductible = $166 per year
IRHC Rate = $81.32/visit
PBRHC PPS Hospital Rate = $81.32/visit
PBRHC <50 bed hospitals = No limit
An RHC is a certification from CMS that allows
physician practices to qualify for cost-based
reimbursement from Medicare and Medicaid
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
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CMS has an “RHC Fact Sheet”
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ RuralHlthClinfctsht.pdf
6 pages of information
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• Independent Rural Health Clinic• Owned by any person that State allows
• I.e. Physicians, NPs, PAs, Hospitals, or anyone allowed
• Individual practitioner(s)
• Can be sole proprietor, partnership, corp. or LLC
• Completes the IRHC cost report each year
• Provider Based Rural Health Clinic• Owned by a Hospital, Skilled Nursing Facility or a HHA
• Treated as a department of the parent facility
• Generally within a 35 mile radius of the parent facility
• Integrated financials
• Access to medical records between departments
• Cost report completed as part of the “parent” cost report
State Operations Manual—Conditions for Certification Compliance with Federal, State, and Local Laws
Location of Clinic
Physical Plant and Environment
Organizational Structure
Staffing and Staff Responsibilities
Provision of Services
Patient Health Records
Program Evaluation
Appendix G – Guidance to Surveyors: Rural Health Clinics (RHCs) – (Rev. 1, 05-21-04)
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Survey for Certification as an RHC
Initial Survey
Periodic Surveys
Complaint Surveys
Surveys after Initial
Typically every 5 years but may be longer
Not necessarily after a Change of Ownership but maybe
Deficiency Statement
Plan of Correction
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• Must be in a “rural” area• Population of 50,000 or less and in a • nonmetropolitan area (last census determines)• Would lose RHC designation if Clinic falls out of
“rural” designation
• Must be in a “shortage” area• Currently do not lose RHC status if area is not in a
current shortage area• Keep up-to-date knowing if your area is designated• If moving clinic, assure site is still in a shortage area
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• RHC must be located in a healthcare shortage area
• Health Professional Shortage Area (HPSA)• Medically Underserved Area (MUA)
• Medically Underserved Population does not meet the shortage area designations (MUP)
• Governor’s list of Healthcare Shortage Areas
• Check website:• http://www.hrsa.gov/shortage/find.html
• Search to find your area as either a HPSA or MUA
• Check the State website for governor’s list of
shortage areas
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Scope of Practice
Follows State’s Medical Practice Act
Have written delineation of duties for PAs and NPs
Providing RHC Services
Medical Services that are normally performed in a
physician clinic
RHC must be “primarily engaged” in RHC services at
least 51% of the total operating schedule
Patient Care Policies
All policies signed off by providers and Governing body
Description of services—direct and indirect services
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Patient Care Policies (continued)
Guidelines for medical management of patients
Regimens to follow and conditions that are treated
Describe medical procedures allowed by NP, PA or CNM
Describe medical conditions that require
consultation/referral
Drugs and Biologicals
Policies on storage of drug—humidity, temp, light, etc
Policies on outdated, deteriorated or adulterated drugs
All drugs locked; all narcotics double locked & counted
Have current drug references and antidote information
Prescribe and dispense in compliance with State law
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Review of Policies
Patient Care Policies reviewed by professional personnel
at least annually and documented
Keep all prior outdated policies on file
Direct Services
Required Services
Diagnostic Examination
6 Basic Laboratory Services (CLIA Waived Certificate)
Emergency treatments
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Records System Written Policies on Maintenance of Records
Responsibility of Designated Professional
Record on Each Person Receiving Healthcare Service
Records kept onsite
Review of records Required
Protection of Records All Must Be Kept Secure
Release of Records Policies
Required Services
Retention of Records Federal Law States at least 6 years from last entry or longer
if State Requires; or 6 years after age of majority
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Evaluation of Clinic’s Total Operation
Must be Completed Annually by the “Advisory Council”
Must include one “third party person” on Council
Not All Have to be Completed at the Same Time by the
Same Staff
Written Report of Annual Evaluation Required
Annual Review Must Include
Review of Services Provided to Include Numbers of
Patient Services and What Services Provided
Review of Records to include Active and Closed Charts
Review of All Policies and Procedures and changes made
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Medicare Benefit Policy Manual Ch 13 – RHC and
FQHC Services Rev 220, 1/15/16
https://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/bp102c13.pdf
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Independent RHC Billing
RHC claims sent to the Medicare payer assigned in the
past or if new RHC, will be with your local MAC
IRHCs are capped at $81.32 per visit 2016, (1.1% increase
over 2015, $80.44)
All professional services in Clinic, SNF, NH, AL, Home, at
scene of an accident
Completes a cost report each year, CMS 222-92
nonRHC services sent to Medicare Pt B MAC
IP, OP, ER, OBS Bed, TCs of screening and diagnostic tests, i.e.
EKG tracing, x-ray TC
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Provider Based Billing
RHC claims sent to Medicare payer of “Parent” facility
If PBRHC part of a <50 bed hospital, no cap on rate
If PBRHC part of a >50 bed hospital, capped at IRHC rate
Many times these will be set up as IRHCs
PBRHC a section of the Hospital cost report
nonRHC service claims sent through hospital OP #
TCs, i.e. EKG Tracing, X-ray TC; labs
nonRHC service claims sent to Medicare Pt B
IP, OP, ER, OBS Bed
Exception for CAHs Method II as OP, ER, OBS Bed professional
services submitted by Hospital on their claim—15% additional
reimbursement
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Physicians—M.D. or D.O. Family Med; Internist; Pediatric; OB/GYN; Gerontology
Physician Assistants
Nurse Practitioners, Certified Nurse Midwife
Psychologists (phD) & LCSW (Masters level w 2 yrs) Must be licensed in the State providing the services
Specialists Must be < 50% of total visits (includes mental health srvs)
IF specialist is a provider of the RHC, then RHC visits
Specialist is paid through the RHC
IF visiting specialist “periodically” in the RHC and:
Not paid through the RHC
Billing is separate from the RHC billing
Typically pays a rental/lease fee for space/supplies used
RHC Services (Sec. 50.1 of RHC Benefit Manual)
Physician Services & services & supplies incident to
NP, PA, CNM Services & services & supplies incident to
CP and CSW Services & services & supplies incident to
Visiting Nurse services in HHA shortage area
Medicare allowed Preventive Services
Influenza, Pneumococcal & Hepatitis B Vaccinations
Hepatitis C screenings
IPPE
AWV
All Medicare-covered preventive services
All Services paid based on RHC AIR (all inclusive rate)
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Non RHC Services (Sec. 60.1 of RHC Benefit Manual)
MCR excluded services, i.e. routine physical check-ups, dental, hearing & routine eye tests
Technical component of an RHC service (i.e. x-ray, EKG)
Laboratory Services (does not include venipuncture)
DME, Prosthetic devices, Braces
Ambulance Services
Hospital Services, ASC, Medicare Comp. OP Rehab Fac
Telehealth distant-site services
Hospice Services (if for DX of hospice)
Group Services
All costs associated with nonRHC services are disclosed on the annual cost report
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Statutorily Noncovered services do not require an Advanced Bene Notice, however encourage one for PR reasons.
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 CMSInternet-Only Manual, Publication 100-4, Ch 1, Sec 60.4.3, "... 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."
Nurse service w/o face-to-face visit or “incident to” visit
I.e. allergy injection, hormone injection, dressing change, venipuncture
A 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
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80.1 – Charges & Waivers Must charge all patients the same rates Copays and Deductibles apply within the RHC May waive copays and deductibles only after good faith
determination made that patient is in financial need but cannot be on a routine basis (42 U.S.C. 1320a7a(6)(A))
80.2 – Sliding Fee Scale Not required, but may have Must be applied to all patients Policy must be posted If based on income, must document that info from patient Copies of wage statements or income tax return not
required Self-attestations are acceptable Is required if using National Health Service Corp provider
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90 – Commingling
Sharing space, staff, supplies, equipment and/or other resources with an onsite Medicare PT B or Medicaid FFS practice operated by the same RHC providers. Commingling is prohibited to prevent:
Duplicate reimbursement or selectively choosing a higher or lower reimbursement rate for services
May NOT furnish RHC services as a PT B provider in the RHC or in an area outside the RHC such as a treatment room adjacent to the RHC during RHC hours of operation
If RHC is in the building with another entity the RHC space MUST be clearly defined.
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90 – Commingling (con’t)
If RHC leases/rents space, all costs must be offset by the fees paid or costs must be deducted from C.R.
Does not prohibit provider going to hosp for emergencies
Must follow schedules for hospital and RHC time
Hours of operation must be clearly stated on signage visible from outside of RHC. Show RHC and nonRHC hours
If a RHC practitioner furnishes a RHC service at the RHC during RHC hours, the service must be billed as a RHC service. The service cannot be carved out of the cost report and billed to Part B.
• 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”
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o Routine INR visit for lab
o Simple suture removal
o Dressing change
o Results of normal tests
o Blood pressure monitoring
o Allergy Injections
o Prescription service only
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
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.
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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.
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MEDICARE:Must file claims within one year from date of
services—effective 3/23/10.I.e. January 1, 2015 must be filed by Dec 31, 2015
NE MEDICAID: Must file claims within 6 months from date of service
I.e. January 1, 2015 must be filed by June 30, 2015
All Procedure Codes that are normally
performed in a physician’s clinic are applicable
in the RHC
If your coder is also your biller, the knowledge
of what service to bill to which payer is
imperative
Some CPT codes will have to be “split” billed,
i.e. EKG tracing and interp, x-ray prof & tech
components
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