Whats new in RHC billing? Charles A. James, Jr. President and CEO North American Healthcare Management Services 888.968.0076.

What’s new in RHC billing?

Charles A. James, Jr.President and CEO

North American Healthcare Management Services

www.northamericanhms.com 888.968.0076

What is an RHC?Rural Health Clinics were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. RHCs have been eligible to participate in the Medicare program since March 1, 1978, and are paid an all-inclusive rate per visit for qualified primary and preventive health services.

(Medicare Benefit Policy Manual. Chapter 13. Section 10.1.)


The RHC Encounter Rate

“In general, the all-inclusive rate (AIR) for an RHC or FQHC is calculated by the MAC/FI by dividing total allowable costs by the total number of visits for all patients. Productivity, payment limits, and other factors are also considered in the calculation.”

(Medicare Benefit Policy Manual. Chapter 13. Section 70.)


RHC Productivity Standard

1 FTE Physician – 4,200 Visits1 FTE NP or PA – 2,100 Visits

If the RHC or FQHC has furnished fewer than expected visits based on the productivity standards, the MAC/FI substitutes the expected number of visits for the denominator and use that instead of the actual number of visits.

(Medicare Benefit Policy Manual. Chapter 13. Section 70.4.)


RHC Claims - Medicare Part A• Rural Health Clinic claims are administered

by Medicare Part A. • It is a Part B (Physician Service) benefit,

using the structure of Medicare Part A.• This is why we deal with UB04, Cost

Reports, Revenue Codes, etc.


Medicare Part B (FFS)

In the RHC world, the term ‘Medicare Part B’ typically indicates those claims which will continue to be paid ‘fee-for-service’ and billed on a CMS-1500.

Non-RHC claims fall in this category.


Qualified RHC Providers

An RHC encounter can be billed for the following providers:

• Physicians (MD, or DO)• Nurse Practitioners, Physician Assistants, and

Certified Nurse Midwives• Clinical Psychologists (PhD)• Clinical Social Workers (CSW or LCSW)


Rural Health Services

• Physicians' services, as described in section 100;• Services and supplies incident to a physician’s

services, as described in section 110;• Services of NPs, PAs, and CNMs, as described in

section 120;• Services and supplies incident to the services of

NPs, PAs, and CNMs, as described in section 130; (Medicare Benefit Policy Manual Chapter 13)


Rural Health Services (Continued)• CP and CSW services, as described in section 140;• Services and supplies incident to the services of

CPs and CSWs, as described in section 150; and• Visiting nurse services to the homebound as

described in section 180. (Medicare Benefit Policy Manual Chapter 13)


The RHC Encounter is:“An RHC or FQHC visit is defined as a medically-necessary, face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more RHC or FQHC services are rendered. An Initial Preventive Physical Examination (IPPE) or an Annual Wellness Visit (AWV) can also be considered an RHC or FQHC visit.” (Medicare Benefit Policy Manual. Chapter 13. Section 40.)


Physician ServicesThe term “physician” includes a doctor of medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, or chiropractic who is licensed and practicing within the licensee’s scope of practice, and meets other requirements as specified.



Physician Services“Physician services are professional services furnished by a physician to an RHC or FQHC patient and include diagnosis, therapy, surgery, and consultation. The physician must either examine the patient in person or be able to visualize directly some aspect of the patient’s condition without the interposition of a third person’s judgment. Direct visualization includes review of the patient’s X-rays, EKGs, tissue samples, etc.



Incident-to Services Defined • Commonly rendered without charge or included in the RHC or FQHC

bill; • Commonly furnished in a physician office or clinic; • Furnished under the physician’s direct supervision; and • Furnished by a member of the RHC or FQHC staff. • Drugs and biologicals that are not usually self-administered, and

Medicare-covered preventive injectable drugs (e.g., influenza, pneumococcal);

• Bandages, gauze, oxygen, and other supplies; or • Assistance by auxiliary personnel such as a nurse, medical assistant, or

anyone acting under the supervision of the physician.


Incident-to Services Defined • Incident-to services are considered covered and paid

under the RHC. • They must be bundled with the RHC encounter. They are

not separately billable or payable.• Services that do not occur on the same date as the

encounter can be bundled if they occur 30 days before or after.

• The effect on payment is an increase in the charge, and therefore in the co-insurance.

• The cost for these services are included in the cost report, but are not separately payable on claims.


Provision of Incident-to Services• Incident to services and supplies can be furnished

by auxiliary personnel. • More than one incident to service or supply can

be provided as a result of a single physician visit. • Incident to services and supplies must be

provided by someone who has an employment agreement or a direct contract with the RHC or FQHC to provide services


Provision of Incident-to Services• Services and supplies furnished incident to

physician’s services are limited to situations in which there is direct physician supervision of the person performing the service.

• Direct supervision does not mean that the physician must be present in the same room…the physician must be in the RHC or FQHC and immediately available.

(Medicare Benefit Policy Manual. Chapter 13. Section 110.1)


Examples of incident-to services• Injections• Suture Removal• Dressing Changes• Prescription Services• Blood Pressure Monitoring• Billing the NP/PA using the physician’s name

and NPI!!


Commingling• For RHCs commingling is fraud.

Commingling is getting paid twice from Medicare.

• Submitting incident-to services to Medicare Part B, since they are covered under the RHC benefit, is fraudulent billing.


Multiple Encounters“Encounters with more than one RHC or FQHC practitioner on the same day, or multiple encounters with the same RHC or FQHC practitioner on the same day, constitute a single RHC or FQHC visit, regardless of the length or complexity of the visit or whether the second visit is a scheduled or unscheduled appointment.”(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)


Multiple Encounters are allowed when:• The patient, subsequent to the first visit, suffers an illness

or injury that requires additional diagnosis or treatment on the same day (2 visits), or

• The patient has a medical visit and a mental health visit on the same day (2 visits), or

• The patient has his/her IPPE and a separate medical and/or mental health visit on the same day (2 or 3 visits). The IPPE, also known as the “Welcome to Medicare Visit”, is a one-time exam that must occur within the first 12 months following the beneficiary’s enrollment.

(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)www.northamericanhms.com 888.968.0076

Global Billing• Surgical procedures furnished in an RHC or FQHC by an

RHC or FQHC practitioner are considered RHC or FQHC services.

• The RHC is paid based on its all-inclusive rate and is not subject to the Medicare global billing requirements.

• Surgical procedures furnished at locations other than RHCs or FQHCs may be subject to Medicare global billing requirements.

(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)


Modifier - 25• This modifier indicates a significant, separately

identifiable service and an office visit which occur on the same day by the same provider.

• Documentation requirements must be met for both services.

• Reasons for usage in an RHC may be for: Same day sick visit and preventive service Same day sick visit and minor surgery


99495 - Transitional Care Mgmt• Communication (direct contact, telephone,

electronic) with the patient and/or caregiver within 2 business days of discharge.

• Medical decision making of at least moderate complexity during the service period.

• Face-to-face visit, within 14 calendar days of discharge.


99496 - Transitional Care Mgmt

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

• Medical decision making of high complexity during the service period.

• Face-to-face visit, within 7 calendar days of discharge.


Non-Rural Health Services

Non-Rural Health Services can be billed to the fee-for-service carrier (or hospital FI). These services include:• Diagnostic testing - X-Ray, EKG, etc.• Laboratory services - Venipuncture• Professional services rendered in the

hospital


Diagnostic Testing and Lab: Independent

• The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter.

• The technical component of these tests are billed to the Medicare Part B carrier using the fee-for-service provider number.

• All lab services are also billed to the Part B carrier.


Diagnostic Testing and Lab: Provider-Based

• The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter.

• The technical components for X-Ray, EKG, ultrasounds, etc. are billed to the FI using the parent entity’s billing number.

• Lab services are also billed to the FI using the parent entity’s billing number.


Hospital Admit and RHC Encounter• Some MACs will pay the Hospital admit and

an RHC encounter on the same day. (Trailblazers, WPS, Cahaba).

• Other’s won’t.• Check with yours to confirm.


Hospice• RHCs and FQHCs can treat hospice beneficiaries

for any medical conditions not related to their terminal illness.

• If a Medicare beneficiary who has elected the hospice benefit receives care from an RHC or FQHC related to his/her terminal illness, the RHC or FQHC cannot be reimbursed for the visit.

(Medicare Benefit Policy Manual. Chapter 13. Section 200)


Non-Hospice Related• When the RHC provider DOES see a hospice

patient for non-hospice related condition:• Occurrence Code ‘07’• Enter ‘Non-Hospice Related Service’ in

remarks


Influenza, Pneumococcal Injections• Flu and pneumonia shots are covered

under the RHC program. These are the only injections that are separately payable.

• These are not billed on a claim, but are submitted on the cost report.

• They are paid with the clinic’s annual cost report reconciliation.


Prevnar - 13• Cahaba will not cover Prevnar on the cost

report. • Most other MACs will allow Prevnar.


Visiting Specialists in an RHC

Any qualified provider (MD, DO, NP, PA) can see patients in an RHC.

The only stipulation is that the RHC must provide primary care services fifty-one percent of operating hours. (FP, IM, Peds, OB)


Two Scenarios for Visiting Specialists

Scenario #1: A specialist rents space from the RHC one morning per week, brings his own staff, and does his own billing.

Configuration: The RHC carves out the cost of the space and removes all associated costs from the cost report.


Visiting Specialists

Scenario #2: A general surgeon comes to the RHC once per week. She sees RHC patients and they are billed as RHC encounters.

Configuration: In-patient surgeries should be billed with modifier 54 (surgery only). Follow-up visits can then be billed as encounters.


Mental Health Services• Mental Health Services performed by a

qualified provider are billed using revenue code 900.

• Diagnostic services are paid as an encounter.

• Therapeutic services are subject to a limitation which is being phased out.


Mental Health Providers• Medicare RHC providers are:

Clinical Psychologist (PhD) LCSW LCPC or CPC is not payable by Medicare(Check with your own state to see if LCPC or CPC are eligible – in most states they are not)


Mental Health Billing• Diagnostic visits are fully payable.• Therapeutic visits are subject to limitation.

Medicare pays 81.5% of RHC rate. Patient pays 18.5% of rate plus co-

insurance/deductible on charge amount. This limitation will be phased out by

2015.


Mental Health Payment Limitation*Period Limitation % Medicare Pays/ Pt. Pays

Through Dec. 31, 2009 62.5% 50% / 50%

Jan. 1, 2010 – Dec. 31, 2011 68.5% 55% / 45%

Jan. 1, 2012 – Dec. 31, 2012 75% 60% / 40 %

Jan. 1, 2013 – Dec. 31, 2013 81.5% 65% / 35%

Jan. 1, 2014 – onward 100% 80% / 20%


* www.cms.gov/MLNMattersArticles/downloads/MM6686.pdf

Telehealth• RHCs are statutorily required to be the

‘originating’ site for telehealth services.• The RHC cannot be remote site.• Must report on UB04 with Q3014. ($23.17)• Can accompany an E/M service or be

reported alone.• ‘Remote’ physician bills an E/M code with

modifier. www.northamericanhms.com 888.968.0076

Preventive Services (MPS)• Initial Preventive Physician Examination• Annual Wellness Visit (AWV) and

Personalized Prevention Plan Services (PPPS)

• Subsequent Annual Wellness Visit• Medicare Preventive Screenings


Preventive Services - Billing• The IPPE and AWV are Medicare covered

preventive services.• These are RHC encounters. • They should be billed with the HCPCS code

on a UB04. • There is no cost sharing (i.e. no patient

deductibles or co-ins.) for IPPEs and AWVs.


Preventive Services – Cost Reporting• Medicare pays 80% of the RHC Encounter

rate, but no co-insurance or deductible. • Track Medicare Preventive Services (MPS)

charge amounts. • These are to be entered on the cost report.


IPPE – Initial Preventive Physician Exam• Otherwise known as the ‘Welcome to Medicare Visit’.• Payable once per lifetime.• Must be rendered within 12 months of the beneficiaries’

Medicare coverage date.• Co-Insurance and deductible do not apply.• Is payable as a separate RHC encounter. One occasion

where two encounters on the same day are payable.• Any preventive diagnostic screenings are billed to

Medicare Part B.


IPPE BillingThe total charge for the IPPE is $175.00. The line items would be reported as follows:

Rev Code HCPCS DOS Charges

052X G0402 3.22.2013 $175.00

One encounter rate will be paid. Patient co-ins and deductible are waived.


Annual Wellness Visit and PPPS• The patient is eligible if they are no longer in the first 12

months of Medicare coverage and have NOT had the IPPE in the last twelve months.

• Co-Insurance and deductible do not apply.• When rendered during an RHC encounter, only one

payment is made.


Annual Wellness Visit BillingThe total charge for the Annual Wellness Visit is $175. The line items would be reported as follows:


052X G0438 3.22.2013 $175.00

One encounter rate will be paid. Patient co-ins and deductible are waived.


MPS Visit and ‘Sick’ Visit Same day• There will be two line items on this claim:

One line with the RevCode/MPS HCPCS Code/charge One line with the RevCode/Charge Amount for the sick

visit.These will be paid as one encounter. The MPS have no co-insurance/deductible applied.The ‘sick visit’ WILL have a co-insurance and deductible amount.


MPS with ‘Sick Visit’ BillingThe MPS is $175.00 and the ‘sick visit’ charge is $150, the line items would be reported as follows:


0521 G0438 3.22.2013 $175.00 0521 3.22.2013 $150.00

Two encounter rate will be paid. Patient co-ins and deductible are waived on the $175.00.Co-insurance will be based on $150.00 ($30.00).


Breast Pelvic Exam/ PAP• G0101: Cervical or vaginal cancer screening; pelvic

and clinical breast examination – Part of the RHC Encounter.

• Q0091: Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.


Registered Dietician• Registered dietician services are covered in

a RHC. • They are not separately payable and do

NOT constitute an encounter. • These are bundled with an otherwise

payable RHC encounter.


Hepatitis Vaccines and MedicareHepatitis vaccines and their administration are included in the RHC visit and are not separately billable. The cost of the vaccines and administration can be included in the line item for the otherwise qualifying visit. A visit cannot be billed if vaccine administration is the only service the RHC provides.

(Medicare Benefit Policy Manual. Chapter 13. Section 210.1.2)


Medicare Preventive Reference

MPS Chart:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MPS_QuickReferenceChart_1.pdf

CMS Preventive Services Center:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

Non-Payable but Covered Services• These services are bundled and are not

separately payable as encounters: Nursing Visits/Injections Telephone Consultation Diabetic Nutrition Counseling Zostavax (can be billed to Part D) Hepatitis


CMS Websites - www.cms.govMedLearn Catalog -www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf

Medicare Claims Processing Manual – Chapter 9 www.cms.gov/manuals/downloads/clm104c09.pdfCMS Medicare Secondary Payor Manual:

www.cms.gov/manuals/downloads/msp105c03.pdfPreventive Services -

www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf


CMS and Medicare ResourcesCMS Rural Health Center – www.cms.gov/center/rural.aspOnline Manuals -

www.cms.gov/Manuals/IOM/list.asp?listpage=1Cahaba – www.cahabagba.comCahaba MSP Flow Sheet and Informationhttp://

www.cahabagba.com/documents/2012/02/part-a-quick_msp.pdf

WPS RHC FAQ!!!http://www.wpsmedicare.com/j5macparta/resources/provider_types/rhc-billing-qanda.shtml


http://www.cms.gov/center/rural.asp

http://www.cms.gov/Manuals/IOM/list.asp?listpage=1

http://www.cahabagba.com/

http://www.cahabagba.com/documents/2012/02/part-a-quick_msp.pdf



http://www.wpsmedicare.com/j5macparta/resources/provider_types/rhc-billing-qanda.shtml

http://www.wpsmedicare.com/j5macparta/resources/provider_types/rhc-billing-qanda.shtml

Preventive Service LinksIPPE (MM6445)

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm6445.pdf

Annual Wellness Exam (MM7079) http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7079.pdf

MPS Chart:http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickReferenceChart_1.pdf

CMS Preventive Services Guide:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/mps_guide_web-061305.pdf


http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickReferenceChart_1.pdf



More CMS ResourcesMedicare Claims Processing Manual – UB04 Completion

www.cms.gov/manuals/downloads/clm104c25.pdf

Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues

www.cms.gov/manuals/downloads/clm104c09.pdf

!! NEW !! Medicare Benefit Policy Manual – Chapter 13 RHC/FQHC www.cms.gov/manuals/downloads/clm104c09.pdf


http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

http://www.cms.gov/manuals/downloads/clm104c25.pdf



Contact InformationCharles A. James, Jr.North American Healthcare Management ServicesPresident and [email protected]


mailto:[email protected]

Whats new in RHC billing? Charles A. James, Jr. President and CEO North American Healthcare Management Services 888.968.0076.

Documents

fqhc services

rhc claims medicare

nurse services

csw services

services of nps

professional services

services of cps

preventive health services