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Maximizing RHC Revenue
Louisiana’s Health Initiative
Are You Leaving Money on the Table?
Opportunities for Reimbursement
Qualifying RHC Encounters
Medical ServicesSickVisits• Mostcommontypeofclinicvisit/encounterWellness/PreventiveVisits
MEDICARE• InitialPreventivePhysicalExam(IPPE)- G0402
• ONCEperlifetime;within12monthsfpatient’sPartBenrollment• Isreimbursedseparately,ifbilledsamedateasanotherRHCencounter
• AnnualWellnessVisit(AWV)- G0438,G0439• Coveredonceevery12months
LOUISIANAMEDICAID• PreventiveCareVisits(agespecific)- 99381-99397
• IncludesEPSDTScreeningServicesforBirththroughage20SpecialtyVisits• Volumecannotexceed49%oftotalRHCencounters
Behavioral Health (BH) Services
MentalHealthorSubstanceAbuseVisits• MustberenderedbyaqualifiedBHprovider
• Psychiatrist• ClinicalPsychologist• LicensedClinicalSocialWorker
• Individualvisitsonly(Groupvisitsnotcovered)• CanbebilledonsamedayasaMedicalorDentalencounter
• AsofApril1,2019,LOUISIANAMEDICAIDnowpaysforBHencounteronsamedayasMedicalorDentalencounter
Dental Services
NotCommoninanRHCSetting• CanbebilledonsamedayasMedicalorBehavioralHealthEncounter
Telehealth Services
MEDICARE• CurrentlyonlycoversoriginationsiteforRHCs• BillusingHCPCScodeQ3014 ($26.15forCY2019)
LOUISIANAMEDICAID• Onlycoversdistancesiteproviderfortelemedicineservices• EffectiveAugust1,2019,providersshouldnolongerusethe–GTmodifiertoindicateservicesprovidedviaTelemedicine.
• Asof8/1/2019,usePlaceofService-02andappendmodifier-95 toeachserviceprovidedviatelehealth
• ReimbursementissameasotherRHCencountersandservices
RHC Places of Service
q CLINIC
q NURSINGHOME(includingSNF)
q PATIENT’SHOME
q SCENEOFANACCIDENT
Services Reimbursed in Addition to RHC Encounters
RHC Services
WHAT are they?
Care Management Services
CoveredbyMEDICAREONLYTransitional Care Management (TCM)• NOT separately reimbursed, but DO qualify as a billable RHC encounter• Time period for TCM is 30 days (day of discharge plus 29 more)
General Care Management• Separately reimbursed (in addition to RHC encounter rate)• Can be billed alone, or with another RHC encounter• Chronic Care Management (CCM) • Behavioral Health Integration (BHI)
Psychiatric Coordination of Care Model (CoCM)• Separately reimbursed (in addition to RHC encounter rate)• Can be billed alone, or with another RHC encounter
WHAT are they?
Care Management Services
Transitional Care Management (TCM)Transitional Care Management Services include the following required elements:
• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
• Certain non-face-to-face services• One face-to-face TCM visit with qualified RHC provider
o99495 - Medical decision making of at least moderate complexity during the service period face-to-face visit, within 14 calendar days of discharge.
ORo99496 - Medical decision making of high complexity during the service
period face-to-face visit, within 7 calendar days of discharge.
WHAT are they?
Care Management Services
TransitionalCareManagement(TCM)
• TCMcanbebilledaloneorwithotherpayableRHCservices• IfTCMistheonlyserviceprovidedonthatday,RHCprovidersarepaidattheRHC
encounterrate• IfTCMfurnishedonsamedayasanothermedicalvisit,onlyone RHCencounter
willbepaid• CannotbillforTCMonthesamedayasothercaremanagementservices,suchas
CCM,BHI,etc.
YoumayaccessthefollowinglinkformoredetailedinformationonTCMhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf
WHAT are they?
Care Management Services
GeneralCareManagementRequirements(CCM&BHI)InitiatingVisit• Evaluation&Management(E/M)service,MedicareInitialPreventivePhysicalExam(IPPE),
MedicareAnnualWellnessVisit(AWV)furnishedbyqualifiedRHCprovider(physician,NP,PA,CNM)
• Hasoccurrednomorethan1yearpriortocommencingofcaremanagementservices
PatientConsent• Canbeobtainedduringorafterinitiatingvisit,butmustbebeforecommencementofcare
managementservices(patientcoinsuranceapplies)• Canbewrittenorverbal,butmustbedocumentedinmedicalrecord
Billing• G0511 - 20minutesormoreofclinicalstafftimeforChronicCareManagement(CCM)services
orBehavioralHealthIntegration(BHI) servicesdirectedbyanRHCpractitioner(physician,NP,PA,orCNM),percalendarmonth.
WHAT are they?
Care Management Services
General Care Management RequirementsChronicCareManagement(CCM)PatientEligibility• Multiple(twoormore)chronicconditionsexpectedtolastatleast12months,oruntilthedeath
ofthepatient,and• Chronicconditionsplacethepatientatsignificantriskofdeath,acute
exacerbation/decompensation,orfunctionaldeclineServiceElements• UsingCertifiedEHRTechnology,recordspecifiedpatienthealthinformation(demographics,
problems,medications,medicationallergies)• Providepatients/caregiverswith24/7accesstoclinicalstafftoaddressurgentneeds,regardless
oftimeofdayordayofweek• Providecontinuityofcarewithadesignatedcareteammemberwithwhompatientisableto
schedulesuccessiveroutineappointments.
WHAT are they?
Care Management Services
General Care Management RequirementsChronicCareManagement(CCM)ServiceElements(cont’d)• Providepatientwithcomprehensivecaremanagementincluding:
• Systematicassessmentofmedical,functional,andpsychosocialneeds• Timelyreceiptofrecommendedpreventivecareservices• Medicationreconciliation• Oversightofpatientself-managementmedications
• AComprehensiveCarePlanforallhealthissues,withparticularfocusonthechronicconditionsbeingmanaged,includinganinventoryofresourcesandsupports,andbasedonaphysical,mental,cognitive,psychosocial,functional,andenvironmentalassessment
• TimelyavailabilityofelectroniccopyofCarePlaninformation(withinandoutsideofRHC,asappropriate),andcopyofplanofcareprovidedtopatient/caregiver
WHAT are they?
Care Management Services
General Care Management RequirementsChronicCareManagement(CCM)ServiceElements(cont’d)• Managementofcaretransitionsandreferralsbetweenandamonghealthcareprovidersand
settings• Coordinationwithhomeandcommunity-basedclinicalserviceproviders,includingmedical
recorddocumentationofsaidcommunicationsregardingpatient’spsychosocialneedsandfunctionaldeficits
• Enhancedopportunitiesforpatient(andcaregivers)tocommunicatedirectlywithpractitionerregardingpatient’scareviatelephone,securemessaging,internet,orotherasynchronous,non-face-to-faceconsultationmethods
WHAT are they?
Care Management Services
General Care Management Requirements
BehavioralHealthIntegration(BHI)PatientEligibility• AnybehavioralhealthorpsychiatricconditionbeingtreatedbytheRHCprimarycarepractitioner,includingsubstanceusedisorders,that,intheclinicaljudgementoftheRHCpractitioner,warrantsBHIservices
ServiceElements• Initialassessmentorfollow-upmonitoring,includingtheuseofapplicablevalidatedratingscales• Behavioralhealthcareplanninginrelationtobehavioral/psychiatrichealthproblems,includingrevisionforpatientswhoarenotprogressingorwhosestatuschanges
• Facilitatingandcoordinatingtreatment(suchaspsychotherapy,pharmacotherapy,counselingand/orpsychiatricconsultation)
• Continuityofcarewithadesignatedmemberofthecareteam.
WHAT are they?
Care Management Services
PsychiatricCollaborativeCareModel(CoCM)• InitiatingVisit• SameasCCMandBHI• PatientConsent• SameasCCMandBHI• Billing
• G0512 - 60minutesormoreofclinicalstafftimeforPsychiatricCoCM servicesdirectedbyanRHCpractitioner(physician,NP,PA,orCNM)andincludingservicesfurnishedbyabehavioralhealthcaremanagerandconsultationwithapsychiatricconsultant,percalendarmonth.
• INITIALcalendarmonthbillingrequires70minutes ormore• PatientEligibility
• AnybehavioralhealthorpsychiatricconditionbeingtreatedbytheRHCprimarycarepractitioner,includingsubstanceusedisorders,that,intheclinicaljudgmentoftheRHCpractitioner,warrantspsychiatricCoCM services
WHAT are they?
Care Management Services
PsychiatricCollaborativeCareModel(CoCM)ServiceElements• PsychiatricCoCM requiresaTEAMthatincludesthefollowing:
• RHCPractitioner(physician,NP,PA,CNM)• BehavioralHealthCareManager• PsychiatricConsultant
FormoreinformationonservicerequirementsforCCM,BHIandCoCM services,seeChapter13oftheMedicareBenefitPolicyManualat:
• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-FQHC-bp102c13.pdf
OratthefollowingQ&Alink:• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf
WHY provide them?
Care Management Services
PROs• Only5%ofclinicpatientsaccountforover50%ofclinic’sutilizationandcostof
care• Reimbursementtrendsarequicklymovingtowardvalue-basedcare
CONs• Collecting,tracking,reportingdatacanbechallenging
• EHRsmaynotofferpatientmanagementtools,requiringmanualdatatracking• Mayrequireanadded“patchwork”ofproducts(costprohibitive)• Mayrequireadditionofmanualwork(laborintensive)
WHO can provide them?
Care Management Services
CCM,BHI,andCoCM• DirectedbytheRHCprimarycarepractitioner,whoremainsinvolvedthrough
ongoingoversight,management,collaborationandreassessment• FurnishedbyanRHCpractitioner,orbyclinicalpersonnelundergeneral
supervision• Caremanagementservicesaretypicallyfurnishedinanon-face-to-facesettingbyclinical
personnelworkingundergeneralsupervisionoftheRHCprimarycarepractitioner.• Directsupervisionisnotrequired• RHCFace-to-facerequirementsareWAIVED
WHO can provide them?
Care Management Services
TCM• InitialcontactcanbemadebyaqualifiedRHCprovider orclinicalstaff• Non-face-to-faceservicescanbeprovidedbyaqualifiedRHCprovider ORby
clinicalstaffunderthedirectionofaqualifiedRHCprovider• Face-to-FacevisitmustberenderedbyaqualifiedRHCprovider
HOW / WHEN to provide them?
Care Management Services
CCM,BHI,orCoCM• ServicesfurnishedonorafterJanuary1,2019canbebilledbyaddingtheappropriate
caremanagementcode,toanRHCclaim,eitheraloneorwithotherpayableservices.• G0511 forCCMorBHIservices(2019paymentrateis$67.03)• G0512 forCoCM services(2019paymentrateis$145.96)
• CAN bebilledoncepermonthperbeneficiarywhentheassociatedtimethresholdismetforanyONEcaremanagementservice
• CAN bebilledaloneorinadditiontootherservicesfurnishedduringtheRHCvisit
• CANNOT bebilledifothercaremanagementservices(suchasTCM,CCM,BHI,CoCM,homehealthcaresupervision)arebilledforthesametimeperiod
• CANNOT counttimespentbyadministrativeorclericalstafftowardsthetimerequiredtobilltheseservices
HOW / WHEN to provide them?
Care Management Services
TCM• BillasanRHCencounter,uponcompletionoftherequiredTCMservices• UseONEofthefollowingcodesforbillingTCMservices
• 99495 formoderatelycomplex patients(mustbefurnishedwithin14days ofpatientdischarge)
• 99496 forhighlycomplexpatients(mustbefurnishedwithin7days ofpatientdischarge)
• CannotbillTCMserviceswithothercaremanagementservices
Virtual Communication Services (VCS)
• Billablewhenatleast5minutesofcommunicationtechnology-basedorremoteevaluationservicesarefurnishedbyanRHCpractitionertoapatientwhohashadanRHCbillablevisitwithinthepreviousyear,AND
• BOTHofthefollowingconditionshavebeenmet• ThemedicaldiscussionorremoteevaluationisforaconditionNOTrelatedtoanRHC
serviceprovidedwithintheprevious7days,and• ThemedicaldiscussionorremoteevaluationDOESNOTLEADTOANRHCVISITwithinthe
next24hoursoratthesoonestavailableappointment.
• VCSmustbeinitiatedbythePATIENT!• RHCprovidermustfollowupwithin24hoursofpatientcommunication
CoveredbyMEDICAREONLY
Virtual Communication Services (VCS)
• Typesofcommunicationtechnology• Telephonecall,integratedaudio/videosystem,orthroughastore-and-forwardmethod
suchassendingapictureorvideototheRHCpractitionerforevaluationandfollowupwithin24hours.
• TheRHCpractitionermayrespondtothepatient’sconcernbytelephone,audio/video,securetextmessaging,email,oruseofapatientportal.
• DocumentVCSinpatienthealthrecord(includetotaltimespentinmedicaldiscussionorremoteevaluation)
• BillusingHCPCScodeG0071 (2019paymentrateis$13.69)• NolimitonnumberofVCSservicesbyasingleMedicarebeneficiary
Reimbursement through your Medicare Cost ReportVaccinesadministeredtoMedicarebeneficiaries• ThecostandadministrationofInfluenza andPneumococcal vaccinesare100%reimbursablebyMedicare
• DoNOTreportonanRHCclaimwhenbillingforRHCservices• Must list on the appropriate worksheet on the annual Medicare cost report
to receive reimbursement
Louisiana MedicaidLong Acting Reversible Contraceptives (LARCs)
• EffectiveJanuary1,2019RHCscanbereimbursedforLARCspurchasedforplacementintheclinicsetting.
• BillusingtheCPTcodefortheappropriateLARCinsertionandtheLARCdevice(J-code),inadditiontotheT1015RHCEncountercodeandotherdetaillinesfortheencounter• NOTE:TheLARCandLARCInsertioncannotbetheonlydetail linesontheclaimorthe
claimwilldeny
• ReimbursementwillbethelesseroftheMedicaidrateonfileortheactualacquisitioncost(AAC)oftheLARCforentitiesparticipatingin340B,andcanbefoundontheMedicaidDMEFeeSchedule(seelamedicaid.com)
• Youmayaccessthefollowinglinksformoreinformationonordering/billingforLARCs:• http://ldh.la.gov/assets/docs/BayouHealth/HealthPlanAdvisories/2018/HPA18-17.pdf
• http://ldh.la.gov/assets/docs/BayouHealth/Informational_Bulletins/2016/IB16-11_revised_7.20.18.pdf
Non-RHC Services
Non-RHC Services
HOSPITAL SERVICES• Inpatient• Outpatient/Observation• Emergency Department
DIAGNOSTIC SERVICES - Medicare ONLY • Lab Services
• Including CLIA waived tests
• Other Diagnostic Services (use appropriate code/modifier to bill technical component ONLY)
• X-rays, Ultrasounds, EKGs, Bone Density Studies, etc.
• Provider-based RHC diagnostics must be billed by Hospital (even if performed in the clinic)
Opportunities for Improvement
KIAZENContinualImprovement(Everyday,Everybody,Everywhere)• Constantlyintroducingsmallincremental
changestoimprovequalityand/orefficiency.
• Empowersstaff,recognizingtheyarethebestpeopletoidentifyroomforimprovement.
KiaChange
ZenfortheGood
The Revenue Cycle
FrontOffice• Pre-Appointment• Registration• Check-In/CheckOut
ClinicalStaff• ChargeCapture• Coding
BackOffice• ClaimsManagement• PatientBilling/Collections• AccountsReceivableManagement
HowWellAreYouManagingYourRevenueCycle?
BreakDowntheSilos!AgreatrevenuecyclerequiresalldepartmentstoworkTOGETHER
Scheduling and Registration
• ExtendedHours• OpenorHybridSchedule• RescheduleCancellations• AppointmentReminders• Getdemographicinformationwhenappointmentismade• AutomateEligibilityVerification(oratleastdoitmanuallypriortoappointment)
Check In and Check Out
• Confirmaddress,phoneandinsurance• Collectcopaymentsupfront• Collectcoinsuranceatcheckout• Makefollowupappointmentsatcheckout
Charge Capture and Coding
• AddcodesforALLservicesprovided(evenifreimbursementisincludedinRHCall-inclusiveencounterrate)
• Don’tforgetadministrationcodesforinjections• Tracking,ReportingandCodingofservicespaidmonthly(i.e.CCMservices)
• TechnicalservicesreimbursedoutsideofRHCencounterrate• ServicesreimbursedinadditiontoRHCencounterrate• AppropriatelevelofE/MCoding
Claims Management
• Dailyclaimsfilingisbest,butatleastfileweekly• ReviewandTRACKerrors,rejectionsanddenials• UtilizeElectronicRemittanceAdvice(ERA),whenpossible• Postpaymentstimely• WorkDenialstimely
Patient Billing/Collections
• Ifyoudopatientbilling,spreadoutstatementprocessingthroughoutthemonth(don’tsendthemalloutatonce)
• OfferSlidingFeeScale(considerofferingapromptpaymentdiscountforthosewhopay100%attimeofservice)
• Offerpaymentplans,ifneeded
Accounts Receivable Management
ReviewA/Rreportsmonthly• Aging(15%-18%in>120days)• Transactions• Denials(5%-10%)• Analyzereportsby
• Payer• Provider• Location(ifyouhavemultiplefacilities)
CalculateandtrendDaysinA/R(<45days)CalculateandtrendNetCollectionRate(95-99%)
Don’tunderestimatethevalueofworkingasateam
Thereisvalueinefficiency(timeismoney)
ImportanttoRemember
Kelley LipseyPractice Sustainability Manager
(504) [email protected]
CMS Rural Health Clinics Center• https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
La. Medicaid RHC Manual• https://www.lamedicaid.com/provweb1/Providermanuals/manuals/RHC/RHC.pdf
Access additional RHC resources at
