RHC Beginning Billing 101 - Rural health clinic€¦ · “AnRHC or FQHC visit is a medically-necessary medical or mental health visit, or a qualified preventive health visit. The

RHC Beginning Billing 101

Charles A. James, Jr.President and CEO North American Healthcare Management Services

Page 1

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.)

2

What is an RHC?

A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid reimbursement.

51% of Clinic Services must be Primary Care (FP,IM,OB,Ped) The purpose of the RHC program is improving access to primary care in

underserved rural areas. The clinic must be staffed at least 50% of the time with a midlevel

practitioner.(Rural Assistance Center FAQ)

3

The Rules - 42 CFR 491

This is the Code of Federal Regulations (CFR) which stipulates Rural Health Clinics’ Conditions for Certification.

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/RHC_FQHC.html

4

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/RHC_FQHC.html

Rural Health Clinic Requirements

Compliance with Federal, State, and Local laws Location of Clinic Physical Plant and Environment Organizational Structure Staffing and Staff Responsibilities Provision of Services Policy and Procedure Manual Medical Records Emergency Preparation Annual Evaluation (vs. Quality Assurance)

5

RHC Regulations and Interpretive Guidelines

Social Security Act Section 1861(aa)(2)(K)42 CFR §405.2402 (Basic Requirements)42 CFR Part 491, Subpart A (Conditions for Participation!)State Operations Manual – Appendix G (Surveyor Guidance)Accreditation Organization Standards: AAAASF The Compliance Team

6

https://www.law.cornell.edu/cfr/text/42/405.2402https://www.law.cornell.edu/cfr/text/42/part-491/subpart-Ahttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdfhttps://www.aaaasf.org/docs/default-source/accreditation/standards/standards-manual-and-checklist-v2-2-(rhc).pdf?sfvrsn=24http://www.thecomplianceteam.org/rural_health_clinic.aspx

The RHC Encounter Rate

The Current RHC maximum encounter rate CY 2019 is $84.70. (for independent/freestanding RHCs or PBRHCs ineligible for an uncapped 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.)

7

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.)

8

RHC Rate and Cost Reporting

The RHC Encounter Rate is set via the RHC Cost Report. Provider-based Clinics file as part of the hospital cost report. Costs must appropriately allocated and tracked for the RHC space and

personnel. Provider FTEs should be measured via formal time study. Only time spent in the RHC counts. Medical Director, Physician, PA, NP, Nursing FTEs have a major impact on

cost reporting. Laboratory Expenses must be allocated and reclassified appropriately.

(RHC vs. Non-RHC)

9

Independent RHCs

Independent RHCs are generally private physician offices or hospital clinics whose parent is > 50 beds.

RHC encounters are paid using the current RHC cap. Independent RHCs must file an annual cost report, which is due 5

months after the end of each fiscal year. Failure to file timely cost reports can result in full refunds of RHC

payments.

10

Provider-Based RHCs

Provider-based RHCs (PBRHC) are those owned by a parent entity such as a hospital, nursing facility, or home health agency. PBRHCs owned by a hospital with 50 beds or less qualify for an un-

capped RHC rate. PBRHCs whose parent entity is greater than 50 beds have the same cap

as independents. PBRHCs rate is set under the parent entity’s cost report. Claims are billed to the MAC which services the parent entity.

11

Provider-Based RHCs: Not Outpatient Departments

42 eCFR 413.65 (a)(2):For purposes of this part, the term “department of a provider” does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC.

12

Outpatient PPS 2017

“A key proposal in this year’s rule is to implement Section 603 of the Bipartisan Budget Act of 2015, which will affect how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider (hereinafter referenced as off-campus “provider-based departments” (PBDs).”https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html

13

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html

RHC Claims - Medicare Part A

The Centers for Medicare and Medicaid Services administers Rural Health Clinics payments under Medicare Part A. RHC services are a Part B (Physician Service) benefit, but our reimbursement structure is Medicare Part A.

14

Medicare Part B (FFS)

In the RHC world, the term ‘Medicare Part B’ typically indicates thoseclaims which will continue to be paid ‘fee-for-service’ and billed on a CMS-1500 under the Medicare Physician Fee Schedule (MPFS) paymentstructure.

RHC claims are NOT paid based on the Medicare Fee Schedule. Non-RHC services are those that may be paid outside of the RHC Benefit.

15

Rural Health Clinics and MIPS

Medicare Part A reimbursement for claims submitted on a CMS-UB04 is NOT subject to MIPS negative/positive payment adjustments at present.

Any non-RHC/non-FQHC billing which is submitted on a CMS-1500 WILL be subject to MIPS adjustments.

16

Qualified RHC Providers

An RHC encounter can be billed for the following providers: Physicians (MD, or DO) Nurse Practitioners Physician Assistants Certified Nurse Midwives Chiropractor, Dentist, Optometrist, Podiatrist

17

Behavioral 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)

18

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; Clinical Psychologist and Clinical Social Worker 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)

19

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.

20

RHC Locations

RHC visits may take place in: the RHC or FQHC, the patient’s residence (including an assisted living facility), a Medicare-covered Part A SNF (see Pub. 100-04, Medicare Claims

Processing Manual, chapter 6, section 20.1.1), or the scene of an accident.

(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)

21

Never a RHC Location

RHC Visits may never take place in: an inpatient or outpatient department of a hospital, including a CAH, or a facility which has specific requirements that preclude RHC or FQHC

visits (e.g., Medicare comprehensive outpatient rehabilitation facility, a hospice facility, etc.)

(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)

22

The RHC Encounter is:

“An RHC or FQHC visit is a medically-necessary medical or mental healthvisit, or a qualified preventive health visit. The visit must be a 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 servicesare rendered.”


23

Qualifying Visits

Medical Services RHCs shall report one service line per encounter/visitwith revenue code 052X and a qualifying medical visit from the RHCQualifying Visit List. Payment and applicable coinsurance and/ordeductible shall be based upon the qualifying medical visit line.

RHC Qualifying Visit Listhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

24

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

RHC Services – Claim Form

RHC Services are submitted on a CMS-UB04 claim form. The electronic format is ANSI837-Institutional. Type of Bill is “711” for an original claim. All services must be reported using the appropriate revenue code. All claims must have a qualifying visit denoted with a “CG” Modifier. Incident-to services must be reported on the claim, but bundled with

the qualifying visit.

25

Revenue Codes

0521 All Clinic Visits and Professional Services by qualified RHC provider;0522 Home visit by RHC provider;0524 Visit by RHC provider to a Part A SNF bed;0525 Visit by RHC provider to a non-SNF bed,

NF or other residential facility (non-Part A);0527 Visiting Nurse service in home health shortage area0528 Visit by RHC provider to other non-RHC site (scene of an accident) 0250 Pharmacy (Does not need the HCPCS)0300 Venipuncture0636 Injection/Immunization0780 Telehealth0900 Behavioral Health

Page 26

CG Modifier

“…beginning on October 1, 2016, RHCs shall add modifier CG (policycriteria applied) to the line with all the charges subject to coinsurance anddeductible.” (Med Learn Matters SE1611)

“If only preventive services are furnished during the visit, the RHC shouldreport modifier CG with the preventive HCPCS code that represents theprimary reason for the medically necessary face-to-face visit and thebundled charges.”

27

Billing Example: CG Modifier and Line Items

FL42 FL43 FL44 FL45 FL46 FL47Rev CD Desc HCPCS/CPT DOS Units Total Charge

0521 Office Visit Est III 99213CG 4/2/2019 1 100.00$ 0001 Total Charge 100.00$

An established patient is seen and a qualifying visit of 99213 for $100 is generated. The applicable coinsurance and/or deductible shall be based upon $100.

28

RHC

FL42FL43FL44FL45FL46FL47

Rev CDDescHCPCS/CPTDOSUnitsTotal Charge

0521Office Visit Est III99213CG4/2/191$ 100.00

0001Total Charge$ 100.00



0900Psytx Pt Family 30 Min90836 CG4/2/161$ 120.00








0521Office Visit Est III992134/2/171$ 300.00

0900Rx Management908324/2/161$ 120.00




0521Arthrocentesis20610 CG4/2/161$ 500.01

0521Synvisc InjectionJ33014/2/161$ 0.01




0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 20.00

0636ToradolJ18854/2/161$ 30.00




0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 0.01

0636ToradolJ18854/2/161$ 0.01


CCM Service with Billable RHC Encounter



0521OV Est 399213 CG4/2/161$ 150.00

0521CCM994904/2/161$ 43.00


CCM Service - No Other Services to Report



0521CCM994904/2/161$ 43.00


TCM Service - No Other Services to Report



0521TCM99495CG4/2/161$ 150.00


ACP Service - No Other Services to Report



0521ACP99497CG4/2/161$ 125.00


ACP Service - Part of AWV



0521Annual Wellness VisitG0439CG4/2/161$ 150.00

0521ACP994974/2/161$ 125.00




0521Arthrocentesis20610 RT CG4/2/161$ 800.02

0521Arthrocentesis20610 LT4/2/161$ 0.01

0636SynviscJ33014/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 130.00

521EKG-PC930104/2/161$ 30.00




521OV Est 399213 CG4/2/161$ 130.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


FQHC

G0466: New Patient Medical Visit

FL42FL43FL44FL45FL46FL47TotalMedicareCoinsurance

Rev CDDescHCPCS/CPTDOSUnitsTotal ChargePmtPayment

0521FQHC Visit, New PtG04661/31/171$ 195.00$ 195.00$ 156.00$ 39.00

0521OV New, Level 4992041/31/171$ 180.00$ - 0$ - 0$ - 0

0300Routine Venipuncture364151/31/171$ 15.00$ - 0$ - 0$ - 0

0001$ 390.00



0521FQHC Visit, Established PtG04671/31/171$ 150.00$ 150.00$ 120.00$ 30.00

0521OV Est Patient III992131/31/171$ 135.00$ - 0$ - 0$ - 0


0001$ 300.00

G0466 and G0469: New Patient Medical Visit plus Behavioral Health




0521OV New Patient III992031/31/171$ 170.00$ - 0$ - 0$ - 0

0636InjectionJ10401/31/171$ 25.00

0900FQHC Visit, New Pt MHG04691/31/171$ 150.00$ 150.00$ 120.00$ 30.00

0900Psychiatric Evaluation907911/31/171$ 150.00$ - 0$ - 0$ - 0

0001$ 690.00$ 323.57$ 254.57$ 69.00

G0467 Established Patient and Flu Shot





0636Immunization Admin*90655 PS1/31/171$ 25.00CARC246$ - 0$ - 0

0771Flu Vaccination*G0008 PS1/31/171$ 25.00CARC246$ - 0$ - 0

0001$ 335.00

G0467 Established Patient and Hepatitis Shot





0636Hep B Adult90746 PS1/31/171$ 25.00CARC246$ - 0$ - 0

0771Hep B AdministrationG0010 PS1/31/171$ 25.00CARC246$ - 0$ - 0

0001$ 335.00

G0467 Established Patient and Pap-Pelvic





0521Breast-Pelvic ExamG0101 PS1/31/171$ 75.00CARC246$ - 0$ - 0

0521Pap CollectionQ0091 PS1/31/171$ 50.00CARC246$ - 0$ - 0

0001$ 410.00

G0468 Subsequent AWV/Well-Woman Exam



0521FQHC Visit, IPPE or AWVG04681/31/171$ 165.00$ 165.00$ 165.00$ - 0

0521Subsequent AWVG0439 PS1/31/171$ 165.00$ - 0$ - 0$ - 0

0521Pelvic/Breast ExamG0101 PS1/31/171$ 80.00$ - 0

0521PAP SmearQ0091 PS1/31/171$ 80.00$ - 0

0001$ 490.00

G0468 IPPE



0521FQHC Visit, IPPE or AWVG04681/31/171$ 165.00$ 165.00$ 165.00$ - 0For Medical visit with revenue code 052X Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20%

0521IPPEG0402 PS1/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 330.00

G0467 and 99490 Chronic Care ManagementFor G0467 billed with modifier 59 Payment = 160.00 * 80% = 128.00 Coinsurance = 160.00 * 20% = 32.00






0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 341.90

99490 Chronic Care Management



0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 41.90

G0467 and Modifier-59



0521FQHC Visit, EstablishedG04671/31/171$ 150.00$ 150.00$ 120.00$ 30.00


0521FQHC Visit, EstablishedG0467-591/31/171$ 150.00$ 150.00$ 120.00$ 30.00

0521OV Est Patient IV992141/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 600.00



0900FQHC Visit, MH NewG04691/31/171$ 150.00$ 150.00$ 120.00$ 30.00


0001Total Charge$ 300.00$ - 0$ - 0$ - 0



0900FQHC Visit, Est Pt MHG04701/31/171$ 320.00198.58134.58$ 64.00

0900Psytx Pt Family 30 Min908364/2/161$ 120.00

0900Rx Management908324/2/161$ 200.00




0521OV Est 399213 CG4/2/161$ 130.01

0636ToradolJ18854/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 145.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


Sheet2

Sheet3

Billing Example: Medical Visit plus Ancillary

The charge amount for Toradol ($30.00) and the administration($20.00) will be added to the 99213 ($100) for a qualifying visitline of $150.00. The total charge line is artificially inflated – butcorrect.


0521 OV Est 3 99213 CG 4/2/2019 1 150.00$ 0636 Injection Admin 96372 4/2/2019 1 20.00$ 0636 Toradol J1885 4/2/2019 1 30.00$ 0001 Total Charge 200.00$

29

RHC







0521OV Est 399213 CG4/2/191$ 150.00

0636Injection Admin963724/2/191$ 20.00

0636ToradolJ18854/2/191$ 30.00













0900Rx Management908324/2/161$ 120.00









0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 0.01

0636ToradolJ18854/2/161$ 0.01





0521OV Est 399213 CG4/2/161$ 150.00

0521CCM994904/2/161$ 43.00





0521CCM994904/2/161$ 43.00





0521TCM99495CG4/2/161$ 150.00





0521ACP99497CG4/2/161$ 125.00






0521ACP994974/2/161$ 125.00






0636SynviscJ33014/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 130.00

521EKG-PC930104/2/161$ 30.00




521OV Est 399213 CG4/2/161$ 130.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


FQHC





0521OV New, Level 4992041/31/171$ 180.00$ - 0$ - 0$ - 0


0001$ 390.00






0001$ 300.00






0636InjectionJ10401/31/171$ 25.00



0001$ 690.00$ 323.57$ 254.57$ 69.00








0001$ 335.00








0001$ 335.00








0001$ 410.00







0521PAP SmearQ0091 PS1/31/171$ 80.00$ - 0

0001$ 490.00

G0468 IPPE




0521IPPEG0402 PS1/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 330.00







0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 341.90




0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 41.90







0521OV Est Patient IV992141/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 600.00





0001Total Charge$ 300.00$ - 0$ - 0$ - 0





0900Rx Management908324/2/161$ 200.00




0521OV Est 399213 CG4/2/161$ 130.01

0636ToradolJ18854/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 145.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


Sheet2

Sheet3

Service Detail

Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR.

The Toradol charge amount ($30.00) plus $.01, the injection administration (20.00)plus $.01 are bundled with the $100 charge on the 99213 qualifying visit line.Medicare will use the line with the qualifying visit code (99213) to determine thetotal charge and calculate co-insurance.


0521 OV Est 3 99213 CG 4/2/2019 1 150.00$ 0636 Injection Admin 96372 4/2/2019 1 0.01$ 0636 Toradol J1885 4/2/2019 1 0.01$ 0001 Total Charge 150.02$

30

RHC







0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 20.00

0636ToradolJ18854/2/161$ 30.00













0900Rx Management908324/2/161$ 120.00









0521OV Est 399213 CG4/2/191$ 150.00

0636Injection Admin963724/2/191$ 0.01

0636ToradolJ18854/2/191$ 0.01





0521OV Est 399213 CG4/2/161$ 150.00

0521CCM994904/2/161$ 43.00





0521CCM994904/2/161$ 43.00





0521TCM99495CG4/2/161$ 150.00





0521ACP99497CG4/2/161$ 125.00






0521ACP994974/2/161$ 125.00






0636SynviscJ33014/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 130.00

521EKG-PC930104/2/161$ 30.00




521OV Est 399213 CG4/2/161$ 130.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


FQHC





0521OV New, Level 4992041/31/171$ 180.00$ - 0$ - 0$ - 0


0001$ 390.00






0001$ 300.00






0636InjectionJ10401/31/171$ 25.00



0001$ 690.00$ 323.57$ 254.57$ 69.00








0001$ 335.00








0001$ 335.00








0001$ 410.00







0521PAP SmearQ0091 PS1/31/171$ 80.00$ - 0

0001$ 490.00

G0468 IPPE




0521IPPEG0402 PS1/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 330.00







0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 341.90




0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 41.90







0521OV Est Patient IV992141/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 600.00





0001Total Charge$ 300.00$ - 0$ - 0$ - 0





0900Rx Management908324/2/161$ 200.00




0521OV Est 399213 CG4/2/161$ 130.01

0636ToradolJ18854/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 145.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


Sheet2

Sheet3

RHC Use of Modifiers -59 and -25

Modifier-59 indicates that separate conditions on the same treated are unrelated. This is used only a subsequent illness or injury on the same day as another visit. Modifier-25 in an RHC in interchangeable with -59!

Modifier-59 and -25 indicate two encounters. -25 is different in an RHC. Modifier 25 or 59 is only on the SECOND line item UB-04 on a claim form.

RHC Pro Tip: Modifier-25 is NOT used to distinguish an Evaluation and Management Service from a procedure.

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Billing Example: Medical Visit plus Procedure

Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.


0521 OV Est 3 99213 CG 4/2/2019 1 250.01$ 0521 Procedure 11100 4/2/2019 1 0.01$ 0001 Total Charge 250.02$

32

RHC







0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 20.00

0636ToradolJ18854/2/161$ 30.00




0521OV Est 399213 CG4/2/171$ 120.00

0636Allergy Injection951154/2/171$ 20.00




0521OV Est 399213 CG4/2/171$ 120.01

0636Allergy Injection951154/2/171$ 0.01













0900Rx Management90832CG4/2/161$ 120.00









0521OV Est 399213 CG4/2/161$ 150.00

0636Injection Admin963724/2/161$ 0.01

0636ToradolJ18854/2/161$ 0.01





0521OV Est 399213 CG4/2/161$ 150.00

0521CCM994904/2/161$ 43.00





0521CCM994904/2/161$ 43.00





0521TCM99495CG4/2/161$ 150.00





0521ACP99497CG4/2/161$ 125.00






0521ACP994974/2/161$ 125.00






0636SynviscJ33014/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 130.00

521EKG-PC930104/2/161$ 30.00




521OV Est 399213 CG4/2/161$ 130.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01




0521OV Est 399213 CG4/2/161$ 120.00

0521Breast/PelvicG01014/2/161$ 75.00

0300Venipuncture364154/2/161$ 20.00




0521OV Est 399213 CG4/2/161$ 120.01

0521Breast/PelvicG01014/2/161$ 75.00

0300Venipuncture364154/2/161$ 0.01




0521OV Est 399213 CG 4/2/161$ 250.00

0521Procedure111004/2/161$ 150.00




0521OV Est 399213 CG4/2/191$ 250.01

0521Procedure111004/2/191$ 0.01


FQHC





0521OV New, Level 4992041/31/171$ 180.00$ - 0$ - 0$ - 0


0001$ 390.00






0001$ 300.00






0636InjectionJ10401/31/171$ 25.00



0001$ 690.00$ 323.57$ 254.57$ 69.00








0001$ 335.00








0001$ 335.00








0001$ 410.00







0521PAP SmearQ0091 PS1/31/171$ 80.00$ - 0

0001$ 490.00

G0468 IPPE




0521IPPEG0402 PS1/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 330.00







0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 341.90




0521CCM - 20 Minutes994901/31/171$41.90$ 41.90$ 33.52$ 8.38

0001$ 41.90







0521OV Est Patient IV992141/31/171$ 165.00$ - 0$ - 0$ - 0

0001$ 600.00





0001Total Charge$ 300.00$ - 0$ - 0$ - 0





0900Rx Management908324/2/161$ 200.00




0521OV Est 399213 CG4/2/161$ 130.01

0636ToradolJ18854/2/161$ 0.01




521OV Est 399213 CG4/2/161$ 145.01

521EKG-PC930104/2/161$ 0.01




0521OV Est Level 499214 CG4/2/161$ 540.01

0521Laceration12002 594/2/161$ 0.01


Sheet2

Sheet3

Preventive RHC Services

RHC services also include certain preventive services. These include: Welcome To Medicare Visit (G0402) Annual Wellness Visit/Subsequent Annual Wellness (G0438/G0439) Medicare-covered Preventive Services (DMST is NOT eligible as an RHC Visit!) Influenza, Pneumococcal (Medicare Cost Report – Medicare Flu/Pneumo Only) Chronic Care Management (G0511/G0512) Virtual Communication Services (G0071)

(Medicare Benefit Policy Manual Chapter 13)

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Preventive Services and Same Day Billing

“RHC/FQHC can receive a separate payment for an encounter in additionto the payment for the [Certain Preventive Services] when they areperformed on the same day.” MLN SE1039

The IPPE (G0402) is the only Medicare Preventive Service eligible for same-day billing.

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Preventive Services and Stand-Alone Encounters

All other preventive services are ‘stand-alone’ encounters. If a “StandAlone” encounter is the only service rendered on a particular date ofservice, then it will be paid at the AIR. If it is furnished on the same day asanother medical visit, it is not a separately billable visit.

The beneficiary coinsurance and deductible may be waived, depending onthe service rendered.

35

Medicare Preventive Services (MPS)

“RHCs and FQHCs are paid for the professional component of allowablepreventive services when all of the program requirements are met andfrequency limits (where applicable) have not been exceeded.

The beneficiary copayment and deductible (where applicable) is waivedby the Affordable Care Act for the IPPE and AWV, and for Medicare-covered preventive services recommended by the USPSTF with a grade orA or B.”

36

Non-Rural Health Services

“RHCs and FQHCs must be primarily engaged in furnishing primary careservices, but may also furnish certain services that are beyond thescope of the RHC or FQHC benefit.

If these services are authorized…the services must be billed separately(not by the RHC or FQHC) to the appropriate A/B MAC under thepayment rules that apply to the service.

RHCs and FQHCs must identify and remove from allowable costs on theMedicare cost report all costs associated with the provision of non-RHC/FQHC services such as space, equipment, supplies, facilityoverhead, and personnel.”

(Medicare Benefit Policy Manual Chapter 13; Section 60)37

Non-Rural Health Services

Certain services are not considered RHC or FQHC services either because they 1) arenot included in the RHC or FQHC benefit, or 2) are not a Medicare benefit. Non-RHC/FQHC services include, but are not limited to:

Medicare excluded services Ambulance servicesTechnical component of an RHC or FQHC service

Prosthetic devices

Laboratory services Body BracesDurable medical equipment Practitioner services at certain other

Medicare facilityTelehealth distant-site services Hospice ServicesGroup Services

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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.

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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 hospital CCN number. Lab services are also billed to the FI using the hospital CCN number.

40

Medicare Fees (Patient Charges)

“RHCs and FQHCs must charge Medicare beneficiaries the same rate that non-Medicare beneficiaries are charged.”


41

Medicare Payments

“In general, Medicare pays 80 percent of the RHC or FQHC’s all-inclusive rate, subject to a per-visit payment limit. The beneficiary in an RHC must pay the deductible and coinsurance amount.”


42

Visiting Specialists in an RHC

Any qualified provider (MD, DO, NP, PA) can see patients in an RHC. RHC must provide primary care services fifty-one percent of operating

hours. (FP, IM, Peds, OB)

43

Medicare Advantage Plans

Medicare Advantage plans are considered commercial payers for RHC purposes and cost reporting purposes. Most of these will pay your RHC encounter rate and follow

Medicare RHC reimbursement. RHC services should be submitted on a CMS-UB04; Non-RHC services may be submitted on a CMS-1500. Pneumoccal and Influenza injections should not be reported

on the RHC Cost Report.

44

Telehealth

Report on UB04 with Q3014. (app. $23.17) Can accompany an E/M service or be reported alone. ‘Remote’ physician bills an E/M code with modifier.

45

Telehealth

RHCs and FQHCs are not authorized to serve as a distant site fortelehealth consultations, which is the location of the practitioner at thetime the telehealth service is furnished, and may not bill or include thecost of a visit on the cost report.* (*State rules vary!!)

This includes telehealth services that are furnished by a RHC or FQHCpractitioner who is employed by or under contract with the RHC orFQHC, or a non-RHC or FQHC practitioner furnishing services through adirect or indirect contract.

46

Chronic Care Management becomes Care Coordination

CCM services furnished on or after January 1, 2018: CCM services can be billed byadding the general care management G code, G0511, to an RHC or FQHC claim, eitheralone or with other payable services. Payment is set annually at the average of thenational non-facility PFS payment rate for CPT codes 99490 (20 minutes or more ofCCM services), 99487 (60 minutes or more of complex CCM services), and 99484 (20minutes or more of general behavioral health integration services).

For CCM services furnished between January 1, 2016 and December 31, 2017: CPT code 99490 ONLY applies to these old claims. 99490 is dead.

47

G0511: General Care Management Services

G0511: General Care Management Services billed alone or with other payable services on a RHC or FQHC claim. This code could only be billed once per month per beneficiary, and could not be

billed if other care management services are billed for the same time period. Payment for G0511 is set at the average of the 3 national non-facility PFS payment

rates for the CCM (CPT code 99490 and CPT code 99487) and general BHI (CPT code99484).

The current payment rate is $61.37 for FY2018. The rate is updated annually based on the PFS amounts and coinsurance applies.

48

Effective January 1, 2019: Virtual Communication

RHCs can receive payment for Virtual Communication Services when at least5 minutes of communication technology-based or remote evaluation servicesare furnished by an RHC practitioner to a patient who has had an RHC billablevisit within the previous year.

The medical discussion or remote evaluation is for a condition not related to an RHC service provided within the previous 7 days, and -

The medical discussion or remote evaluation does not lead to an RHC visit within the next 24 hours or at the soonest available appointment.

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Virtual Communication Services - Payment

G0071 (Virtual Communication Services) is billed either alone or with other payable services.

Payment for G0071 is set at the PFS national average of the non-facility payment rate for HCPCS code G2012 (communication technology-based services) and HCPCS code G2010 (remote evaluation services).

For 2019, the payment amount for code G0071 will be $13.69 (average of HCPCS codes G2012 and G2010).

50

G2010: Virtual Communication Services

Virtual Check-In: Brief Communication Technology-based Service: by a physician or other qualified health care professional; provided to an established patient; not originating from a related E/M service provided within the

previous 7 days; nor leading to an E/M service or procedure within the next 24

hours or soonest available appointment; 5-10 minutes of medical discussion.

51

G2012: Virtual Communication Services

Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24

business hours, not originating from a related E/M service provided within the previous

7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

52

RHC - CMS Resources

Virtual Communication FAQhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/VCS-

FAQs.pdf

State Operations Manual Appendix G (Updated 1.2.18)https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf

Provider-Based Rules (42 CFR 413.65)https://www.law.cornell.edu/cfr/text/42/413.65

53

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/VCS-FAQs.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdfhttps://www.law.cornell.edu/cfr/text/42/413.65

RHC - CMS Resources

Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues www.cms.gov/manuals/downloads/clm104c09.pdf

Medicare Benefit Policy Manual – Chapter 13 RHC/FQHC www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

Medicare Claims Processing Manual UB04 Completionwww.cms.gov/manuals/downloads/clm104c25.pdf

Medicare Benefit Policy Manual- Chapter 15 Other Serviceswww.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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http://www.cms.gov/manuals/downloads/clm104c09.pdfhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdfhttp://www.cms.gov/manuals/downloads/clm104c25.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Contact Information

Charles A. James, Jr.North American Healthcare Management ServicesPresident and CEO888.968.0076cjamesjr@northamericanhms.comwww.northamericanhms.com

55

RHC Beginning Billing 101What is an RHC?What is an RHC?The Rules - 42 CFR 491 Rural Health Clinic RequirementsRHC Regulations and Interpretive GuidelinesThe RHC Encounter RateRHC Productivity StandardRHC Rate and Cost ReportingIndependent RHCsProvider-Based RHCsProvider-Based RHCs: Not Outpatient DepartmentsOutpatient PPS 2017RHC Claims - Medicare Part AMedicare Part B (FFS)Rural Health Clinics and MIPSQualified RHC ProvidersBehavioral Health ProvidersRural Health ServicesIncident-to Services Defined RHC LocationsNever a RHC LocationThe RHC Encounter is:Qualifying VisitsRHC Services – Claim FormRevenue CodesCG ModifierBilling Example: CG Modifier and Line ItemsBilling Example: Medical Visit plus AncillaryService DetailRHC Use of Modifiers -59 and -25Billing Example: Medical Visit plus ProcedurePreventive RHC ServicesPreventive Services and Same Day BillingPreventive Services and Stand-Alone EncountersMedicare Preventive Services (MPS)Non-Rural Health ServicesNon-Rural Health ServicesDiagnostic Testing and Lab: IndependentDiagnostic Testing and Lab: Provider-BasedMedicare Fees (Patient Charges)Medicare PaymentsVisiting Specialists in an RHCMedicare Advantage PlansTelehealthTelehealthChronic Care Management becomes Care CoordinationG0511: General Care Management ServicesEffective January 1, 2019: Virtual CommunicationVirtual Communication Services - PaymentG2010: Virtual Communication ServicesG2012: Virtual Communication ServicesRHC - CMS ResourcesRHC - CMS ResourcesContact Information

Documents

RHC Beginning Billing 101 - Rural health clinic€¦ · “AnRHC or FQHC visit is a medically-necessary medical or mental health visit, or a qualified preventive health visit. The