advanced rural health clinic billing v.2020 june 17, 2020...rhcs must report hcpcs code g2025 on...

Advanced Rural Health Clinic Billing v.2020

June 17, 2020

Charles James, Jr.North American HMSPresident and CEO

9245 Watson Industrial ParkSt. Louis, MO 63126314.560.0098314.968.6883 (Fax)[email protected]

Charles A. James, Jr. - North American HMS

Telehealth Claims during the PHEWhat goes on RHC claims!! (Hint: RHC Services) Claim Reporting and Multiple Encounters IPPE and AWV, and Medicare Preventive Services Care Service Claim Examples Negative Payment Remits

This is Advanced Billing: Let’s Dig Deeper

CMS released NEW GUIDANCE on April 30, 2020, revising what was released on 4.17.2020.

Telephone only visits are now payable at $92.03!! Please read on.

4.30.2020 Update: CMS has changed again!

Payment to RHCs and FQHCs for distant site telehealth services is set at $92.03, which is the average amount for all PFS telehealth services on the telehealth list, weighted by volume for those services reported under the PFS.

Because these changes in policy were made on an emergency basis, CMS needs to implement changes to claims processing systems in several stages.

RHC – FQHC Distant Site Provider Payment

RHCs and FQHCs must use HCPCS code G2025, the new RHC/FQHC specific G-code for distant site telehealth services, to identify services that were furnished via telehealth beginning on January 27, 2020, the date the COVID-19 PHE became effective.(see https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx).

Changes in eligible originating site locations, including the patient’s home during the COVID-19 PHE are effective beginning March 6, 2020.

G2025 Only

https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx

For telehealth distant site services furnished between January 27, 2020, and June 30, 2020: RHCs must report HCPCS code G2025 on their claims with the CG modifier. Modifier “95” (Rendered via Real-Time Interactive Audio and Video) may also be

appended but is not required. These claims will be paid at the RHC’s all-inclusive rate (AIR), and automatically

reprocessed beginning on July 1, 2020, at the $92.03 rate. RHCs do not need to resubmit these claims for the payment adjustment.

RHC Telehealth Distant Site Services:furnished between January 27, 2020, and June 30, 2020

RHCs and FQHCs can furnish and bill for these services using HCPCS code G2025. To bill for these services: at least 5 minutes of telephone E/M service by a physician or other qualified health

care professional who may report E/M services must be provided to an established patient, parent, or guardian.

These services cannot be billed if they originate from a related E/M service provided within the previous 7 days or lead to an E/M service or procedure within the next 24 hours or soonest available appointment.

Medicare Telephone Only Visits

During the COVID-19 PHE, RHCs and FQHCs can furnish any telehealth service that is approved as a Medicare Telehealth Service under the PFS. (See Medicare Approved Telehealth Services )

Effective March 1, 2020, these services include CPT codes 99441, 99442, and 99443, which are audio-only telephone evaluation and management (E/M) services. RHCs and FQHCs can furnish and bill for these services using HCPCS code G2025.

We can adjust telephone only claims that were billed G0071 to G2025 to be paid the higher rate – back to March 1, 2020.

Medicare Telephone Only Visits = G2025

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.)

Payment Rate for 2021 Only distant site telehealth services furnished during the COVID-19 PHE are authorized for payment to RHCs and FQHCs. If the COVID-19 PHE is in effect after December 31, 2020, this rate will be updated based on the 2021 PFS average payment rate for these services, weighted by volume for those services reported under the PFS.

After December 31, 2020

Distant site telehealth services can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice. (This includes 99201 and 99211.)

Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC or FQHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS)!!

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

Distant Site Providers

https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

“As stated on the MLN, any service that is approved as a distant site telehealth service under the Physician Fee Schedule can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice, and the RHC would bill this as a distant site telehealth service, for a payment of $92.03.

CPT 99201 and 99211 are on the list and can be furnished by an RN if within the RN scope of practice. Payment would be [$92.03]”

Email Quotation from CMS

ANY Provider During the Emergency

RHC Medicare Telehealth Visits: E/M with Audio and Video

Dates of Service HCPCS/CPT Modifiers

January 27 – June 30, 2020 G2025CG 95 (Optional)July 1, 2020 to end of PHE G2025 95 (Optional)

RHC Telehealth Distant Site Services:furnished between January 27, 2020, and June 30, 2020

Rev CD Desc HCPCS/CPT DOS Units Total Charge0521 RHC Distant Site G2025CG95 01/27/2020 1 $ 94.00 0001 Total Charge $ 94.00

RHCs must report HCPCS code G2025 on their claims with the CG modifier.

Modifier “95” (Real-Time Interactive Audio and Video) may also be appended but is not required.

These claims will be paid at the RHC’s all-inclusive rate (AIR), and automatically reprocessed beginning on July 1, 2020, at the $92.03 rate.

RHCs do not need to resubmit these claims for the payment adjustment.

RHC Telehealth Distant Site Services:Beginning July 1, 2020

Rev CD Desc HCPCS/CPT DOS Units Total Charge0521 RHC Distant Site G2025 08/21/2020 1 $ 94.00 0001 Total Charge $ 94.00

Beginning July 1, 2020, RHCs should no longer put the CG modifier on claims with HCPCS code G2025.

These claims will be paid at $92.03.

Patient Consent: Beneficiary consent is required for all services, including non-face-to-face services.

For RHCs and FQHCs, beneficiary consent to receive these services may be obtained byauxiliary personnel under general supervision of the RHC or FQHC practitioner; and theperson obtaining consent can be an employee, independent contractor, or leasedemployee of the RHC or FQHC practitioner.

(see: https://www.cms.gov/files/document/covid-final-ifc.pdf).

Patient Consent: Virtual Check-In

Medicare Telehealth

Medicare WILL apply cost-sharing (co-insurance and deductible) to Telehealth services.

Telehealth Co-Insurance and Deductible

“Under this Notice, however, OCR will not impose penalties against covered health care providers for the lack of a BAA with video communication vendors or any other noncompliance with the HIPAA Rules that relates to the good faith provision of telehealth services during the COVID-19 nationwide public health emergency.”

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

OCR and HIPAA during COVID

https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

The following are approved platforms. Skype for Business / Microsoft Teams Updox VSee Zoom for Healthcare Doxy.me Google G Suite Hangouts Meet Cisco Webex Meetings / Webex Teams Amazon Chime GoToMeeting

The following are NOT approved: Facebook Live – Streams to the public! TikTok – If you don’t know what it is

your kids or grandkids do!

Medicare Telehealth Visits via FaceTime/Skype

In response to the unique circumstances resulting from the outbreak of 2019 novel coronavirus (COVID-19), the HHS Office of Inspector General (OIG) provided flexibility for healthcare providers to reduce or waive beneficiary cost-sharing for telehealth visits paid for by Federal health care programs through a policy statement issued on March 17, 2020.

Ordinarily, if physicians or practitioners routinely reduce or waive costs owed by Federal health care program beneficiaries, including cost-sharing amounts such as coinsurance and deductibles, they would potentially implicate the Federal anti-kickback statute, the civil monetary penalty and exclusion laws related to kickbacks, and the civil monetary penalty law prohibition on inducements to beneficiaries.

The policy statement notifies providers that OIG will not enforce these statutes if providers choose to reduce or waive cost-sharing for telehealth visits during the COVID-19 public health emergency, which the HHS Secretary determined exists and has existed since January 27, 2020.

HHS Office of Inspector General Fact Sheet – March 2020

Providers MAY waive Co-Insurance at their discretion

https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/factsheet-telehealth-2020.pdf

For services related to COVID-19 testing, including telehealth, RHCs and FQHCs must waive the collection of co-insurance from beneficiaries.

For COVID-related services in which the coinsurance is waived, RHCs and FQHCs must report the “CS” modifier on the service line.

CS Modifier for COVID-Related Services:Co-Insurance MUST be Waived

COVIDRHC and FQHC claims with the “CS” modifier will be paid with the coinsurance applied. Medicare Administrative Contractor (MAC) will automatically reprocess

these claims beginning on July 1. Coinsurance should not be collected for COVID-related services.

CS Modifier – Claims with Co-Insurance Applied

RHCs can receive payment for Virtual Communication Services when at least 5 minutesof communication technology-based or remote evaluation services are furnished by anRHC practitioner to a patient who has had an RHC billable visit 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.

Virtual Communication – NOT an Encounter!

Virtual communication services would be initiated by the patient contacting the RHC or FQHC by:

a telephone call;integrated audio/video system;a store-and-forward method such as sending a picture or video to the RHC or

FQHC practitioner for evaluation and follow up within 24 hours.

The RHC or FQHC practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.

G0071 FAQ: Types of Communication

6/24/2020www.northamericanhms.com 24

Virtual Check-In (Brief Communication Technology-based Service): Performed by a physician or other qualified health care professional; Revenue Code: 0521 COVID-19: Available to ALL patients, including new patients, effective

3.17.2020. 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. Text and email count.

G0071: Virtual Check-In

E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. RHCs bill these using G0071.

The services may be billed using CPT codes 99421-99423 as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services. Patient Consent can be obtained by the staff, verbally. Providers can waive cost-sharing for all telehealth services and visits.

eVisits – 99421,99422, 99423

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

Payment for G0071 is temporarily (during PHE) set at the PFS national average of the non-facility average for G2010, G2012, 99421, 99422, and 99423.

For 2020, the payment amount for code G0071 will be $24.76.

Virtual Communication Services – Billing

Virtual Check-In RHC Claim Example

Rev CD Desc HCPCS/CPT DOS Units Total Charge0521 Virtual Check-In G0071CS 4/2/2020 1 24.76$ 0001 Total Charge 24.76$

Do NOT report with CG. G0071 is for RHCs only. We do not bill G2010 OR G2012. Virtual Check-In G0071 encompasses Remote Check-In AND Remote Evaluation. Use modifier CS to waive co-ins/ded ONLY IF COVID-related. MACs will automatically reprocess any claims with G0071 for services furnished

on or after March 1, 2020 that were paid before the claims processing system was updated.

RHC

FL42FL43FL44FL45FL46FL47

Rev CDDescHCPCS/CPTDOSUnitsTotal Charge

0521Office Visit Est III99213CG4/2/171$ 100.00

0001Total Charge$ 100.00



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





0900Psytx Pt Family 30 Min90836 CG4/2/171$ 120.00









0900Rx Management90832CG4/2/161$ 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$ 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




0521OV Est 399213 CG4/2/161$ 120.00

0521Breast/PelvicG01014/2/161$ 75.00

0300Venipuncture364154/2/161$ 20.00



0521Virtual Check-InG0071CS4/2/201$ 24.76


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

For 2020, the payment amount for code G0071 will be $13.69 (average of HCPCS codes G2012 and G2010).

Claims submitted with HCPCS codes G2012 or G2010 are NOT paid. Only G0071.Telehealth and virtual communication services ARE NOT the same.There are no frequency limitations [for billing G0071] at this time.Only billable by RHCs and FQHCs only when the discussion requires the skill level of

an RHC or FQHC practitioners. [Physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers]

Pre-COVID: G0071 FAQ: Virtual Communication Services

Commercial Insurance each have their own requirements as well. Most of these follow Medicare Part B – FFS rules.

NOT what RHCs are required to do. Please confirm their policies and reimbursement provision.

Commercial Insurance

Medicaid plans are state specific with variation among plans with HCPCS codes, modifiers and whether telephone visits are allowed.

Medicaid and Medicaid MCO

RHCs and FQHCs can bill for visiting nursing services furnished by an RN or LPN to homebound individuals under a written plan of treatment in areas with a shortage of home health agencies (HHAs). Effective March 1, 2020, and for the duration of the COVID-19 PHE, the area typically served by the RHC, and the area included in the FQHC service area plan, is determined to have a shortage of HHAs, and no request for this determination is required. RHCs and FQHCs must check the HIPAA Eligibility Transaction System (HETS) before providing visiting nurse services to ensure that the patient is not already under a home health plan of care.

Home Health Agency Shortage Requirement

“To prevent RHCs that are currently exempt from the national per-visit payment limit from losing their exemption due to the COVID-19 PHE, and to not discourage hospitals from increasing bed capacity if needed, CMS will use the number of beds from the cost reporting period prior to the start of the COVID-19 PHE as the official hospital bed count for determining exemption to the payment limit.

As such, RHCs with provider-based status that were exempt from the national per-visit payment limit in the period prior to the effective date of the COVID-19 PHE (January 27, 2020) will continue to be exempt from the national payment limit for the duration of the PHE for the COVID-19.”

Bed Count Revision

What goes on the RHC claim?!?

Remember our Question:

What we already know: 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

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

One Qualifying Visit – Majority of the Care

Medical Services RHCs shall report one service line perencounter/visit with revenue code 052X and a qualifyingmedical visit from the RHC Qualifying Visit List. Payment andapplicable coinsurance and/or deductible shall be based uponthe qualifying medical visit line.

Some services are covered by Medicare but do not meet the requirements for a medically necessary visit with an RHC or FQHC practitioner:

Services MUST be Medically Necessary

Not Medically Necessary EncountersBlood Pressure Checks Nursing Services Allergy Injections Bandages, gauze, oxygen,

dressing changesPrescriptions Venipuncture

50.1 - RHC Services (Rev. 252, Issued: 12- 07-18, Effective: 01-01-19, Implementation: 01- 02-19) RHC services include: Physicians' services, as described in section 110; Services and supplies incident to a physician’s services, as described in section 120; Services of NPs, PAs, and CNMs, as described in section 130; Services and supplies incident to the services of NPs, PAs, and CNMs, as described in section 140; CP and CSW services, as described in section 150; Services and supplies incident to the services of CPs, as described in section 160; and Visiting nurse services to patients confined to the home, as described in section 190. Certain care management services, as described in section 230. Certain virtual communication services, as described in section 240.

RHC Services

50.1 - RHC Services (Rev. 252, Issued: 12- 07-18, Effective: 01-01-19, Implementation: 01- 02-19) RHC services also include certain preventive services (see section 220 – Preventive Health Services). These services include: Influenza, Pneumococcal, Hepatitis B vaccinations; IPPE; Annual Wellness Visit (AWV); and Medicare-covered preventive services recommended by the U.S. Preventive Services Task Force

(USPSTF) with a grade of A or B, as appropriate for the individual.

RHC Services

Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through the cost report. No line items should be billed. These costs should not be included on a claim. These are the only injections that are payable outside of RHC claims. The beneficiary coinsurance and deductible are waived.

Influenza (G0008) and Pneumococcal and Vaccines (G0009)

Medicare does not adjudicate RHC claims based on the 0001 Total Charge amount.

Medicare adjudicates RHC claims using the Qualifying Visit Line. The qualifying visit line should be the sum of all RHC charges minus

any preventive services.

Total Charges WILL be reported as allowed charges on remits, BUT: Patient Co-Insurance/Deductible amounts are based on the Qualifying Visit Line.

Qualifying Visit Line Charge (052X) vs Total Charge (0001)

Billing Example: CG Modifier

An established patient is seen and a qualifying visit of 99213 for $100 is generated. The applicable coinsurance and/or deductible is calculated using $100.

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

0521 Office Visit Est III 99213CG 04/02/2020 1 $ 100.00 0001 Total Charge $ 100.00

Billing Example: Incident-To Services

J1885 ($30.00) and 96372 ($20.00) are bundled with 99213 ($100) on thequalifying visit line.

The total QVL Charge is $150.00; the sum of all services reported on the claim. The total charge line (0001) is inflated due to duplicating the injection/admin

charges from the detail lines.


0521 OV Est 3 99213 CG 6/10/2020 1 150.00$ 0636 Injection Admin 96372 6/10/2020 1 20.00$ 0636 Toradol J1885 6/10/2020 1 30.00$ 0001 Total Charge 200.00$

RHC







0521OV Est 399213 CG6/10/201$ 150.00

0636Injection Admin963726/10/201$ 20.00

0636ToradolJ18856/10/201$ 30.00












0521Office Visit Est III992134/2/171$ 300.00

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

The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and

AR. Patient Co-Insurance and Deductible are based on the CG

Modifier-QVL line.

“Alternate Method” for Reporting Service Detail

“Alternate Method” Service Detail Reporting

The Injection and Medication Charges ($20.00/$30.00) are added to the 99213qualifying visit line.

The detail lines are reported as $.01. The total charges are no longer falsely inflated.


0521 OV Est 3 99213 CG 4/2/2019 1 150.02$ 0636 Injection Admin 96372 4/2/2019 1 0.01$ 0636 Toradol J1885 4/2/2019 1 0.01$ 0001 Total Charge 150.04$

RHC







0521OV Est 399213 CG4/2/191$ 150.02

0636Injection Admin963724/2/191$ 0.01

0636ToradolJ18854/2/191$ 0.01












0521Office Visit Est III992134/2/171$ 300.00

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

Billing Example: Bundled Injection/Different Dates

Four weekly allergy injections @ $20.00 each were provided. An Office Visit occurredon 4.2.2020. Four allergy injections 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 the

total charge and calculate co-insurance.


0521 OV Est 3 99213 CG 04/02/2020 1 $ 180.04 0636 Allergy Injection 95115 04/02/2020 4 $ 0.04 0001 Total Charge $ 180.08

Billing Example: Medical Visit plus Procedure


0521 OV Est Level 4 99213 CG 04/02/2020 1 $ 280.00 0521 Joint Injection 20610 04/02/2020 $ 0.01 0001 Total Charge $ 280.01

An office visit is performed in addition to a joint-injection at the same visit. The joint injection ($180.00) is bundled with the ($100.00) office visit charge. These should be bundled and submitted on the same encounter. The joint injection is on the QVL; if performed independently it is paid at the

AIR.

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 Behavioral health visit on the same day (2 visits), or

The patient has his/her IPPE and a separate medical and/or Behavioral health visit on the same day (2 or 3 visits).

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

Multiple Encounters are allowed when:

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.

RHC Use of Modifiers -59 and -25

Modifier-59 Example: Subsequent Injury

Modifier CG and modifiers 25/59 are NOT reported on the same service line together to indicate a subsequent medically necessary visit.

FL42 FL43 FL44 FL45 FL46 FL47

Rev CD Desc HCPCS/CPT DOS Units Total Charge0521 OV Est 3 99213 CG 04/02/2020 1 $ 350.00 0521 Laceration Repair 12002 59 04/02/2020 1 $ 0.01 0001 Total Charge $ 350.01

Modifier CG should be reported once per day for a qualified medical visit (revenue code 052x) and/or once per day for a qualified Behavioral health visit (revenue code 0900).

NOTE: Limited number of scenarios that require TWO CG Modifiers!

Claim Example: Sick Visit and Behavioral Health


Rev CD Desc HCPCS/CPT DOS Units Total Charge0521 Office Visit Est III 99213CG 04/02/2020 1 $ 220.00 0900 Rx Management 90832CG 04/02/2020 1 $ 120.00 0001 Total Charge $ 340.00

Billing Example: IPPE plus Office Visit

“Modifier CG does not need to be reported with the IPPE HCPCS code whether it is billed alone or with other payable services on a claim. When IPPE is furnished with another medically necessary face-to-face service, modifier CG is reported with the HCPCS code for the other billable service.” RHC Reporting FAQ


0521 Est Patient III 99213CG 04/02/2020 1 $ 100.00 0521 IPPE G0402 04/02/2020 1 $ 200.00 0001 Total Charge $ 300.00

Is modifier CG reported on a subsequent visit which occurs on the same day as an earlier visit?

A13. No.

Q14. Should modifier CG and modifier 25 or modifier 59 be reported on the same service line together to indicate a subsequent medically necessary visit?

A14. No.

A15. Modifier 25 or 59 is reported only on the line that represents the primary reason for the subsequent visit.

No CG Modifier on Subsequent Illness or Injury

Preventive 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)

Preventive RHC Services

“RHCs are paid an all-inclusive rate (AIR) per visit for qualified primary and preventive health services…

If an IPPE visit occurs on the same day as another billable visit, two visits may be billed. Except for DSMT/MNT, all of the preventive services…may be billed as a stand-alone visit if no other service is furnished on the same day. “

Medicare Preventive Services (MPS)

“The professional components of preventive services are part of the overall encounter, and for TOB 71x, these services have always been billed on revenue lines with the appropriate site of service revenue code in the 052x series.

Payment for the professional component of allowable preventive services is made under the all-inclusive rate when all of the program requirements are met.”

“Lab and technical components should continue to be billed as-non-RHC services.”

MLN SE1039

Medicare Preventive Services: PC-TC

“When one or more qualified preventive service is provided as part of a RHC visit……charges for these services must be deducted from the total charge for purposes of calculating beneficiary copayment and deductible.”

No Copayment and Deductible for Preventive Services

“RHC/FQHC can receive a separate payment for an encounter in addition to the payment for the [Certain Preventive Services] when they are performed on the same day.”

MLN SE1039

Preventive Services and Same Day Billing

The IPPE is a one-time exam that must occur within the first 12 months following the beneficiary’s enrollment. If an IPPE visit is furnished on the same day as another billable visit,

two visits may be billed. The IPPE (G0402) is the only Medicare Preventive Service eligible for

same-day billing. The beneficiary coinsurance and deductible are waived.

Initial Preventive Physical Exam (G0402)

Billing Example: IPPE Only

The IPPE was the only service performed. The CG modifier is optional when G0402 is reported.


0521 IPPE G0402 6/10/2020 1 200.00$ 0001 Total Charge 200.00$

Sheet1



0521IPPEG04026/10/201$ 200.00


Sheet2

Sheet3

Billing Example: IPPE plus Office Visit

“Modifier CG does not need to be reported with the IPPE HCPCS codewhether it is billed alone or with other payable services on a claim. WhenIPPE is furnished with another medically necessary face-to-face service,modifier CG is reported with the HCPCS code for the other billable service.”

(RHC Reporting FAQ)


0521 Est Patient III 99213CG 6/10/2020 1 100.00$ 0521 IPPE G0402 6/10/2020 1 200.00$ 0001 Total Charge 300.00$

Sheet1



0521Est Patient III99213CG6/10/201$ 100.00

0521IPPEG04026/10/201$ 200.00


Sheet2

Sheet3

Annual Wellness Visit (AWV) and Personalized Prevention Plan Services (PPPS)

Subsequent Annual Wellness Visit Advanced Care Planning Medicare Preventive Screenings

Stand-Alone Encounters

If a “Stand Alone” encounter is the only service rendered on a particulardate of service: it will be paid as an RHC Encounter at the AIR. If it is furnished on the same day as another medical visit, it is not a

separately payable visit. The beneficiary coinsurance and deductible may be waived, depending

on the service rendered.

Stand Alone Encounter Billing

The AWV is a personalized prevention plan for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an IPPE or AWV within the past 12 months. The AWV can be billed as a stand-alone visit if it is the only medical service provided on that day with a RHC practitioner. If the AWV is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible are waived.

Annual Wellness Visit (G0438 and G0439)

Billing Example: Well-Woman Exam

Medicare does not pay a well-woman exams (99381-99387). An annual or subsequent wellness visit (G0438/G0439) is reported for the examination, plus the breast/pelvic exam (G0101), and the pap smear (Q0091).

All Preventive Services are listed to capture quality measure and to report utilization to Medicare for COB. The patient is not responsible for any co-insurance or deductible for these Medicare Preventive Services.


Rev CD Desc HCPCS/CPT DOS Units Total Charge

0521 Subsq AWV G0439 CG 04/02/2020 1 $ 175.00 0521 Breast/Pelvic G0101 04/02/2020 1 $ 75.00 0521 Pap Smear Q0091 04/02/2020 1 $ 50.00 0001 Total Charge $ 300.00

Office Visit and Preventive w. Ancillary

An established patient is seen and a qualifying visit of 99213 for $100 is generated. A breast/pelvic exam was performed for $75.00. A venipuncture was taken for $20.00.

The charge for the pelvic exam should NOT be bundled in the 99213 line since there will be no co-insurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the 99213 charge for $100.00.


0521 OV Est 3 99213 CG 4/2/2020 1 120.00$ 0521 Breast/Pelvic G0101 4/2/2020 1 75.00$ 0300 Venipuncture 36415 4/2/2020 1 0.01$ 0001 Total Charge 195.01$

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





0521OV Est 399213 CG4/2/171$ 120.01














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 CG4/2/171$ 540.01

0521Laceration12002 594/2/171$ 0.01




0521OV Est 399213 CG4/2/201$ 120.00

0521Breast/PelvicG01014/2/201$ 75.00

0300Venipuncture364154/2/201$ 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

Diabetes counseling or medical nutrition services provided by aregistered dietician or nutritional professional at a RHC may beconsidered incident to a visit with a RHC practitioner provided allapplicable conditions are met.

Diabetes Counseling and Medical Nutrition Services

Stand Alone Encounters

Preventive Screening HCPCS Code Description

Alcohol Screening and Behavioral Counseling G0442, G0443

Annual alcohol misuse screening, 15 minute

Screening for Depression G0444 Annual depression screening, 15 minutes

Screening for Sexually Transmitted Infections and High Intensity Behavioral Counseling

G0445High intensity behavioral counseling to prevent sexually transmitted infection; face to-face, individual

Intensive Behavioral Therapy for Cardiovascular Disease

G0446Annual, face-to face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

Stand Alone Encounters

MPS Code Description

Intensive Behavioral Therapy for Obesity G0447

Face-to-face behavioral counseling for obesity, 15 minutes

Smoking and Tobacco Cessation Counseling G0436

Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes

Smoking and Tobacco Cessation Counseling G0437 greater than 10 minutes

Code DescriptionG0101 CA Screen/PelvicG0102* Prostate screeningG0117* Glaucoma Screen G0118* Glaucoma Screen - SupervisedG0296 Visit to determine LDCT Eligibility (Lung Cancer)G0436 Tobacco-use counsel 3-10 min G0437 Tobacco-use counsel >10 G0442 Annual alcohol screen 15 min G0443 Brief alcohol misuse counsel

Stand Alone EncountersPreventive Service Codes

* Co-Insurance and Deductible apply

Qualifying Visit

G0444 Depression screen annual G0445 High intensity behavioral counseling, 30 minG0446 Intensive behavioral therapy - Cardio diagnosticG0447 Behavioral counseling obesity, 15 min Q0091 Obtaining screening pap smear

Stand Alone Visit Codes

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. An RHC provider cannot bill as the ‘remote’.

Telehealth: Pre-COVID/Post COVID?

Telehealth Claim Example: Originating Site


0780 Telehealth Q3014 4/2/2019 1 23.17$ 0001 Total Charge 23.17$

Telehealth can be billed as an independent line-item or with a qualifying visit.

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





0521OV Est 399213 CG4/2/171$ 120.01














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





0780TelehealthQ30144/2/191$ 23.17


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

TCM Claim Example


0521 Tx Care Management 99495 4/2/2020 1 150.00$ 0001 Total Charge 150.00$

TCM cannot be billed with Care Management Services. TCM are billed and paid at the All-Inclusive Rate (AIR).

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





0521OV Est 399213 CG4/2/171$ 120.01














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

0001Total Ch

advanced rural health clinic billing v.2020 june 17, 2020...rhcs must report hcpcs code g2025 on...

Documents