rhc billing for independent rhcs...rhc billing for independent rhcs “dedicated to providing access...
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“Dedicated to providing access to quality health care in rural communities”
RHC Billing for Independent RHCs
“Dedicated to providing access to quality health care in rural communities”
RHC Services• An RHC Encounter is defined as a medically-
necessary, face-to face (one-on-one) medical or mental health visit, or a qualified preventative health visit, with a RHC practitioner during which time one or more RHC services are rendered.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf
“Dedicated to providing access to quality health care in rural communities”
RHC Providers• Physicians• Nurse Practitioners• Physician Assistants• Certified Nurse Midwifes (CNM)• Clinical Psychologists• Clinical Social Workers (CSW or LCSW)
“Dedicated to providing access to quality health care in rural communities”
What about Specialists?• 491.9 Condition of Coverage: Provision of Services-
Providing Rural Health Clinic Services:o A facility may provide services in addition to RHC services, usually,
related health care services such as the “other ambulatory services”
• Must be 51% Primary Care Services
• http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf
“Dedicated to providing access to quality health care in rural communities”
RHC Billing Requirements• Beginning October 1, 2016, RHCs shall add modifier
CG to the line with all the charges subject to coinsurance and deductible. (SE1611) **Exception is the Initial Preventative physical Exam (IPPE)**
• RHCs are required to bill the appropriate HCPCS code for each line along with the correct revenue code on each line.
“Dedicated to providing access to quality health care in rural communities”
Claim ExamplesWhen a claim is for an office visit only then you would have the 0521 revenue code, with a CG modifier placed at the end of the procedure code
“Dedicated to providing access to quality health care in rural communities”
Medicare Part A Only• If the patient only has Part A then they aren’t
covered under RHC services
“Dedicated to providing access to quality health care in rural communities”
Medicare Advantage Plans• Billed the same as regular Medicare.
“Dedicated to providing access to quality health care in rural communities”
Claim Submission Information• Claims are submitted on a UB-04• RHC Claims billed to Part A.
“Dedicated to providing access to quality health care in rural communities”
Revenue Codes• 0521- Clinic Visit• 0522- Home Visit • 0524- Part A SNF Visit• 0525- SNF, NF or Residential facility (Non Part A) Visit• 0528- Scene of an Accident• 0780- Telehealth • 0900- Mental Health Service
“Dedicated to providing access to quality health care in rural communities”
Bill Types• RHC claims typically have 4 types of bills:o710- Non payment/ Zero Claimo711- Original Claim o717- Adjustment Claim (Replacement of prior
claim)o718- Cancelled Claim (Void/Cancel Prior claim)
“Dedicated to providing access to quality health care in rural communities”
Non RHC Services• Hospital Visits- Billed to Part B• DME- Must have a DME Provider number• Part D Drugs- www.mytransactrx.com
•
“Dedicated to providing access to quality health care in rural communities”
ABNs
“Dedicated to providing access to quality health care in rural communities”
Lab Charges• Must be able to furnish these 6 tests onsite
o Blood Sugaro Pregnancy Testso Primary Culturing for transmittal to a certified labo Hemoglobin or hematocrito Exam of stool specimen for occult bloodoChemical exam of urine by stick or tablet or both
“Dedicated to providing access to quality health care in rural communities”
How to Bill Labs• All lab charges should be billed on a HCFA 1500 and
Billed to Part B with your Group Information.
“Dedicated to providing access to quality health care in rural communities”
Procedures• EKGs: 93000 vs 93005, 93010 (93005 should be
billed to Part B and 93010 should be billed to Part A)
• X-rays (Technical goes to Part B, Professional Part A)
“Dedicated to providing access to quality health care in rural communities”
Claim Example
0521 Office Visit 99213CG $225.00 ($175.00)
0521 EKG 93010 $50.00
“Dedicated to providing access to quality health care in rural communities”
Preventive Services• Preventive services can be stand alone visits or billed
with another visit. • https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf
“Dedicated to providing access to quality health care in rural communities”
Deductible/Coins Waived
“Dedicated to providing access to quality health care in rural communities”
Initial Preventive Exam
Procedure Code Description Paid at the AIR Eligible for Same Day Billing
Coins/Deductible Applied
G0402 Initial Preventive Exam
Yes Yes Waived
“Dedicated to providing access to quality health care in rural communities”
Annual Wellness VisitProcedure Code Description Paid at the AIR Eligible for Same
Day BillingCoins/Deductible Applied
G0438 Initial Visit Yes No Waived
G0439 Subsequent Yes No Waived
“Dedicated to providing access to quality health care in rural communities”
ScreeningsProcedure Code Description Paid at the AIR Eligible for Same
Day Coins/Deduct Applied
G0101 CA Screening. Pelvic/Breast
Yes No Waived
Q0091 Obtaining Pap
Yes No Waived
“Dedicated to providing access to quality health care in rural communities”
Claim Examples• Preventative services with an Office visit.
“Dedicated to providing access to quality health care in rural communities”
Two Visits on the Same Day
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1611.pdf
“Dedicated to providing access to quality health care in rural communities”
Claim Example
0521 Office Visit
99213CG25 or 59 175.00
0521 Office visit 99215CG 250.00
“Dedicated to providing access to quality health care in rural communities”
Claim Example
0521 Office Visit 99213CG25 275.00 (175.00)
0521 Procedure 12001 100.00
“Dedicated to providing access to quality health care in rural communities”
Claim Example
0521 Office Visit 99213CG25 $175.01 ($175.00)
0521 Procedure 12001 $0.01
“Dedicated to providing access to quality health care in rural communities”
Influenza and Pneumonia Vaccines• Should be put on your Shot Log and submitted as
part of your cost report. Do not submit on a claim.
Patient NameHealth Insurance Number
Date of Service
Donald Duck 123456789A 10/15/2017
Daisy Duck 987654321A 10/15/2017
“Dedicated to providing access to quality health care in rural communities”
Chronic Care Management• Patient must have 2 or more chronic conditions• Patient has to agree to service and can cancel
anytime. • Care plan developed as either a part of the Annual
Wellness Exam or other face to face visit. • Requires: EHR, Documented Care plan• 20 minutes of documented clinical time
“Dedicated to providing access to quality health care in rural communities”
Chronic Care Management• Coinsurance and Deductible Apply• Procedure Code is billed as 99490• Billing Date can be the day the 20 minutes is met or
anytime after that but must be before the end of the month
• Diagnosis code(s) billed should reflect the chronic condition that the patient has.
“Dedicated to providing access to quality health care in rural communities”
Advanced Care Planning• Stand alone service or billed with Annual Wellness
Visit. • Explanation and discussion of Advanced Directives
such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional.
“Dedicated to providing access to quality health care in rural communities”
Advanced Care Planning• 99497 for the first 30 minutes• 99498 for additional 30 minutes
Deductible/Coins Applied
Deductible/Coins Not Applied
AWV and ACP XXACP XXSick Visit and ACP
XX
“Dedicated to providing access to quality health care in rural communities”
Telehealth Services• RHCs may only serve as the “originating” site• Billable as the only service or as an additional service
with another visit• RHCs cannot be the “consulting/distant” site• Billed with 0780 Revenue Code with Q3014
“Dedicated to providing access to quality health care in rural communities”
Hospice Services• Can treat a patient for Non-Hospice Diagnosis• If treating for Non-Hospice Diagnosis then 07
condition code must be applied to the claim• If provider is treating for Hospice related diagnosis
then claim should be billed to hospice company or adjusted. Claim cannot be billed to Part B.
“Dedicated to providing access to quality health care in rural communities”
Questions??
“Dedicated to providing access to quality health care in rural communities”
Contact Information107 Saluda Pointe DrLexington, SC 29072Phone: 803-454-3850Fax: 803-454-3860chambers@scorh.net
http://www.scorh.nethttp://twitter.com/scruralhealthhttp://www.facebook.com/SCORHhttp://www.youtube.com/user/scruralhealth
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