Clinical Integration Beyond the Basics By Janet Lytton, RHIT, Director of Reimbursement

1. Clinical Integration Beyond the Basics By Janet Lytton, RHIT, Director of Reimbursement Rural Health Development P.O. Box 487, Cambridge, NE 69022 308-647-6455 janet.lytton@rhdconsult.com June 2012

2. OBJECTIVES Participants will understand: What services are required of the RHC What services may be added without being part of the RHC What services can be added that may serve beneficial to the RHC

3. RHC Services Services typically provided in a physician’s clinic i.e. Family care Pediatrics Gerontology OB/GYN Internal Medicine

4. RHC Services Six Basic lab tests Hemoglobin or Hematocrit; dipstick UA; blood glucose; pregnancy test; hemoccult; transfer of ultures Nursing services if have designation of a HHA shortage area Coordination of services beyond the RHC, i.e. IP Hosp Specialists Home Health

5. RHC Places of Service In the Office In the patient’s home In the Nursing Home or Skilled Nursing Home Must be your clinic patient or a new patient to your clinic Does not have to be in same town or county At the Scene of an Accident In area designated as HHA shortage area (special designation by CMS) **All Services must be “reasonable and medically necessary”

6. SO….WHAT CAN WE DO? THINK OUTSIDE THE BOX!

7. WHAT IF SPECIALISTS? Can “rent/lease” space to the Specialist Must be at fair-market value Money received is offset of an expense on Cost report Perhaps offset of your rent/lease Or, utilities If use your nursing staff must have a payment method for this The Specialist does his/her own billing Have an agreement as do not want to get into any “Stark” violations

8. ADD A SURGEON? Can be an RHC Provider Pre and Post visits are RHC visits/services When billing as an RHC it is a facility billing Surgery in Hospital setting Procedure only is charged When billing in the Hospital, it is the provider billing Surgical Procedure only is charged & billed Some smaller procedures may be performed in RHC Compare the Medicare fee schedule with the facility fee schedule to determine Don’t forget the 20% co-pay amount And the charge is the Private Pay fee schedule

9. ADD OB/GYN? Can be an RHC Provider Clinic visits are each RHC visits/services Delivery only is billed as hospital service Medicaid is determined by State policy Many pay same method as Medicare PP payment method would not change Many female patients may prefer OB/GYN Maintenance exams Some smaller procedures may be performed in RHC Analyze utilization to determine how reimbursement would compare in the clinic setting as compared to the hospital setting

10. OTHER EXPANDED SERVICES LABORATORY Laboratory beyond the basic 6 tests Many on the waived list OR can be a higher complexity lab PBRHC lab services are billed as if done in the hospital setting—no change in reimbursement IRHC bills Part B for all lab services Paid on the Medicare Physician Fee Schedule

11. OTHER EXPANDED SERVICES RADIOLOGY Not required in the RHC Can be part of the RHC Carve out of personnel and supplies Split billing with TC sent to Part B and interp as part of the RHC visit PBRHC TC billed as if performed in the hospital setting and interp as part of the RHC visit

12. OTHER EXPANDED SERVICES MAMMOGRAPHY Mammography services Preventive service paid by Medicare 77057 $43.35 TC, $33.36 Interp G0202 $99.10 TC, $33.46 Interp Split billed for TC to Part B and interp as RHC service w/ or w/o visit but must show HCPCS code on claim This example is Medicare fee schedule, and your charge would be the PP fee schedule for the professional services (Interpretations)

13. OTHER EXPANDED SERVICES ULTRASOUND Ultrasound Services Split billing with TC sent to Part B and interp as part of the RHC visit Analyze the costs of equipment and the number of procedures that could be generated IRHC – Carve out of the nonRHC equipment and time of tech PBRHC – Billed as if performed in the hospital setting by TC billed from hospital and interp is part of the Office Visit Clinic Payer mix may determine the feasibility of offering Ultrasound in the clinic setting

14. Behavioral Health Services Clinical Psychologist (PhD) Clinical Social Worker (CSW) Huge deficit in availability of services Reimbursement increasing to be 80/20 Medicare payment by 2014 (as shown on next slide) Use 900 revenue code to bill therapeutic behavioral health The first visit of the provider to determine need for behavioral services is an RHC visit, then behavioral health services apply

15. Behavioral Health Services 2009 = 50% Co-Insurance due 2010 = 45% Co-Insurance due 2012 = 40% Co-Insurance due 2013 = 35% Co-Insurance due 2014 = 20% Co-Insurance due *Per Medicare Improvements for Patients and Providers Act of 2008

16. Telehealth Services Must be set up as a site for telehealth Many clinics have this capability and more are being added Bill with Revenue Code 780 Q3014 code is paid separately from all- inclusive rate at the Medicare Phys Fee Schedule Bill for transmission fee MUST put the Q code on the claim

17. DENTAL SERVICES • Add Dental Services with the Dentist renting space. • May be beneficial since more are moving to “the medical home” concept • The RHC will be recognized more and be convenient for patients to utilize • Don’t set up as an RHC service as Dental is not a payable service in the RHC

18. PHARMACY SERVICES • Pharmacy in same building or very close • Can have rented space to pharmacy • Could be right next door to pharmacy • Some States allow pharmacy directly in the clinic

19. What if RHC loses their PA or NP? Must meet staffing compliance within 90 days If > 60 days, contact State and apply for MLP waiver Can operate 1 year as an RHC while recruiting If unsuccessful, may have to adjust your schedule Set X hours per week as nonRHC to continue as an RHC Continue to recruit to be able to be an RHC 100% of time May want to do the higher end procedures on the nonRHC hours and bill to Part B There will be a nonRHC carve-out associated with the X amount of time as nonRHC, i.e. 1 day nonRHC and 4 days RHC, then 20% of certain costs will be a carveout.

20. Websites of Interest www.cms.gov/ www.cms.gov/MLNProducts/downloads/RuralHlthClinfctsht.pdf www.cms.gov/Manuals/IOM/list.asp www.narhc.org Rural Health Development Website & my e-mail: www.rhdconsult.com janet.lytton@rhdconsult.com

21. Questions ? ? ? ? ? ? ?