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Office of the Governor | Mississippi Division of Medicaid Rural Health Clinic Division of Medicaid Important Information 2013
Kimberley Funchess – Facilities and Transportation Programs RHC basics
Rural Health Clinics • Governing Document: Administrative Code Title 23, Part 212 • Found on Division of Medicaid’s Website: www.medicaid.ms.gov • Reimbursement for RHC Services: Funded by Medicare and Medicaid
Rural Health Clinics Provide to Mississippians: • Primary healthcare • including specialty practice (OB/GYN, pediatric, etc.) • Six specified lab tests required on-site • urine, HGB/HCT, blood glucose, stool, pregnancy, cultures • Supportive services not mandated
Hospital Services • Services provided in an inpatient or outpatient hospital setting are NOT eligible for reimbursement by an RHC provider • These services must be billed by a qualified, eligible provider using his/her Medicaid provider number • Claims billed by an RHC provider with the following places of service will be denied: POS 21 POS 22 POS 23 • Providers employed by an RHC may render services in an inpatient or outpatient hospital, but the services must be billed by the provider, not the RHC
Service Limits • All service limits are applicable • Physician visits • Dental • Vision • Mental Health • Additional benefits are available for beneficiaries who qualify for Expanded EPSDT services. • COE limits apply • COE 029, 031, 051, 54, 045, 088
Prior Authorization • All prior authorization requirements are applicable: • Dental • Expanded EPSDT • Pharmacy • Vision
Documentation • Provider documentation must: • Include complete patient records • Verify appropriate services provided • Include date of service, presenting complaint, findings, treatment rendered, provider signature • Include details such as drug dosages, lab values, radiology reports, etc. • Documentation may be audited by DOM or a contracted entity at any time • Services not documented may be subject to recoupment or further investigation by Program Integrity • Providers referred to a regulatory body may be prosecuted for fraud or suffer monetary penalties
Co-mingling • Definition: • Simultaneous operation of an RHC and another physician practice, thereby mixing the two practices (share hours of operation, space, staff, equipment, supplies, and other resources). • Physicians and non-physician practitioners may not operate private Medicare and Medicaid practice during RHC hours of operation using clinic resources.
Marilyn Dickerson, CPC – Coding Specialist RHC ReimbursementKEY POINTS
RHC Reimbursement • Paid based upon encounter rates • Encounter rates are set for individual providers • One encounter rate per face-to-face visit allowed • Provider must bill encounter code to receive reimbursement • Codes other than encounter codes will reimburse at a rate of zero
Multiple Encounters Same Day • Up to four encounters may be reimbursed for the same date of service • Limited to one encounter for each visit type • Medical • Dental • Vision/Eyeglass • Mental Health • Additional medical encounters may be paid on the same date of service by submitting a paper claim with supporting documentation
Obstetrical Billing Antepartum Visits • CPT codes 99201 – 99215, 59425 and 59426 • Visit 1, 2, or 3 one per visit in 99201 – 99215 range • Visit 4, 5, or 6 use 59425 • Visit 7 or more use 59426 Postpartum visits • When clinic physician is not the delivering physician use 59430 Modifiers • Include modifier -TH with all antepartum, delivery and postpartum codes
Billing Reminders • RHC should not be listed as the servicing provider on the claim • Non-covered and invalid procedure or diagnosis codes will deny if billed • $3.00 copay applies, unless exempted by policy • National Correct Coding Initiative Edits (NCCI) do not apply • 5% assessment does not apply
Additional Billing Informationwww.medicaid.ms.gov/publications.aspx Provider Reference Guide Part 212 – Rural Health Clinics
Shanda Boarden, RN – EPSDT Program EPSDT PROGRAM
Mississippi Cool KidsEarly and Periodic Screening, Diagnosis and Treatment (EPSDT) Secondary Facility Location Requirements
Enrollment Requirements for Secondary Locations • Contact the Bureau of Provider Enrollment at (601) 359-6133 and request to link a secondary location to the primary location’s provider facility group number. • The Bureau of Provider Enrollment will notify the requestor that the secondary location has been linked. It is the responsibility of the requestor to contact the Bureau of Medical Services at (601) 359-5565 to request the MS Cool Kids Secondary Location Form. After receipt and approval the requestor will be notified.
EPSDT Servicing Providers The EPSDT Servicing Provider must be one of the following provider types: • Physician • Nurse Practitioner • Physician Assistant
Equipment, Supplies, and Other Requirements • Pediatric Scales (Balanced) • Adult Scales (Balanced) • Equipment to measure height • Equipment to measure infant length and head circumference • Audioscope or Audiometer, (calibrated annually) • Snellen Eye Chart or Titmus Machine • Plus Lens • Pediatric Blood Pressure Cuff • Anemia testing machine (HCT/HGB) • HCT/HGB equipment calibration log • Ophthalmoscope • Otoscope • Disposable gloves and Sharps container • Urine dipstick for glucose and protein (Expiration Date) • Containers for urine specimen collection
Equipment, Supplies, and Other Requirements continued • Developmental Assessment Tool (Denver Kit or Alternative Supplies) • Gown and Drapes available • Supplies available to obtain necessary lab (Lead, RPR) • Private Medical Record Filing System (HIPPA complaint) • Private Exam Area • Waiting room adequate for isolation of well and sick child • Bathroom and hand washing facilities • Exit doors clearly marked • Handicap Ramp or access • Fire extinguisher • Disaster/Fire plan posted • Administrative Policies, procedure manual, job descriptions