Indiana Rural Health Association Fall Workshop Rural Health Clinics

1. Indiana Rural Health Association Fall Workshop Rural Health Clinics October 1, 2008

2. Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.hhs.gov.

3. Acronyms

4. Acronyms

5. Objectives • Cover RHC criteria and covered services • Documentation Requirements • To provide the basic requirements for billing RHC Clinic services to Medicare and payment calculations

6. RHC Background • Rural health clinics are located in areas designated both by the Bureau of the Census as rural and by the Secretary of the Department of Health and Human Services as medically underserved population • There is an insufficient number or shortage of needed health care practitioners in the RHC setting

7. Face to Face Encounter • A face to face encounter in an outpatient setting between a patient and a RHC Core Practitioner • An encounter between a clinical psychologist or clinical social worker and a family member only is not billable • Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and location is billed as one unit

8. Face to Face Encounter Exceptions to 1 encounter per day rule • If the patient leaves and later returns the same day with a different illness or impairment requiring additional diagnosis or treatment (medical records must support this), or • The patient has a medical visit and a mental health visit on the same day (CP or CSW)

9. Covered RHC Services • Physician services • Professional services that include diagnosis, therapy,surgery, and consultation • Physician services performed at the clinic are payable only to clinic or center • Physician services away from the clinic are covered services e.g., (patient’s home)

10. Covered RHC Services/Drugs • Covered drugs are furnished by, and incident to, services of physicians and nonphysician practitioners of the RHC IOM Publication 100-2, Chapter 15, Section 50

11. Covered RHC Services/Drugs • Services and supplies incident to a physician’s professional services are covered if they are: • Furnished as an incidental, but integral part of a physician’s professional services • A type commonly rendered either without charge or included in the RHC bill

12. NP, CNM and PA Services • Services are covered if: • Furnished by an employee of the clinic or an individual who receives compensation from the clinic • General (or direct, if State Law requires) medical supervision of a physician • Furnished in accordance with clinic policies and any physician medical orders for the care and treatment of a patient

13. NP, CNM, and PA Services • Practitioners who furnish the service must be legally permitted by state law to perform them in the state in which the service is rendered • Must be of a type that would be covered under Medicare if performed by a physician

14. Services and Supplies Incident to NP, CNM, or PA • To be covered as RHC service/supply must be: • Type commonly found in a physician office • Type commonly rendered without charge or included in the RHC bill • Furnished as a incidental, but integral part of the professional services offered • Furnished under direct supervision of a NP, PA, or CNM, and • In cases of services, furnished by a member of the clinic’s staff who is an employee of the clinic

15. Diabetes Self-Management Training (DSMT) • RHCs can become certified providers of DSMT • Report cost of such services on their cost report • Inclusion in computation of all-inclusive rate • Considered incident to services and do not constitute an RHC visit IOM Publication 100-4, Chapter 9, Section 181 IOM Publication 100-2, Chapter 15, section 300.2

16. Visiting Nurse Services • Visiting nurse services are covered as RHC service if: • RHC is located in a home health shortage area as determined by CMS • Patient is homebound • Patient is furnished part time or intermittent nursing care by a registered nurse, licensed practical nurse or licensed vocational nurse who is employed by the RHC • Services are furnished under a written plan of treatment

17. Clinical Psychologist (CP) Covered Services • CPs may provide the following services: • Diagnostic & therapeutic services that the CPs is legally authorized to perform in accordance with state law and regulation • Services/supplies furnished incident to CPs services (requirements that apply to services incident to a physician’s service) are met and furnished by an employee of the RHC

18. Clinical Psychologist (CP) Covered Services • To be covered the services/supplies must be: • Mental health services that are commonly furnished in CPs’ offices • An integral, although incidental, part of professional services performed by CP, and • Performed under the direct supervision of the CP • Must be physically present and immediately available

19. CSW Services • Covered CSW services are: • The type of services that are otherwise covered if furnished by a physician, or incident to a physician’s service; • Performed by a person who meets the definition of a CSW; and • Not otherwise excluded from coverage

20. Non covered RHC Services • If services are excluded from Medicare they are not covered: • State laws do not supercede this rule • Services perform at the clinic or away from the clinic are payable to the clinic. Services must be billed to the fiscal intermediary

21. Telehealth Services • Originating Site is the location of the beneficiary and is payable in a RHC • Must be located in in a rural HPSA or non-metropolitan statistical area county • Covered services are outlined in Publication 100-2, Benefit Policy Manual, Chapter 15, Section 270.2

22. Documentation requirements • Must be legible • Practitioner’s credentials must be clear to identify as a core practitioner • Beneficiary name present on documentation • A core practitioner co-signing a note of a non billable service is not considered proof that a face to face encounter occurred.

23. Preventive Services • Professional components of preventive services are part of the overall encounter • Associated technical component billed on other type of claims • Vaccines are not reported separately • Influenza virus or PPV • Included on cost report • Hepatitis vaccine reimbursed thru cost report • Not paid at 100%

24. Initial Physical Preventive Exams • Payment for professional services will be made under the all-inclusive rate • Beneficiary CWF records will not be updated to reflect the IPPE exam when it is provided in an RHC • Provider-based RHC bill the technical component of the EKG through your main provider • Bill G0344 with revenue code 52x

25. Inpatients and outpatients of a hospital are not payable to the RHC When an agreement exist that specifically doesn’t compensate the practitioner for hospital services, payment may be sought under Part B of Medicare RHC Services for Hospital

26. SNF’s Part A resident receives services of a physician from an RHC are excluded from consolidated billing provision Effective 01-01-05 RHC Services for Skilled Nursing Facility (SNF )

27. Services Provided by Clinics Which are Non RHC Services • Leg, arm, back and neck braces • Artificial legs, arms and eyes, including replacements if required due to change in physical condition • Services provided in a hospital setting Note: These charges should never be on the RHC claim because they are covered under a different benefit category/ payment method

28. Services Provided by Clinics Which are Non RHC Services • Technical component of the following preventative services: • Prostate cancer screening • Colorectal cancer screening tests • Screening mammography • Bone mass measurements • Glaucoma screening • screening pap smears and pelvic examinations

29. Laboratory Services • Provider Based RHC providers should bill laboratory services through their main provider • The technical component of RHC labs are not considered RHC services

30. RHC Billing

31. Deductible and Coinsurance • The Part B deductible is applied to RHC services • The beneficiary is responsible for 20 percent of billed charges

32. Bill Type and Revenue Codes • Bill type for RHC is 711 • Revenue codes are: • 0900- Psychological services • Use this code for services provided by a psychologist and clinical social worker for treatment of mental illness of a patient

33. RHC Site of Service Revenue Codes Effective 7-01-06 • 0521- Clinic visit by member to RHC • 0522- Home visit by RHC practitioner • 0524- Visit by RHC practitioner to a member in a covered Part A stay at the SNF

34. RHC Site of Service Revenue Codes • 0525- Visit by RHC practitioner to a member in a SNF (no Part A stay) or NF or ICF or other residential facility • 0527- RHC Visiting Nurse Service(s) to a member’s home when in a home health shortage area • 0528- Visit by RHC practitioner to other non RHC site (e.g., scene of accident)

35. Telehealth Services • 0780 - Telehealth services effective April 1, 2005 • Q3014 – Facility fee • Only one encounter (and Telehealth service) will be accepted on a claim per day effective April 4, 2005

36. Billing Manual References • Publication 100-4, Medicare Claims Processing Manual • www.cms.hhs.gov/manuals/IOM/list.asp • Chapter 1 General Billing Requirements • Chapter 2 Admission/Registration Requirements • Chapter 9 RHC & FQHC Manual • Chapter 18 Preventive and Screening Services • Chapter 25 UB04 Claim Completion

37. Vaccines • RHCs do not bill for influenza and Pneumococcal vaccines on the UB-04 • Vaccines and administration is included at cost report time • Hepatitis B vaccine is included at cost report time • No line item specifying the vaccine s/b listed on the claim IOM Publication 100-4, Chapter 9, Section 120

38. Coverable Not Billable Details • There are RHC services that on their own do not generate a RHC encounter • However, these charges can be added to those of the appropriate (previous or subsequent) encounter • The date of the face to face encounter would be used as the single date on the line item billed as one unit • These allowable costs would affect the provider’s future all inclusive payment rate

39. Payment Calculations • Medical Encounter Provider Payment • (Medicare Primary Payer) To Calculate Provider payment is equal to the number of visits times the provider’s all-inclusive payment rate times 80 percent. Each provider has its own specific encounter rate For example: 1 visit x 91.03 (encounter rate) x 80% =$72.82 provider reimbursement

40. Payment Calculations • Mental Health Calculation- coinsurance • Multiply charges for revenue code 900 by 62.5% to calculate recognized charges • Multiply the recognized charges by 20% Example: Revenue code 900 charges($50.00)X 62.5% = $31.25 Then take $31.25 X 20% = $6.25

41. References • IOM Publication 100-2, Chapter 13 • IOM Publication 100-4, Chapter 9 • Code of Federal Regulations 42CFR Sec 405.2400 -405.2472 • SSA 1861(aa), SSA 1861(r)

42. Miscellaneous • Website addresses: • CMS • www.cms.hhs.gov/Manuals/IOM/list.asp/ • http://www.cms.hhs.gov/transmittals/ • Access transmittals • Provider Updates and CMS forms

43. www.NGSMedicare.com • Key features • Personalized portal pages • Searchable Frequently Asked Questions • Events Calendar • Navigational tools • Site Tutorial • Site Map

44. NGS Part A Customer Care • Effective February 1, 2008 • Automated Interactive Voice Response (IVR) Inquiries • Illinois 1-877-309-4290 • Indiana 1-866-419-9462 • Kentucky/Ohio 1-866-289-6501 * IVR Guide Available on website

45. NGS Part A Customer Care • Customer Care Inquiries • Illinois 1-877-702-0990 • Indiana 1-866-758-3856 • Kentucky/Ohio 1-866-590-6703 * If a call is placed to Customer Care number with an issue that should be addressed via the IVR, the call will be referred back to the IVR line

46. Written Inquires • Written CorrespondenceNational Government Services, Inc. P.O. Box 7191 Indianapolis, Indiana 46207-7191 • Written Correspondence form available on the website for all lines of business • Part A, Part B and DME MAC

47. Questions? Thank You