NE Rural Health Association Certified Rural Health Clinics Rural Health Clinic Billing & Coding Janet Lytton, Director of Reimbursement Rural Health Development 308-647-6455 email@example.com Kearney, NE April 15, 2014
OBJECTIVES Changes in CMS RHC billing regulations; Understand the impact of CMS changes to the RHC Understand the general billing and many billing "challenges“ Q & A
RHC MEDICARE BENEFIT POLICY Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 166 issued 1/1/13, effective 3/1/13 MM8504 issued 11/22/13 updates effective 1/1/14
RHC STAFFING 30.1 - RHC Staffing MUST employ NP or PA (W-2 or owner) NP, PA or CNM at least 50% of clinic hours A Locum Tenens NP or PA would not meet reg It has been proposed to allow contract services to meet this regulation, however, it has not be approved
RHC UPDATED REGULATIONS 40.1 – RHC Visit Location Clinic, Home, ALF, NF, SNF Any location except IP or OP hospital or CAH Medicare IP Rehab Fac; Hospice Facility In a location other than the RHC if: Practitioner is compensated by the RHC Cost of service is included in the RHC cost report 40.2 - RHC is required to post hours of operations All services during scheduled hrs are RHC services It was discussed to have clear schedules Cannot rotate from clinic to hosp during RHC hrs
Medicare Part A Revenue Codes 521 Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All services and CPT codes, I.e. drugs, supplies, are bundled with the visit code charges, your system will have itemized
RHC UPDATED REGULATIONS 40.3 – Multiple Visits Same Day, Payable if Patient has second visit for additional DX A medical visit and a mental health visit same day IPPE and Medical Visit and Mental Health Visit (up to 3) AWV and a Mental Health Visit Clinic visit and Hosp admit is per your MAC WPS & Cahaba will allow if medically necessary
RHC UPDATED REGULATIONS 40.4 – Global Billing All procedures in the RHC are not subject to Globals If RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 mod If RHC provperforms hospproc, bill w/54 mod, and then bill each visit at clinic level as not in global Services never included in global surgical package Initial visit to determine surgery required Visits unrelated to DX for surgical procedure Treatment for underlying condition or an added course of treatment which is not part of normal recovery 40.5 – 3-Day Payment Window RHC services are not subject
RHC UPDATED REGULATIONS 50.1 – RHC Services Physician Services & services & supplies incident to NP, PA, CNM Services & services & supplies incident to CP and CSW Services & services & supplies incident to Visiting Nurse services in HHA shortage area Medicare allowed Preventive Services Influenza, Pneumococcal & Hepatitis B Vaccinations IPPE AWV All Medicare-covered preventive services
Medicare RHC Covered Services E & M services Procedures Professional Component of diagnostic tests Injections Dressings Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals not separately billable for RHCs but indirectly paid CMS Manual 100-02 Chapter 13 Section 50
GLOBAL BILLING 40.4 – Global Billing All procedures in the RHC are not subject to Globals If RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 mod If RHC provperforms hospproc, bill w/54 mod, and then bill each visit at clinic level as not in global Services never included in global surgical package Initial consultation Visits unrelated to DX for surgical procedure Treatment for underlying condition or an added course of treatment which is not part of normal recovery
RHC UPDATED REGULATIONS 50.3 – Emergency Services Neither IRHCs or PBRHCs are subject to EMTALA Must have drugs & biologicals commonly used in life-saving procedures 60.1 - Non RHC Services MCR excluded services, i.e. dental, hearing & eye tests Technical component of an RHC service Laboratory Services DME, Prosthetic devices, Braces Ambulance Services Hospital Services, ASC, MCORF Telehealth distant-site services Hospice Services (if for DX of hospice) Auxiliary Services, i.e. language interp, transp, security
RHC UPDATED REGULATIONS 80.1 – Charges & Waivers Must charge all patients the same rates May waive copays and deductibles after good faith determination made that pt is in financial need but cannot be on a routine basis (42 U.S.C. 1320a7a(6)(A)) 80.2 – Sliding Fee Scale Not required, but may have Must be applied to all patients Policy must be posted If based on income, must document that info from pt Copies of wage statements or income tax return no required Self-attestations are acceptable
RHC UPDATED REGULATIONS 90 – Commingling Sharing space, staff, supplies, equipment and/or other resources with an onsite Medicare Pt B or Medicaid FFS practice operated by the same RHC providers. Commingling is prohibited to prevent: Duplicate reimbursement or selectively choosing a higher or lower reimbursement rate for services May NOT furnish RHC services as a Pt B provider in the RHC or in an area outside the RHC such as a treatment room adjacent to the RHC during RHC hours of operation If RHC is in the building with another entity the RHC space MUST be clearly defined. If RHC leases/rents space, all costs must be offset by the fees paid Does not prohibit provider going to hosp for emergencies Must follow schedules for hospital and RHC time
PHYSICIAN SUPERVISION 120.2 – Physician Supervision At least one supervisory visit every 2 weeks onsite CMS has a proposed rule submitted in the Feb 7 Federal Register to allow the off site reviews to be completed, but as off today, the regulation has not been changed. It is expected that by the end of the year, these proposals will be put in place.
HOSPICE SERVICES 200 – Hospice Services Can treat Patient for condition not related to hospice DX, must use a condition code of 07 on claim to be paid If treat hospice ailment, cannot bill for visit, even if medically necessary and must look to the hospice company for payment or write off. Cannot send to Pt B. CMS has asked for methods to allow for these services to be billable but at this time, they are not. Providers should coordinate care with the Hospice Co.
RHC UPDATED REGULATIONS 210 – Preventive Health Services Only the professional services are billed as RHC TCs are billed as nonRHC Must use the appropriate G-codes Flu and Pneumo Vaccines Hepatitis Vaccines Many preventive services have no copay or deductible Diabetes Counseling and Medical Nutrition Services Not separately billable but “incident to” service Costs allowed on the cost report
2014 Medicare Rates Patient Deductible = $147 per year IRHC Rate = $79.80/visit PBRHC PPS Hospital Rate = $79.80/visit PBRHC <50 bed hospitals = No limit
Forms & Paperwork Required Consent to be treated Authorization to Bill HIPAA Privacy notification Medicare Secondary Payer Questions asked (keep 10 yrs) Pub 100-5 Chapter 3, section 20 Required each time the patient presents to the clinic ABN issued if applicable Given when service does not meet medical necessity Routine services contractually non-covered do not require an ABN, I.e. physical, can use the NEMB form Surgical Consent Coordination of Benefits Customer Service for CWF 1-800-999-1118 8 am–8 pm EST TDD 800-318-8782 Beneficiaries, providers, attorneys, third party payers
Patient RecordS All billable services must be documented in the patient record to support billing of procedures and E & Ms Each service must be specific CBC is only a CBC, not CBC with differential Injection given must be ordered in chart and also noted as given by the nurse Lesions must be noted as to size, number, method of removal, closure method Follow-up or plan with patient instructions must be documented If more than one visit per day, document date and time If counseling is reason for visit, then time in and out can be used to determine E & M Level
PATIENT RECORDS All pages of the Medical Record must have patient identifier All Reports must be reviewed and signed off with patient receiving results that is documented All documentation must be authenticated Signature Electronic signature – affirmation and password protected—DO NOT leave screen on when leave room Stamped signature is not allowed (CR5971, SE0829) with the exception for a provider that is disabled and cannot sign his/her name
Coding Levels of Care DOES IT MATTER HOW WE CODE A VISIT? Patient payment is affected Medicare considers OVER CODING as a violation of the fraud and abuse regulations because of the additional reimbursement Medicare considers UNDER CODING as a violation of the fraud and abuse regulations because it encourages patients to overuse the clinic
CPT Procedure Codes All Procedure Codes that are normally performed in a physician’s clinic are applicable in the RHC If your coder is also your biller, the knowledge of what service to bill to which payer is imperative Some CPT codes will have to be “split” billed, i.e. EKG, xray prof & tech comp
Productivity Standards Physician FTE (Full Time Equivalent = 40 hrs/wk, 52 wks/yr or 2080 hrs year) 4,200 visits per each FTE PA, NP, CNM 2,100 visits per each FTE VISITS OF ALL PAYER CLASSES ARE COUNTED TO DETERMINE PRODUCTIVITY STANDARD
What is a Visit? Face-to-Face with the Provider Physician, PA, NP, CNM Clinical Social Worker or Clinical Psychologist Medically necessary Does it require the skills of a Provider? Payer Class All payer classes are counted in the total visit count Place of Service Clinic, Home, NH, SNF/SW B, Scene of Accident Level of Service All levels apply, to include procedures To include all services “incident to”
Medicare RHC Covered Services E & M services Procedures Professional Component of diagnostic tests Injections Dressings CMS Manual 100-02 Chapter 13 Section 50
RHC Covered Services Physician services NP, PA & CNM services Services & Supplies incident to provider service Diabetes self-management training services and medical nutrition therapy services for diabetic patients provided by registered dietitians or nutritional professionals not separately billable for RHCs but indirectly paid Visiting nurse services in non HHA area Clinical psychologist & clinical social worker CP & CSW supplies & services “incident to”
NonCovered as RHC Services (Covered if Billed to Correct Payer) Hospital patient services Lab tests (except venipuncture is part of Visit) Part D Drugs & Self administrable drugs DME Ambulance services Technical components of diagnostic tests i.e. xrays & EKG, Holter Monitoring Technical components of screening services i.e. screening paps/pelvic, PSA Prosthetic devices Braces CMS Pub. 100-02. Ch 13, Sec 60 & 60.1
Medicare Covered But Nonbillable Services Nurse service w/o face-to-face visit or “incident to” visit I.e. allergy injection, hormone injection, dressing change, venipuncture Provider MUST be in clinic to have “incident to” CMS Manual 100-02 Chapter 13 Section 110.2 Telephone services CMS Manual 100-02 Chapter 13 Section 100 & 120 Prescription services CMS Manual 100-02 Chapter 13 Section 100 & 120
Examples of no medical necessity Routine INR visit for lab Simple suture removal Dressing change Results of normal tests Blood pressure monitoring B12 injection Allergy Injection Prescription service only
ACCURATE CODING Compliance Policy Required if practice receives Medicare dollars Levels coded accurately = correct reimbursement Reimbursement difference from a level 3 and 4 of an established patient is approximately 50% more than the lower level charged As an RHC this is important due to the 20% copay based on the actual charge billed for Medicare
Accurate Coding Better documentation does not mean MORE documentation checklists are not always a good practice just because a system is checked it doesn’t mean it was examined If it isn’t documented, it didn’t happen if audited, the record must stand alone - Many times work is done, but no documentation Providers tend to undercode their cognitive services Levels coded accurately = correct reimbursement
E & M Coding Definitions: New Patient Patient who has not had any professional services from that provider or any provider in the same specialty who are part of the same group practice within the past 3 years. If seen in the hospital and then in the clinic and if billed under a different tax ID number, then the patient is considered new; if same tax ID number patient is considered established. Established Patient Patient who has received professional services from the provider or any other provider in the same group within the past 3 years.
E & M Coding Definitions: Preventive CPT codes CPT codes for physical exams based on age Use when patient has no significant complaints or follow up of ailments Medicare does not pay for Preventive physical CPT codes with the exception of the Introduction to Medicare Physical, paps, pelvic, annual wellness visit, PSA, etc. (those listed in the Medicare beneficiary booklet)
E & M Coding Definitions: Time Used to determine E & M Level when counseling and/or coordination of care is >50% Outpatient time is face-to-face time Inpatient time is unit/floor time Must document total time spent in minutes document what the counseling was about and/or what coordination of care was provided State “Counseling or Coordination of care greater than 50%” Counseling can be visiting about ailments, teaching, planning for treatments, etc.
E & M Coding Definitions: Concurrent Care Similar services i.e. inpatient subsequent care, to the same patient by different providers of different specialties on the same day but must be for different problems. Example: Orthopedist seeing patient after knee surgery; family physician seeing patient in hospital for diabetes. As long as different ICD 9 Diagnosis codes, both are allowed when different specialties.
MODIFIER -25 Significant, separately identifiable E/M service by same provider on the same day of a procedure or other service. Append to E/M code , I.e. 99214-25 (in system only) Use Modifier 25 when one of the following criteria is met: Visit for a problem unrelated to the procedure Visit for a new problem or a problem that has changed significantly and requires re-evaluation before performing the procedure. Visit for the same problem in different sites; one treated surgically and one treated medically.
EXAMPLES OF MODIFIER -25 Visit for a problem unrelated to the procedure or service Preventive Care Visit = patient seen for annual physical E/M service = Patient also c/o leg pain, swelling and hot spot. Evaluated for phlebitis Supporting Documentation E/M documentation identifiably distinct from procedure documentation Must meet ALL requirements for E/M visit along with documentation of procedure.
Medicare Part A Billing RHC Services UB 04 form or 837i electronic format Bill Type 711 Revenue Codes (NO CPT CODES ON CLAIM) Exception when billing preventive services Sent to Fiscal Intermediary Claims for all RHC visits Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident Actual charges billed
Medicare Part A Revenue Codes 521 Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All drugs& supplies, are bundled with the visit code charges in the Revenue Codes shown above
Timely Filing MEDICARE: Must file claims within one year from date of services—effective 3/23/10. I.e. August 1, 2012 must be filed by July 31, 2013 MEDICAID: Must file claims within 6 months from date of service—effective 9/1/13 PB 13-50 I.e. Sept 1, 2013 must be filed by Feb 28, 2014
Medicare RHC Provider Number RHC office visit services Excludes all labs, x-ray TC & EKG Tracing, any TC Includes venipuncture effective 1/1/14 Billed to the FI, UB04 Form or electronic Paid on the clinic’s “all inclusive rate” All Medicare coverage rules apply Reasonable & necessary Allowed preventive is covered, I.e. pap, PSA
Medicare Part B Provider Number (IRHC) All labs, x-ray TC, EKG tracing, any technical components (venipuncture is part of the office visit bundled service) All hospital services (IP, OP, ER, OBS) Billed to WPS/MAC, HCFA 1500 Form Paid on the Medicare Pt B fee schedule
Medicare Part B Provider Number (PBRHC) All hospital services (IP, OP, ER, OBS)* Billed to WPS MAC, HCFA 1500 Form Paid on the Medicare existing fee schedule * The only exception is if the CAH is Method II reimbursement; then the OP, ER & OBS professional component is part of the hospital’s claim.
PBRHC - Hospital OP Provider Number ALL Laboratory performed in the RHC, including 6 basic tests (venipuncture is part of the office visit bundled service) Billed using 141 bill type for PPS Hospitals CAH 851 bill type For any facility owned by CAH or CAH employee performing Technical Component X-ray EKG Holter Monitor All TC’s Billed using 131 bill type for PPS Hosp All TC’s Billed using 851 bill type for CAH Paid on the Medicare Pt B Fee Schedule
PBRHC - Hospital OP Provider Number CAH Method II Hospital bills for both the professional and technical component when performed in the hospital setting: X-ray EKG Holter Monitor ER OP/OBS/ASC Must have separate line item for the prof service Paid on the Medicare Pt B Fee Schedule + 15%
State Medicaid RHC/nonRHC Billing Each State Medicaid is specific as to their State requirements—50 states, 50 plans May use either the 1500 or UB04 Managed Care Plans have choice as well Coverage is specific to each state Most States require both RHC and nonRHC Medicaid provider numbers Paid on the RHC rate or a PPS rate NE has transitioned to Managed Care Payers
NE Medicaid Each Managed Care Payer (MCP) can require either/both—UB04 or 1500 All Services for the Managed Care patients are sent to the MCP—nothing sent to DHHS MCP can determine how to bill and how to pay claims MCPs are given RHCs facility specific payment rates to assure MCP is paying the most current rate—RHC Medicaid year is 7/1 through 6/30 each year
NE Medicaid Must have RHC and nonRHC number Form for each is per the Managed Care Payer Ailments are RHC services Preventive services are nonRHC services IRHCs receive 100% of their Medicaid PPS rate PB of <50 bed hosp receive 100% of their actual charges PB of >50 bed hosp receive 100% of MCD PPS rate Must send in a copy of your Medicare CR annually as is a Federal Requirement With PPS payments there are no cost report settlements
NE Medicaid IRHC RHC services = bundled services—UB04 or 1500 Lab, X-ray TC and EKG tracings are billed on the nonRHC # X-ray PC and EKG interp is part of visit and bundled on the RHC Provider # All preventive, IP, OP, ER, OBS are nonRHC services, billed with nonRHC Provider # OB is global with exception of first visit If only visits, then nonRHC# and list visit dates All surgeries at the hospital have 2 wk global