RON L. NELSON, PA PRESIDENT. Health Services Associates, Inc. Website: www.hsagroup.net Email: firstname.lastname@example.org. 2 East Main Street Fremont, Michigan 49412 Ph: 231-924-0244 Fx: 231-924-4882. Understanding Billing Issues. RHC/FQHC Services Part B Services
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RON L. NELSON, PAPRESIDENT Health Services Associates, Inc. Website: www.hsagroup.net Email: email@example.com 2 East Main Street Fremont, Michigan 49412 Ph: 231-924-0244 Fx: 231-924-4882
Understanding Billing Issues • RHC/FQHC Services • Part B Services • Provider Based vs. Independent
RHC Services • Physician Services • PA/NP/CNM • Psychologist • Clinical Social Worker • Services and Supplies “Incident-To” to the above Services
Part B Services • Inpatient – Professional Component • Lab – Technical • X Ray – Technical • Diagnostic – Technical • Radiologist Fees (four walls test applies)
Billing for PA/NP/CNM • Obtain UPIN’s for PA’s, NP’s and/or CNM’s • Medicare Advantage – review how PA, NP, CNM are covered • Medicaid – review participation agreements
Vaccines • Flu • Pneumococcal What information do I need to capture?
Billing for Procedures • Endoscopies • Biopsies • Surgical Procedures (office based) • Commingling – defined How can we correctly carve out procedures?
MEDICAID – What is Covered? • Core Services • Other Services • Managed Care How to analyze its impact
Behavioral Health Services • Clinical Psychologist (PhD) • Clinical Social Worker (CSW) • Initial Diagnostic Visit Paid at 100% • Four walls test applies
Telehealth • Bill to RHC/FQHC Program • Q3014 code is paid separately from all all-inclusive rate • Bill for $20, transmission fee • Real Time Audio/Video Transmission • Separate service not subject to fee schedule restrictions
SNF, Swing Bed Visits • January 1, 2005 - bill all to RHC FI • The requirements for visits are every 30 days (not less than 21 days) • Medical necessity allows acute visits
Billing for Procedures • Endoscopies • Biopsies • Surgical Procedures (office based)
Billing Crossovers • Problems with EOB • How to get Paid • How to Remain Compliant
Provider-Based Issues • Only Visits Billed to Intermediary • Ancillaries Billed Under Hospital Fee Schedule Hospital provider type • Exceptions – CAH – offsite clinics
What constitutes a visit • Face to face encounter a patient and a physician, physician assistant, nurse practitioner, nurse-midwife, or visiting nurse. • Encounters with more than one health professional and/or multiple encounters with the same health profession that take place on the same day at a single location constitutes a single visit.
Pap/Pelvic Bill Professional component to FI under revenue code 521 Bill Technical component to the Part B Carrier See Medi 913-01 Colorectal Screening/Bone Mass/Prostate Cancer Screening Bill Professional component to FI under revenue code 521 Bill Technical component to the Part B Carrier See Medi 799-00 Diabetic Outpatient Self-Management Training Services Not reimbursed by Medicare at this time for services rendered by RHC.
SERVICES RENDERED ON NON-VISITDAYS Can be combined with claims with visits Recommend they be within 30 days List only the date of the visit Show charges for all services Adjustments OK Otherwise, handle thru cost report
LIST ACTUAL CHARGES The RHC should list their actual charge for each service. Do not automatically default to listing the all-inclusive rate amount only.
SIGNATURES MEDICAL RECORDS- ACCEPTABLE- HANDWRITTEN ELECTRONIC STAMPED + HANDWRITTEN UNACCEPTABLE- STAMPED STAMPED + INITIALS CLAIMS- ACCEPTABLE - HANDWRITTEN ELECTRONIC STAMPED “SIGNATURE ON FILE”
Medicare Reimbursement • ONE VISIT PER PATIENT PER DAY WITH FEW EXCEPTIONS • SECOND ENCOUNTER ON SAME DAY MAY BE BILLED IF UNRELATED (SORE THROAT AND BROKEN HAND) • MAY BILL FOR A PART A VISIT AND A PART B non-RHC/FQHC VISIT (HOSPITAL VISIT) ON SAME DAY
Medicare Reimbursement (continued) • Pneumonia and Influenza immunizations • Medicare will pay cost at the end of the year on the cost report. • Cost based reimbursement is two to three times standard payment levels • Do not bill Medicare. The clinic is only required to maintain a log
Medicare Reimbursement (continued) • Pneumonia and Influenza logs required Must include all patients Separate log for pneumonia and for influenza Information needed: • Date of service • Patient name • Patient Medicare number, if Medicare patient
Bonus Payment Non RHC/FQHC Part B Services Health Professional Shortage Area: HPSA Geographic 10% Physician Scarcity Areas: PSA 5% Specialty Physician Scarcity Area: SPSA 5% www.cms.hhs.gov/providers/bonuspayment Apply to physician services – not services provided by non physicians.