Nebraska Rural Health Association RHC Group By Janet Lytton, - - PowerPoint PPT Presentation

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Presented on Behalf of

Nebraska Rural Health Association RHC Group

By

Janet Lytton, Director of Reimbursement Rural Health Development 308-647-6455 janet.lytton@rhdconsult.com April 16, 2016

 Difference between Independent vs Provider Based  Specialists in the RHC  RHC, nonRHC services and locations  Bundling of “incident to” services  Exceptions for more than 1 visit per day paid

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 Understand how to bill:

 Mental Health (Behavioral Health) Billing  Preventive Services  Telehealth Services  Hospice Services  Medicare Secondary claims

 Claim form Completion and revenue codes used

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• Medicare Pt A = Hospital Service charges
• Most Patients receive these benefits without additional premium
• Medicare Pt B = Professional service charges
• Patients have choice of participating in Medicare Pt B benefits
• Additional premium for most of $104.60 (2016)
• RHC Services are professional services paid using Medicare Pt

B eligibility, but paid through Medicare Pt A Payer

• Any DME supplies are only payable through DMERC
• Any Medicare Pt D Drugs are payable through the

patient’s Pt D plan

• Medicare Pt C (Medicare Advantage) is outside the

traditional Medicare coverages

• Plans can set equal to or greater benefits for patients

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• Patient Deductible = $166 per year
• IRHC Rate = $81.32/visit
• PBRHC PPS Hospital Rate = $81.32/visit
• PBRHC <50 bed hospitals = No limit

 An RHC is a certification from CMS that allows

physician practices to qualify for cost-based reimbursement from Medicare and Medicaid

 4,100 RHCs across the country out of 230,187

physician practices (1.7%)

 Who are the RHCs in your State?

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ rhclistbyprovidername.pdf

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 CMS has an “RHC

Fact Sheet”

http://www.cms.gov/Outrea ch-and-Education/Medicare- Learning-Network- MLN/MLNProducts/downlo ads/ RuralHlthClinfctsht.pdf 6 pages of information

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• Independent Rural Health Clinic
• Owned by any person that State allows
• I.e. Physicians, NPs, PAs, Hospitals, or anyone allowed
• Individual practitioner(s)
• Can be sole proprietor, partnership, corp. or LLC
• Completes the IRHC cost report each year
• Provider Based Rural Health Clinic
• Owned by a Hospital, Skilled Nursing Facility or a HHA
• Treated as a department of the parent facility
• Generally within a 35 mile radius of the parent facility
• Integrated financials
• Access to medical records between departments
• Cost report completed as part of the “parent” cost report

 State Operations Manual—Conditions for

Certification

 Compliance with Federal, State, and Local Laws  Location of Clinic  Physical Plant and Environment  Organizational Structure  Staffing and Staff Responsibilities  Provision of Services  Patient Health Records  Program Evaluation

Appendix G – Guidance to Surveyors: Rural Health Clinics (RHCs) – (Rev. 1, 05-21-04)

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• Survey for Certification as an RHC
• Initial Survey
• Periodic Surveys
• Complaint Surveys
• Surveys after Initial
• Typically every 5 years but may be longer
• Not necessarily after a Change of Ownership but maybe
• Deficiency Statement
• Plan of Correction

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• Must be in a “rural” area
• Population of 50,000 or less and in a
• nonmetropolitan area (last census determines)
• Would lose RHC designation if Clinic falls out of

“rural” designation

• Must be in a “shortage” area
• Currently do not lose RHC status if area is not in a

current shortage area

• Keep up-to-date knowing if your area is designated
• If moving clinic, assure site is still in a shortage area

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• RHC must be located in a healthcare shortage

area

• Health Professional Shortage Area (HPSA)
• Medically Underserved Area (MUA)
• Medically Underserved Population does not meet the

shortage area designations (MUP)

• Governor’s list of Healthcare Shortage Areas
• Check website:
• http://www.hrsa.gov/shortage/find.html
• Search to find your area as either a HPSA or MUA
• Check the State website for governor’s list of

shortage areas

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• Scope of Practice
• Follows State’s Medical Practice Act
• Have written delineation of duties for PAs and NPs
• Providing RHC Services
• Medical Services that are normally performed in a

physician clinic

• RHC must be “primarily engaged” in RHC services at

least 51% of the total operating schedule

• Patient Care Policies
• All policies signed off by providers and Governing body
• Description of services—direct and indirect services

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• Patient Care Policies (continued)
• Guidelines for medical management of patients
• Regimens to follow and conditions that are treated
• Describe medical procedures allowed by NP, PA or CNM
• Describe medical conditions that require

consultation/referral

• Drugs and Biologicals
• Policies on storage of drug—humidity, temp, light, etc
• Policies on outdated, deteriorated or adulterated drugs
• All drugs locked; all narcotics double locked & counted
• Have current drug references and antidote information
• Prescribe and dispense in compliance with State law

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• Review of Policies
• Patient Care Policies reviewed by professional personnel

at least annually and documented

• Keep all prior outdated policies on file
• Direct Services
• Required Services
• Diagnostic Examination
• 6 Basic Laboratory Services (CLIA Waived Certificate)
• Emergency treatments

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• Records System
• Written Policies on Maintenance of Records
• Responsibility of Designated Professional
• Record on Each Person Receiving Healthcare Service
• Records kept onsite
• Review of records Required
• Protection of Records
• All Must Be Kept Secure
• Release of Records Policies
• Required Services
• Retention of Records
• Federal Law States at least 6 years from last entry or longer

if State Requires; or 6 years after age of majority

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• Evaluation of Clinic’s Total Operation
• Must be Completed Annually by the “Advisory Council”
• Must include one “third party person” on Council
• Not All Have to be Completed at the Same Time by the

Same Staff

• Written Report of Annual Evaluation Required
• Annual Review Must Include
• Review of Services Provided to Include Numbers of

Patient Services and What Services Provided

• Review of Records to include Active and Closed Charts
• Review of All Policies and Procedures and changes made

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• Medicare Benefit Policy Manual Ch 13 – RHC and

FQHC Services Rev 220, 1/15/16 https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/bp102c13.pdf

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• Independent RHC Billing
• RHC claims sent to the Medicare payer assigned in the

past or if new RHC, will be with your local MAC

• IRHCs are capped at $81.32 per visit 2016, (1.1% increase
• ver 2015, $80.44)
• All professional services in Clinic, SNF, NH, AL, Home, at

scene of an accident

• Completes a cost report each year, CMS 222-92
• nonRHC services sent to Medicare Pt B MAC
• IP, OP, ER, OBS Bed, TCs of screening and diagnostic tests, i.e.

EKG tracing, x-ray TC

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• Provider Based Billing
• RHC claims sent to Medicare payer of “Parent” facility
• If PBRHC part of a <50 bed hospital, no cap on rate
• If PBRHC part of a >50 bed hospital, capped at IRHC rate
• Many times these will be set up as IRHCs
• PBRHC a section of the Hospital cost report
• nonRHC service claims sent through hospital OP #
• TCs, i.e. EKG Tracing, X-ray TC; labs
• nonRHC service claims sent to Medicare Pt B
• IP, OP, ER, OBS Bed
• Exception for CAHs Method II as OP, ER, OBS Bed professional

services submitted by Hospital on their claim—15% additional reimbursement

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• Physicians—M.D. or D.O.
• Family Med; Internist; Pediatric; OB/GYN; Gerontology
• Physician Assistants
• Nurse Practitioners, Certified Nurse Midwife
• Psychologists (phD) & LCSW (Masters level w 2 yrs)
• Must be licensed in the State providing the services
• Specialists
• Must be < 50% of total visits (includes mental health srvs)
• IF specialist is a provider of the RHC, then RHC visits
• Specialist is paid through the RHC
• IF visiting specialist “periodically” in the RHC and:
• Not paid through the RHC
• Billing is separate from the RHC billing
• Typically pays a rental/lease fee for space/supplies used

• RHC Services (Sec. 50.1 of RHC Benefit Manual)
• 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
• Hepatitis C screenings
• IPPE
• AWV
• All Medicare-covered preventive services
• All Services paid based on RHC AIR (all inclusive rate)

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• Non RHC Services (Sec. 60.1 of RHC Benefit Manual)
• MCR excluded services, i.e. routine physical check-ups,

dental, hearing & routine eye tests

• Technical component of an RHC service (i.e. x-ray, EKG)
• Laboratory Services (does not include venipuncture)
• DME, Prosthetic devices, Braces
• Ambulance Services
• Hospital Services, ASC, Medicare Comp. OP Rehab Fac
• Telehealth distant-site services
• Hospice Services (if for DX of hospice)
• Group Services
• All costs associated with nonRHC services are

disclosed on the annual cost report

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Statutorily Noncovered services do not require an Advanced Bene Notice, however encourage one for PR reasons.

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If all charges are noncovered, send 710 TOB with all charges as noncovered and condition code 21.

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If only some of the charges are noncovered, per CMS Internet-Only Manual, Publication 100-4, Ch 1, Sec 60.4.3, "... all of a bundled service must be billed as noncovered, or none of it. Therefore, as long as part of a bundled service is certain to be covered or medically necessary, billing the entire bundled service as covered is appropriate."

• Nurse service w/o face-to-face visit or “incident to”

visit

• I.e. allergy injection, hormone injection, dressing

change, venipuncture

• A 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

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• 80.1 – Charges & Waivers
• Must charge all patients the same rates
• Copays and Deductibles apply within the RHC
• May waive copays and deductibles only after good faith

determination made that patient 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 patient
• Copies of wage statements or income tax return not

required

• Self-attestations are acceptable
• Is required if using National Health Service Corp provider

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• 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
• r 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.

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• 90 – Commingling (con’t)
• If RHC leases/rents space, all costs must be offset by

the fees paid or costs must be deducted from C.R.

• Does not prohibit provider going to hosp for

emergencies

• Must follow schedules for hospital and RHC time
• Hours of operation must be clearly stated on signage

visible from outside of RHC. Show RHC and nonRHC hours

• If a RHC practitioner furnishes a RHC service at the

RHC during RHC hours, the service must be billed as a RHC service. The service cannot be carved out of the cost report and billed to Part B.

• 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”

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• Routine INR visit for lab
• Simple suture removal
• Dressing change
• Results of normal tests
• Blood pressure monitoring
• Allergy Injections
• Prescription service only

• Significant, separately identifiable E/M service by

same provider on the same day of a procedure

• r other service.
• Append to E/M code , I.e. 99214-25
• 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.

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• 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.

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MEDICARE: Must file claims within one year from date of services—effective 3/23/10. I.e. January 1, 2015 must be filed by Dec 31, 2015 NE MEDICAID: Must file claims within 6 months from date of service I.e. January 1, 2015 must be filed by June 30, 2015

• 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
• f what service to bill to which payer is

imperative

• Some CPT codes will have to be “split” billed,

i.e. EKG tracing and interp, x-ray prof & tech components

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