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• 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”•

All Procedure Codes that are normally performed in a physician’s clinic are applicable in the RHCIf your coder is also your biller, the knowledge of what service to bill to which payer is imperativeSome CPT codes will have to be “split” billed, i.e. EKG tracing and interp, xray prof & tech comp

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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 servicesCMS Manual 100-02 Chapter 13 Section 100 & 120

Prescription servicesCMS Manual 100-02 Chapter 13 Section 100 & 120

o Routine INR visit for labo Simple suture removalo Dressing changeo Results of normal testso Blood pressure monitoringo B12 injectiono Allergy Injectiono Prescription service only

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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 and only pays the alloweable G or Q-codes to include: IPPE, paps, breast & pelvic exam, annual wellness visit, PSA, etc. (those listed in the Medicare beneficiary booklet)

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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:

Visit for a problem unrelated to the procedureVisit 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.

(DO NOT use -25 on claim as it means there was a separate visit on the same day for unrelated diagnosis, effective 10/1/16)

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Visit for a problem unrelated to the procedure or service

Preventive AWV = patient seen for annual wellness visitE/M service = Patient also c/o leg pain, swelling and hot

spot. Evaluated for phlebitisSupporting 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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• UB 04 form or 837i electronic format• Bill Type 711• 52X and/or 900 Revenue Code(s) with CPT code

of face-to-face visit with CG modifier and the bundled charges minus any preventive service charges

• All other revenue codes listed on separate lines with CPTs of the “bundled” charge line items

• Charges on subsequent lines must be $.01 or >• Sent to MAC • Claims for all RHC visits

• Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident

521 Office visit in clinic522 Home visit524 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, ALPatient not on a Part A SNF Stay

527 Visiting Nurse Service in a HHA shortage528 Visit at other site, I.e. scene of accident900 Mental Health Services

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052X and/or 0900 with Qualifying Visit code noted with the CG modifier, HCPCS of QVC, total bundled charges of all service lines except preventive codes; separate line for each bundled service with charge > $.01, list each preventive service with HCPCS code and charge.

IPPE requires CG modifier as always a separate payment; any “stand alone preventive service requires CG modifier

Detail of all Revenue codes except the following are allowed:002X-024X, 029X, 045X, 054X, 056X, 060X, 065X, 067X-072X,

080X-088X, 093X, 096X-310XSome common allowed Revenue codes may be:

052X, 0250, 0300, 0420, 0430, 0440, 0636, 0780, 0900 (this is not an all inclusive list)

All HCPCS codes must match Revenue codes used; 0250 does not require any CPT code

* References are CMS CR9269 and SE161150

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The 0521 RC is a total of the services of the day with the otherRCs showing what additional services were performed, copay and deductible will be determined from the 0521 line; 1 AIR paid; if preventive services, these are not bundled, each on as a line item.

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Effective10/1/16, the CG modifier will be attached to the 521 RC and/or the 900 RC line item that is the bundled amount of services. Copay and deductible will be determined from the CG line(s), not the total at the bottom of the claim—1 AIR paid; if both 521 & 900 RC have CG—then 2 AIRs pd; if preventive services performed, these are not bundled, each service is a separate line item. ( Per CMS SE 1611)

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Example of claim effective10/1/16, with both 521, 900 and preventive services on the claim. Note the CG modifier is attached to 1 of the 521 lines and 1 of the 900 lines with the 521 preventive services not included in either of those lines.

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Effective10/1/16, the -25 or -59 will only be attached to the RC line item with the CG modifier that is the second visit on the same date of service for an unplanned different ailment of the patient. DONOT use the -25 on your E & M code on claim if there is also a procedure performed. When billing with the -25 or -59, RHC will receive 2 AIRs.

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MEDICARE:Must file claims within one year from date of

services—effective 3/23/10.I.e. January 1, 2016 must be filed by Dec 31, 2016

NE MEDICAID: Must file claims within 6 months from date of service

I.e. January 1, 2016 must be filed by Jul 31, 2016Any adjustment must be completed w/I 90 daysMCD MCOs may have longer timely filing; Heritage

Health will begin 1/1/17

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• 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

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• 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 MAC, HCFA 1500 Form

• Paid on the Medicare Pt B fee schedule

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• 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.

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ALL Laboratory performed in the RHC, including 6 basic tests (venipuncture is part of the office visit bundled service)

Billed as would have been if provided at the hospitalTechnical Component

X-rayEKGHolter MonitorAll TC’s Billed as would have been if provided at the hospital

Paid on the Medicare Pt B Fee Schedule

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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%

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Each State Medicaid is specific as to their State requirements—50 states, 50 plans

May use either the 1500 or UB04Managed Care Plans have choice as well

Coverage is specific to each stateMost States require both RHC and nonRHC

Medicaid provider numbersPaid on the RHC rate or a PPS rateNE has transitioned to Managed Care Payers

Heritage Health to begin 1/1/17

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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 claimsMCPs 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

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Must have RHC and nonRHC numberForm for each is per the Managed Care Payer

NE Plans use the UB04 for RHCsAilments are RHC servicesPreventive services are nonRHC servicesIRHCs receive 100% of their Medicaid PPS ratePB of <50 bed hosp receive 100% of their actual chargesPB of >50 bed hosp receive 100% of MCD PPS rateMust send in a copy of your Medicare CR annually as is

a Federal RequirementWith PPS payments there are no cost report settlements

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RHC services = bundled services—UB04 or 1500Lab, X-ray TC and EKG tracings are billed on the

nonRHC provider # 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 visitIf only visits, then nonRHC# and list visit datesAll surgeries at the hospital have 2 wk global

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RHC services —UB04Detailed line itemsLab, X-ray TC, EKG tracing billed with Hosp OP #Professional components are part of the visitAll preventive, IP, OP, ER, OBS are nonRHC

services, billed with the nonRHC #OB is global with exception of first visitIf only OB visits, bill nonRHC# and list visit datesAll surgeries at the hospital have 2 wk global

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“Incident to” services without a face-to-face visit are billed on the nonRHC # i.e. injection only

Must have both the administration CPT code and the NDC of the drug administered

If VFC is used, administration CPT is billed on the nonRHC # with charge; CPT of vaccine given with 0 charge and SL modifier on claim (DHHS PB 1549)

nonRHC services paid using the fee schedule and not your RHC rates

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• Billed as in fee-for-service clinic• No changes in reimbursement• Must not discount charges

• no cash discounts at time of service payment• no professional discounts given

• All discounts given should be based on finances of patients

• i.e. sliding fee scales can be developed to as high as 400% of poverty guidelines per Federal Regulations

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Two types of plansPFFS – Private Fee for Service

Send Claims on UB04 with Medicare Rate letterRegional/PPO Plans

Must provide service to the entire region per CMSSend Claims on UB04; you negotiate payment

When patients switch to MA, they are on your “Private” section of your visit countsYou may want to keep them separate as they will count as Medicare patients if you need to figure the % of Medicare utilization.

The RHC Encounters and Medical NecessityRural Health ServicesNon-RHC ServicesPreventive Services“Incident to” ServicesTransitional Care ManagementChronic Care ManagementBasic claim submission requirementsCost Reporting Basics and why we need the info

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Injections with an Office VisitCharge All CPT codes in systemBundle all charges with the QVC; list the 0250 or 0636

Rev Code with the J-code & submit claim to RHC MCRIf it is a Pt D drug, it must be sent to Pt D plan or Patient

Injections only—nurse service (Incident to service)Charge in systemEither DO NOT bill (write off) as there is no f-t-f visitOR can be bundled with a visit within 30 days pre or post

nursing service and submitted with that f-t-f visit If injectable is a Part D drug it MUST not be a part of an

RHC claim as it is only billable to the patient or to Part D

Part B Drugs cannot be obtained from a Pharmacy and then a physician service be charged in the clinic for the administration effective with DOS 10/1/11. The clinic would be required to obtain the drug from the pharmacy and pay the pharmacy, and clinic would submit claim for all Pt B services to the patient or insurance for payment.

MM CR 7397 revised & Transmittal R2437CP

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Injectable/Vaccine as a Part D drug – 1/1/08The injectable/vaccine is payable only through Pt D If injectable/vaccine is obtained at the clinic level, then

the patient is to pay for the injectable/vaccine and the administration privately and then they have to submit that claim to their Part D company to be reimbursed for the services.

Clinics can link to: www.mytransactrx.com and bill the Pt D drug and get payment to include administration of the drug and let you know the copay amount.

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• Only allowed if a different unplanned illness or injury• If same diagnosis, accumulate to set E & M level• Is to be billed with a -59 modifier; or after 10/1 also can use -25

• Visit by physician and then the mental health provider both are billable—2 visits—Each bundled 521 or 900 will have a CG modifier effective 10/1/16

• IPPE and an ailment visit—is 2 visits• IPPE, ailment and mental health visit—is 3 visits• Visit in clinic, then hospital admit (MAC determines);

generally not both billable• Visits by two different specialties on same day—is 1 visit

CMS Manual 100-02 Chapter 13 Section 40.3

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• Clinical Psychologist (PhD)• Doctoral level of education

• Clinical Social Worker (CSW)• Masters level with at least 2 years experience

• Use 900 revenue code to bill therapeutic behavioral health• After 10/1/16 will require a CG modifier on the bundled line item

• The first visit to determine services by a physician/PA/NP is an RHC visit, then behavioral health services apply

• Reimbursement in 2014> is 80/20• Can be only service on claim or can also have 521 rev code

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QVC required; AIR paid with copay and deductible applied, after 10/1/16 the CG modifier required

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As shown, 2 per diems; does not require the 521 for BH to be paid, after10/1/16, CG modifier on both line items required

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RC 521 IPPE is an AIR, no copay/ded; plus other 521 99213 is an AIR, copay/ded applied; other RCs for info only and no copay/dedapplied, after 10/1/16, 99213 & G0402 require CG modifier

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As shown, 3 per diems; IPPE, Office Visit, Behavior Health Visit, after 10/1/16, all lines on this claim require the CG Mod.

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2 visits in one day, different diagnoses & episodes; must have modifier 59 (per CR 9269) (10/1/16 either -25 or -59 can be used along with the CG modifier; caution DO NOT USE traditional use of -25 on claims)

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Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04

Technical Components, labs, EKG tracing are billed on the nonRHC side, either through the Hospital OP provider number (PBRHC) or to MCR Pt B (IRHC) use correct G-codes

Each preventive service MUST be on a separate line on the UB with the G-code