Rural Health Clinic Billing Cheat Sheet

Effective: April 1, 2005

This form is designed to provide general guidance regarding the billing of Rural Health Clinic services to Medicare (Medicaid & Insurance rules are different in most cases) as of April 1, 2005. These guidelines change frequently and have different interpretations depending on the intermediary paying the claim. There are also some variances between provider-based and independent RHCs. Provider-based clinics are no longer required to use HCPCS codes and bill Non/RHC, Medicare services using the hospital provider number instead of billing to the Part B Carrier. Examples of Non-RHC/Medicare services are as follows:

• All laboratory services including the six required tests

• Technical components of procedures (ie. Radiology)

• Hospital services

• Hospice services

Before billing any claim using this form, you should review guidance from your intermediary to determine if our prescribed billing method is appropriate in your situation.

RHC billing and UB-92 requirements changed on April 1, 2005 based upon guidance from Medicare (CMS). This 31-page document simplifies billing for RHC services by no longer requiring RHCs to report additional line items when billing for preventive services. Except for the telehealth originating site facility fee reported using revenue code 0780, all charges must now be reported on the following revenue code line for the encounter or the claim will be returned to the provider. RHCs must now only use one line on the UB-92 and must bundle charges into one of the following revenue codes:

0522 RHC Nursing Home Services

0521 RHC Office Services

0522 RHC Home Services

0900 Behavioral Health Treatments (subject to the 37.5% psychiatric reduction

Three new sources of information for rural health clinics regarding billing have been published by CMS over the last several months. Those sources have been listed with the appropriate hyperlink listed in the table. These documents are a good starting place to help you understand the billing requirements for rural health clinics.

Date	Description	Hyperlink
11/12/2004	Instructions for completion of UB-92 (93 pages)	http://www.cms.hhs.gov/manuals/pm_trans/R368CP.pdf
11/19/2004	Updated RHC Billing Instructions (31 pages)	http://www.cms.hhs.gov/manuals/pm_trans/R371CP.pdf
1/2005	The Medicare Guide to Preventive Services (167 pages)	http://www.cms.hhs.gov/medlearn/psguid.pdf

General Billing Guidelines for RHCs

The following table is a summary of information related to the billing of services under Medicare RHC regulations.

A billable encounter is between a physician, NP, PA and a patient where a medically necessary service RHC covered service is provided. For example, a nurse drawing blood, or taking blood pressure would not be considered a billable encounter. A rural health clinic encounter must meet all of the following to be billable to the RHC intermediary:

1. Must be a Medicare covered service

2. Must be a RHC covered service (not laboratory, hospital, or technical component for example)

3. Must have a face to face with a physician, NP, PA

4. Must be a medically necessary service

5. Must be a service that requires the skill of a physician, NP, or PA (scope of practice)

Additionally encounters will be denied as not medically necessary if the frequency of visits is not consistent with norms in other outpatient venues, such as:

1. Other patients in your practice

2. Other rural health clinics

3. Other physician clinics

4. Other hospital outpatient clinics

The deductible is the same as Part B which increased to $110 in 2005.

The co-insurance percentage is 20% of actual charges for RHC services versus 20% of the Medicare allowable for Medicare Part B services.

The actual charge should be billed to Medicare. (Not the reimbursement rate – Note: Some Medicaid programs require you to bill your rate.)

Professional Components are RHC services & included on the UB-92.

Technical Components are paid fee-for-service by Medicare Part B.

The maximum RHC cost per visit is $70.78 in 2005 and 68.65 in 2004.

RHC services are reimbursed on a cost per visit basis from the Medicare Part A Intermediary (Riverbend, Trailblazer, etc.). Use a UB-92 Form for Billing.

Non-RHC services (laboratory, technical comps, hospital visits) are paid Fee-for-Service by the Medicare Part B Carrier. Use a HCFA-1500 Form for Billing.

RHCs do not use CPT codes when billing RHC services to Part A.

RHCs should review the Local Medical Review Policies (LMRP) for billing guidelines.

The Bill Type is 711 when billing charges to Medicare Part A.

A Provider should be present in the office suite any time patients are treated under RHC Conditions of Participation regulations.

RHC Reimbursement Table - Visits

RHC Covered Services

Type of Service	RHC Service	Insurance Form	Revenue Code
Office Visit (Do not use 99211-nurse only)	Yes	UB-92	0521
NF (Level) 1 - Nursing Home LMRP – (1 routine every 60 days)	Yes	UB-92	0522
SNF (Level II) Skilled NH (as of 1/1/2005) LMRP – (1 routine every 30 days)	Yes	UB-92	0522
Hospital Swing-Bed (SNF)	Yes	UB-92	0522
Welcome to Medicare Physical (IPPE) 2005 – One physical during the 1^st 6 months a person has Medicare	Yes[1]	UB-92	0521
Pap Smear–Professional Comp.[2] No Medical Necessity required	Yes	UB-92	0521
Home Care Oversight	Yes^[3]	None	NA
Home visits	Yes	UB-92	0522
Therapeutic Psychiatric services by a physician, NP, PA, Clinical social worker or Clinical psychologist. (subject to 37.5% reduction)	Yes	UB-92	0900

[1] The technical comp. of EKG or other diagnostic tests are billed to the Carrier (Part B).

2 The Technical component is paid Fee-for-service and billed to the Carrier (Part B).

3 Home care oversight is a RHC covered service; but, there is no face-to-face encounter.

Non-RHC Services

Type of Service	RHC Service	Insurance Form	Revenue Code
Hospital Visit	No	HCFA- 1500	NA
Hospice	No	Bill Hospice[4]	NA
Emergency Room	No	HCFA- 1500	NA
Observation Room (Hospital)	No	HCFA- 1500	NA
Nurse Only Visits (99211)	No^[5]	None	NA
EPSDT/Well Baby Visits	No[6]	Medicaid	Medicaid
Physicals (Not “IPPE”)	No[7]	None	NA

4 CMS has recently changed billing regulations for Hospice so that if a physician is designated by the patient as the attending, the physician could receive reimbursement directly from Part B instead of from the Hospice. The only time the RHC intermediary is billed is when the treatment is not related to the terminal condition. (use condition code 07)

5 An encounter with a nurse does not meet the visit requirement for RHCs. An RHC visit must be a medically necessary, face to face encounter between the patient and a physician, PA, or NP to be a billable visit.

6 Each state has different Medicaid rules in relation to well-child and EPSDT visits. They do not meet the Medicare guideline as a visit due to the preventive nature of these visits although there is a face to face encounter.

7 Physicals do not meet the criteria as a Medicare RHC visit due to the preventive nature of these visits and the visits should not be billed to Medicare. The RHC can obtain a waiver and bill the patient directly. There is some flexibility on whether or not to count the visits for cost reporting purposes. Riverbend indicates that they should be counted.

Services Provided during Non-RHC Hours

A rural health clinic can designate certain hours during the week to be a private practice or non-RHC time. During this time all services would be billed to Medicare Part B and paid Fee-for-service including Medicaid services and the cost of the time would be excluded from the cost report. Likewise, some services that are normally RHC services if performed after normal RHC working hours can be billed to Medicare Part B (1) if the visit or service occurs outside the RHC hours, (2) it is documented in the physician compensation agreement and (3) the cost is excluded from the cost report. Some examples of such services are Skilled Nursing visits, Home Care Plan Oversight and Home visits.

RHC Reimbursement Table - Ancillary Services

Type of Service	RHC Service	Insurance Form	Revenue Code
Laboratory (including 6 required tests)	No	HCFA- 1500	NA
Radiology (TC only)	No[8]	HCFA- 1500	NA
Pap Smears (TC Only)	No	HCFA- 1500	NA
Bone Density Scans (TC only)	No[9]	HCFA- 1500	NA
Holter Monitor (setup) & TC	No	HCFA- 1500	NA
B-12 & other Injections	Yes	UB-92	0521
Radiology (Professional Component)	Yes	UB-92	0521[10]
Allergy Shots	Yes	UB-92	0521
Pneumoccoal Vaccine	Yes[11]	Log	NA
Influenza Injections	Yes	Log	NA

8 If the professional component of the X-Ray is read by a physician compensated by the RHC in the RHC during RHC hours the interpretation is bill able on the UB-92 and does not increase the encounter rate. (Only increases co-payments). The technical component of an X-Ray is never a rural health clinic covered service and should be billed to the Medicare Part B carrier and the cost excluded from the cost report.

9 If a professional visit is charge to the RHC intermediary it must meet medical necessity guidelines.

10 Most intermediaries recommend that RHCs bundle all office charges under Revenue code 0521. (make sure only 1 unit or visit is included for the encounter amount)

11 Influenza and Pneumoccoal injections should be logged with the patient name, HIC number, and date of service and this log turned in on the Medicare cost report. RHC receive cost in excess of the cap for these services.