1	Rural Health Clinic Billing Boot Camp
2	Our Address
3	Our Address
4	Goals and Objectives
5	About this Workshop It is an informal workshop setting. Please Ask Questions at any time. Please feel free to elaborate, correct, or inform at any time. I may call “Time Out” which means we are off subject and need to move on.
6	What Game are you Playing
7	Where is a copy of the rules? Local Medical Review Policies National Coverage Determinations CMS – Online Manuals It’s like playing Monopoly with your Big Brother. He makes the rules.
8	What Should You Do with the LMRP? “Bind them around your neck, write them on the tablet of your heart” Proverbs 3:3 “Do not envy the oppressor, and choose none of his ways” Proverbs 3:31
9	Riverbend implements Medicare payment policies
10	Provider-Based or Independent? There are two types of RHCs, independent and provider based. Independent RHCs are defined as freestanding practices that are not part of a hospital, skilled nursing facility, or home health agency.
11	Provider-Based or Independent? A provider based RHC is an integral and subordinate part of a hospital, skilled nursing facility, or home health agency operated with other departments under common licensure, governance, and professional supervision.
12	Independent versus Provider-based
13	Do RHC regulations apply to all payer types? No. These rules just apply to Medicare. Medicaid follows it’s own billing rules. Commercial insurance is not affected by RHC status.
14	It’s Time to go back to School Rural Health Clinic 101
15	Definitions of Common Terms Before we get started let’s define some common terms and Acronyms that will be used during the seminar.
16	Definitions RHC – Clinic meeting criteria established in Public Law 95-210. Intermediary – Insurance company that process Part A Hospital Claims using UB-92. Also contracted to process RHC claims.
17	Medicare Acronyms
18	Medicare Acronyms
19	Medicare Terminology
20	Medicare Part A coverage pays for (not limited to):
21	“Raving Madness” Why RHC Billing is so complex?
22	Why is Medicare so Complicated There are 138,481 pages of Medicare regulations. They are 3 times the size of the IRS code.
23	Medicare Part B covers Medically necessary Doctors services provided in:
24	Medicare Part B coverage also pays for the following:
25	How Does Medicare Part B Reimbursement Work?
26	Medicare Part A reimbursement methodology includes services provided by: •home health agencies; •hospitals; •nursing homes; •rural health clinics; and/or •skilled nursing facilities.
27	How Does Medicare Part A Reimbursement Work? Medicare Part A claims are reimbursed on a cost-based fee. Reimbursement is based on the Medicare Part A provider ’s cost -negotiated with their fiscal intermediary (FI),
28	Why is there so much confusion regarding RHC Billing?
29	What would solve the Problem?
30	When could such a system be implemented?
31	Types of Service
32	Reimbursement Summary
33	RHC’s can provide three different types of services to Medicare Patients
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35	Medicare does not cover
36	Reimbursement Table for Visits Summarizes Billing - Located in your Workbook
37	To Pay Your Claim Medicare Needs to know:
38	Who should do your coding of claims? Who knows best what was done and why it was provided?
39	The Most Common Billing Mistake of New RHCs
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41	Four Requirements to Bill Properly
42	Four Requirements to Bill Properly
43	Completing the UB-92
44	Five RHC Billing Rules 1. There are exceptions to every rule. 2. Professional components in the office are billed to the RHC Intermediary. 3. Technical components can be billed to the Part B carrier. 4. Every UB-92 must have at least one visit to be paid. 5. A visit must have a physician, NP, or PA seeing the Patient.
45	Diagnostic Services The typical billing process is as follows:
46	Seven Numbers you need to Bill Properly
47	Six Information Sources you need to Bill Properly
48	Codes! Codes! Codes! Codes!
49	Bill Type Codes for UB-92’s Description of Bill Type Number First Service to Last Service 711 Interim - first claim 712 Interim - continuing claim 713 Interim - last claim 714 Late Charge 715 Adjustment 717 VOID/CANCEL 718 Request for a Denial 710
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52	RHC Revenue Codes 001 Total Charges 510 Tele-medicine 520 Nursing Home Visits 521 Office Visits 522 Home visits 910 Psychiatric services
53	Common Codes on the 1500
54	Where do you Bill RHC Services?
55	Which Provider Number do you Use?
56	Which UPIN Number do you Use?
57	Physician Supervision Guidelines Program Memorandum B-01-28 was released on 4/19/2001. Adds seven additional levels besides the three levels that have been in place since 1997. If a test is performed in a hospital’s main campus the supervision level is presumed to be meet.
58	Three Most Common Levels of Physician Supervision General Supervision (not in office) Lab Radiology Direct Supervision In the office suite Personally Perform Cardiac treadmill
59	Are Rural Health Clinics subject to “incident to” regulations? Yes and No. Mid-level services do not have to meet the “incident to” regulations while RN’s and other service providers are subject to incident to guidelines.
60	Four Attributes of an “Incident To” Visit Physician must see patient for the first visit Physician must be in office suite at time of visit Physician must have ongoing supervision of patient (some people use one of every three visits) Physician must have employment relationship with provider. (Outside Contracts are now OK.)
61	“Incident To” Part B Billing Implications
62	The Medicare Secondary Payer form should be collected ?
63	MSP are required every 90 days In March, 2004 – CMS provided guidance that indicated MSP forms need only be completed every 90 days.
64	Office Visits Office Visits are a covered RHC Service
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66	General Guidelines A $100 Deductible applies to RHC services based upon a calendar year. Coinsurance of 20% of reasonable charges is the copayment. Limiting or Medicare allowables do not apply to RHC services. Medicare pays 80% of the clinic’s cost per visit or the Cost Per Visit Cap. Medicaid pays 100% of the cost per visit.
67	How much does Medicare Pay? Medicare pays 80 percent of the clinics cost per visit up to a maximum allowable cost per visit. For example if your cost per visit is $60.00 your reimbursement is $48.00.
68	Office Visit Summary
69	On 1/1/2010 a Medicare patient receives a 99214 CPT and is charged $200. The Medicare Deductible is $200. How much will the Medicare Intermediary pay if the clinic’s Cost per visit is $50?
70	An Example of Negative Reimbursement The patient is seen on January 1, 2010. He has an extensive visit and is charged a 99214 for $200. The Medicare encounter rate is $50.00. The Deductible has not been meet .
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72	Rural Health Clinics are paid based upon encounters or visits. RHC's are paid on a visit or encounter rate which is defined as a face to face encounter between a physician nurse practitioner physician assistant.
73	Can you have more than more than one more visit per day? Encounters with more than one health professional, and multiple encounters with the same health professional, that take place on the same day and at a single location constitute a single visit, except when the patient, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment.
74	Two Visits in One day In the remarks section indicate why the ICD-9 visits are not related.; Indicate 2 units of service. Use two ICD-9 codes.
75	99211 Visits are not RHC Visits Brief Established visits (99211’s) do not meet the RHC guidelines. No history or judgment involved with this level of service. Edits are in place for claims less than $30.00.
76	If the clinic is owned by the hospital wouldn't the 72 hour rule apply to the visit? Yes, the 72-hour rule would apply to all diagnostic tests such as laboratory and radiolgy. The professional services would not be subject to the 72-hour rule. (although there are some intermediaries who bundle professional services well.)
77	Hospice RHC’s can get paid for Hospice patient’s if the payment relates to an Unrelated diagnosis. Input condition code 07 which indicates that the diagnosis has nothing to do with the terminal illness.
78	Since we only use 521 codes and not procedure codes are there any special rules for wellness exams as there is with regular Medicare? No, Use Medicare Part B Guidelines for coverage of preventive health services. Physicals are still not covered by Medicare and billed as follows:
79	How are Physicals Billed? They are not a covered Medicare service and there is no requirement to bill or have a waiver signed. If you need a denial for secondary purposes use bill type 710.
80	If your registered nurse gives a flu shot to a patient is counted as a visit? No. The visit must be a face to face encounter between a physician, nurse practitioner or physician assistant. A log is maintained for flu shots and pneumococcal injections and submitted on the cost report for reimbursement.
81	If a physician or mid-levels goes to a church or other designated place to see patients, is that a RHC visit? No - §410.45 Rural health clinic services: Scope and conditions. (b) Medicare pays for rural health clinic services when they are furnished at the clinic, at a hospital or other medical facility, or at the beneficiary's place of residence.
82	Home Health Oversight A rural health clinic can not bill home health plan oversight as a rural health clinic encounter; nor, can the clinic bill Part B for the Home Health Plan. Time spent performing home health care plan can be used in the allowable compensation calculations for the physician.
83	Can you charge a relative for Medicare services under the RHC program? Publication 27, Section 441. CHARGES IMPOSED BY IMMEDIATE RELATIVES OF PATIENT OR MEMBERS OF PATIENT'S HOUSEHOLD. Payment may not be made under Part A or Part B for expenses which constitute charges by immediate relatives of the beneficiary or by members of his/her household.
84	Since RHC's require a face to face visit shouldn't a physician or mid-level see every flu shot and every allergy shot to generate a visit? You should follow a protocol that is reasonable. It is unlikely that it is medically necessary to see the patient for every injection.
85	How are Flu and Pnuemoccal Shots Billed in RHC’s? A log or roster of Medicare patients is maintained and submitted with the cost report at year-end. Medicare pays the cost of the shots. Flu shot reimbursement is up to $28 per visit and pnuemoccal shots are up to approximately $35 per visit. No bill is submitted to Medicare.
86	Provider-based RHC’s no longer bill for Flu and PNU effective 1/1/01 Provider based RHC's and Federally Qualified Health Centers (FQHC's) are not to include charges on Form HCFA-1450 for the influenza virus and pneumococcal pneumonia vaccines. Payment will be made through the cost settlement process in the same manner that is currently in place for independent RHC's/FQHC's.
87	What should be documented in the Flu and Pnu Logs? Medicare requires the following information. Patient Name HIC Number (Medicare Number) Date of service (shot) Charge (what you would have charged if you had been charging)
88	Do I have to log every flu and pnu shot including non-Medicare patients? No. There is no requirement to Log other payor types; but, in order to complete the cost report correctly you need total flu and and total Pnu shots provided.
89	TeleHealth Billing Telehealth will require a HCPCS code Q3014 changes October 1, 2001. This is different in that a HCPCs code is required. Payment will be $20.00 and the revenue code is 510. The intermediary will pay $16.00 plus your encounter rate if you a medically necessary encounter.
90	How do I get paid for Holter Monitor and Ambulatory Blood Pressure Tests
91	Hospital Visits Hospital Visits are not covered under the RHC Benefit
92	Hospital Services
93	A patient is seen in the RHC and admitted to the hospital. How is Medicare billed?
94	Can an RHC bill for both a rural health clinic visit and an inpatient admission on the same day? Yes. An RHC can bill for a rural health clinic visit if an encounter occurs during the RHC hours at the rural health clinic and subsequently during the day the patient is admitted to the hospital. The RHC can bill on the 1500 for the hospital visit as well. Some intermediaries and carriers allow this and some do not. Riverbend does allow this - Trailblazer does not.
95	Hospital Billing Issues Hospital inpatient visits are not rural health clinic visits and the costs should not be included on the cost report. Nurse Practitioners or PA’s seeing patients in the hospital should billing using their own provider number and receive only 85% of the fee schedule.
96	How are inpatient visits counted on the cost report?
97	Swing-Bed and ER services are not RHC services All services performed in a hospital including those to a swing-bed patient or emergency room, are not considered a rural health clinic covered service. These services should be billed to the Medicare Part B carrier using the HCFA 1500 Insurance form and the cost of this time should be excluded from the RHC cost report.
98	How do you bill for Home Visits? If the visit occurs during rural health clinic hours; then, the rural health clinic can bill the visit as a rural health clinic visit under revenue code 522. If the visit occurs outside of rural health clinics hours (which is usally the case) the service would be billable to Medicare Part B and paid at the higher fee for service rate of approximately $80.
99	Home Visits Medicare Part B (carrier or RBRVS reimbursement) now pays more than rural health clinic reimbursement. If the visit occurs outside rural health clinic hours, you may want to bill this to Medicare Part B.
100	Nursing Home Visits
101	Skilled nursing visits (paid by Part A) are billable to:
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103	SNF Reimbursement per Transmittal A-99-8 If the answer to both of these questions is Yes; then , the service can be billed to Medicare Part B. (it is not a RHC service)
104	Skilled Nursing Home Visits If the answer to both of these questions is Yes then bill Medicare Part B using the 1500 form. If either answer is no. Bill it as an RHC visit.
105	ICF nursing visits are billable to:
106	How are ICF or Level 1 Nursing Home patients billed? Bill them to the rural health clinic intermediary using revenue code 520.
107	If you perform a surgery in the hospital using a global fee and the patient has a pre-op and a post-op visit in the RHC, can I bill Medicare for the visit? Answer: No. Since you billed globally. If you billed procedure only – then you could count face to face visits. You need to ensure that you do not charge more than the global fee.
108	Can an RHC open a treatment room and bill Part B for those services? Minor surgeries performed during the hours the RHC is open must be billed to the RHC and cannot be billed to Part B. If the procedure is performed in hours when the RHC is not open or if specific hours have been set aside for this purpose and no RHC patients are seen at that time; then, Part B may be billed.
109	How do you Bill for an Office Surgery performed during RHC Hours? Charge an office visit with revenue code 521 and charge the procedure using revenue code 920 or 940. Medicare will only pay you 80% of the your rate; however, your coinsurance will increase significantly. The next slide is an example of this:
110	Office Procedure Example The patient has a minor office procedure and is charged a 99213 visit for $60. The patient is also charged the appropriate CPT code for the procedure that has a $340 charge. The Clinic Cost Per Visit is $50.00. Deductibles have been meet already.
111	Office Procedure Example
112	Radiology Services
113	Bill the Technical Component to Part B for Radiology The Technical component only (use the TC modifier) is billable to the Medicare Part B carrier using the HCFA 1500 form. You will need to use the appropriate CPT Code and the TC modifier.
114	Professional Component - Radiology The professional component is billable to Medicare on the UB-92; however, it only increases the co-pays and deductibles. A radiologist may bill Part B directly.
115	Laboratory Services Laboratory is not a covered RHC Service
116	Laboratory Services
117	Laboratory Reimbursement Changed Effective January 1, 2001 Effective January 1, 2001 all laboratory tests are billed to the carrier (Part B) and are paid on the fee schedule.
118	Laboratory Tests are no longer subject to copays and deductibles Effective January 1, 2001 deductibles and copays do not apply to laboratory services in a rural health clinic.
119	Venipuncture (Blood Draw) Change Venipuncture can be billed to the carrier. Some intermediaries insisted that this service be billed to them as an RHC covered service.
120	If the laboratory draws blood only how is the blood draw fee paid? It is billed to the Carrier using code G0001 on the 1500 Form.
121	Smaller Providers that use personnel to perform multiple tasks Time studies will be needed to allocate salaries of personnel performing multiple tasks.
122	All Providers must assess the Cost Report Impact of Lab Change All laboratory expenses will be non-allowable on the cost report. (reclass to Line 58 through 60) Your accounting system will need to capture: Laboratory Depreciation Laboratory Salaries Reagent and supply costs
123	Time Studies Time studies need to be one week per month alternating weeks in the study per Medicare regulation; however, these guidelines have been relaxed for RHC’s per a March 2001 Flash Report from Riverbend.
124	What about Medicaid? Most states have not yet adopted this methodology and this may result in a cost report filed one way for Medicare and one way for Medicaid.
125	Preventive Health RHCs are not the best avenues for preventive health due to encounter requirements.
126	Many Providers do not qualify as a visit under RHC Physical therapist Nurses Diabetic counselors Nutritionists
127	Preventive All services are revenue code 521 for independent clinics Pap smears, pelvic exams, breast exams do not require medical necessity. Bone Density, Mammography do require medical necessity for a RHC visit. Technical components are billed to Part B.
128	Preventive - Provider-based Use appropriate Revenue code for service on the following table. See the guidelines provided in March, 2004 Guide to Women’s Preventive Health Services from Med-Learn website.
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130	Can the rectal exam for prostate be charged separately from the face to face encounter and if so, what revenue code is used? No, this a professional service and is part of the 521 revenue code
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132	MSN’s Now Indicate Actual Payment to Providers Effective October 1, 2001, Medicare Intermediaries must disclose the amount actually paid to the RHC on the Medicare Summary Notices.
133	Medicare Claims Audit Findings Riverbend Government Benefits Administrator performs RHC annual claims audits to ensure compliance under the Medicare program. The most prevalent findings of last fiscal year end audits.
134	Medicare Claims Audit Findings Problem findings were, claims being submitted to Medicare when an actual face-to-face-encounter had not occurred. These claims were being billed when patients received injections, i.e. allergy, B12, or when only blood pressure checks were being performed.
135	What is the difference between fraud and abuse?
136	What is Abuse Abuse involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in an unnecessary costs to the program through improper payments. The real difference between fraud and abuse is the person's intent.
137	Review EOB’s for Proper Payment Your clinic should perform quarterly EOB reviews to determine if you are being paid accurately, timely, and in compliance with third party agreements.
138	How do you perform a quarterly EOB Review? Select 10 EOB’s with at least 2 from Medicare and 2 from Medicaid. Determine the amount charged, the amount paid, the date of service, and the date paid. Determine if payment amounts are correct and if payments are timely.
139	Question – In reviewing EOB’s you should look for:
140	Recommendations for Profitability and Survival Charge Master Review Remittance Review – Denials. Rejections, Compliance Compliance – under coding or overcoming Frequent Small Sample Size Audits for specific issues. Less than 6% error rate.
141	Common Traits of Best Practice RHC’s High Physician income 45 days or less to collect accounts Medicaid pays in 10 days or less Medicare pays in 28 days or less
142	Common Traits of Best Performers They collect copays & blame it on the insurance companies. They file away EOB’s and remittances in notebooks. They work the 201’s and EOB’s. The office manager posts claims for ½ day every month.
143	The amazing Six word Operations Improvement Seminar Work harder (see more patients) Code Better (assign CPT levels more accurately) Charge More