Question

Answer

12/30/02: This LMRP appears to represent a de facto national policy decision. Why did Riverbend choose this medicum over a negotiated rulemaking process or by an actual National Coverage Decision?

Riverbend is one of three Fiscal Intermediaries with the responsibility for processing claims from freestanding RHCs, with a primary responsibility for 36 states. This does not equate to national coverage, particularly when considering that facility based RHCs are responsible to an additional set of Fiscal Intermediaries. Fiscal intermediaries are responsible for developing and promulgating formalized coverage and coding decisions and regulatory interpretations for those facilities that use that intermediary to process their claims. Although most of the material contained in this policy is interpretive, and could therefore be published in a simple bulletin, the LMRP process provides greater opportunity for an interactive process with this diverse provider community. The other forums are not open to the Fiscal Intermediary, although any local policy will be subordinate to those other documents should they be developed by CMS.

12/30/02: Does this policy apply to facility based RHCs as well as freestanding RHCs?

Yes, except insofar as reimbursement instructions conflict with their own. This is clarified in the policy.

12/30/02: The LMRP fails to provide for the effect of state law on services required to be performed by RHC auxiliary personnel, and inappropriately restricts the ability of the physician to provide this service that the FI believes should be provided by less qualified RHC personnel.

 Although federal regulations are not subordinate to state law, Riverbend tries to be cognizant of any potential conflicts and to avoid that situation if at all possible. However, Riverbend is aware of no state law that would prohibit ancillary personnel from performing "incident to" services as discussed in the policy. Furthermore, the policy does not mandate that ancillary personnel perform any specific services; rather, it specifies those instances in which an RHC can claim a separate and unique "face-to-face visit" and those services which must be considered ancillary to another medically necessary visit. This is true regardless of whether the services are provided by auxiliary personnel or by the physician (or practitioner) himself.

12/30/02: The LMRP conflicts with CMS definitions of "incident to" and conflicts with CMS supervision rules. Additionally it inappropriately limits the definition of a "face-to-face visit."

The LMRP does not address requirements for the supervision of the ancillary personnel, nor does it set restrictions on the qualifications of those personnel, beyond what is set forth in the Medicare regulations. The discussion of "incident to" is only concerned with addressing ambiguities in the application of the concept of a "face-to-face visit" in the RHC. Currently RHC's vary in their interpretation of the regulations such that, although most providers share a common interpretation and resultant billing pattern, some providers are widely disparate in their billing patterns and consequent compensation. By clarifying the definition and application of the "face-to-face visit", Riverbend seeks to remove that variation and restore uniformity to the reimbursement process as mandated by Medicare regulations.

12/30/02: The requirement to "lay hands on" a patient places undue restrictions on the concept of medical necessity.

 The phrase "lay hands on" is not a legal requirement. Given the lack of comment on this from physicians, it can be assumed that they recognize it for what it was, a figure of speech that describes the physical rendering of the diagnostic or therapeutic service to the patient. This is no different than the expression "face-to-face," which should in no way be seen as restricting payment to a proctologist. 

12/30/02: The level of care for an RHC encounter should mirror requirements for an E/M visit.

 Levels of care are not required for RHC encounters, and the reimbursement systems are not comparable in the two cases. However, the E/M coding definitions do contain valuable information that can be applied to services that "require" the presence of the physician and the appropriate documentation of those services. The definitions for E/M codes were borrowed from heavily in the attempt to better characterize face-to-face visits in this policy.

12/30/02: Applying the "prudent layperson standard" to determine when a visit is medically necessary is inappropriate as this is applicable to the emergency room setting only and does not take into account other factors that may cause a physician to require early follow-up.

The "prudent layperson standard" is a lower standard than pure medical necessity. As used here it provides a lower threshold for determining the "medical necessity" of a patient initiated visit. Patients frequently come into the office for problems that really are medically inconsequential. However, a prudent layperson standard means that the visit should still be regarded as medically necessary if a reasonable person with no medical training would feel the trip to the doctor was warranted. The more rigid "medically necessary" standard is still applied to physician requests for follow-up, but it would be inappropriate to apply that standard to the patient.

 12/30/02: The PIM states that "visits for the sole purpose of obtaining...a prescription...are not covered" but the LMRP "violates" that by stating that "visits for the purposes of obtaining...a prescription...are not medically necessary."

 In accordance with the PIM, a visit solely to obtain a prescription will be denied as noncovered. In accordance with the LMRP, a visit [whose purpose is primarily] to obtain a prescription will be considered as not medically necessary even if it is otherwise covered. The statements do not represent identical circumstances, nor do they represent identical consequences, and the one does not prohibit the other although the latter is derived from the clear intention of the former.  Note that this does not preclude the practitioner from re-examining the patient at medically appropriate intervals to ensure that therapy is still necessary; however, this may or may not coincide with the need to renew a prescription.

12/30/02: We would like you to modify the LMRP to conform with a proposed rule change that would allow physical therapists employed by a clinic to be considered in private practice for Medicare billing purposes.

Existing Medicare regulations do not allow this. The policy will be updated in the future if the regulations change.

12/30/02: Rehabilitation programs are legitimate RHC services.

Cardiac and pulmonary rehabilitation programs may be provided by the RHC. However, in other environments the rehabilitation is supervised by the physician and direct physician evaluation of the patient (see "face-to-face") only occurs a few times during the course of the rehabilitation, to enable the physician to manage and supervise the process. These evaluative and management visits are appropriate RHC services and may be billed as face-to-face visits. The bulk of the program services, however, do not require the services of and are not typically performed directly by physicians; they are still legitimate RHC services but are provided incident to the management visits and therefore may not be claimed as separate face-to-face encounters.

12/30/02: With respect to cardiac rehabilitation, the Coverage Issues Manual makes reference to Group 1 and Group 2 services and defines utilization parameters for them. Group 1 services (telemetry during exercise, rhythm strip interpretation and limited examination) are allowed up to three times per week, but two of these three services require direct physician interaction. The LMRP should be revised to clarify that monitoring and supervising rehabilitation services is a different function than providing direct patient care, as defined in the service groupings. An EKG interpretation following an acute event should be considered a face-to-face encounter, as should a limited face-to-face examination, although EKG interpretations without a face-to-face encounter should be billed to the Carrier. The policy should additionally be revised to state that Group 2 services (new patient evaluation, cardiac stress test, and other physician services) should only be billed when a physician services provided and at such physician services when provided should be billed as face-to-face encounters.

This interpretation of the Coverage Issues Manual is not inconsistent with Riverbend's, but the manual and the LMRP are looking at different classification schemes and therefore have different (but not incompatible) totals for the subclasses. Of the Group 1 services, telemetry during exercise is the recurring service but this is also the service that does not require direct physician interaction. It is therefore not provided as a face-to-face encounter but the thrice weekly limitation of the CIM still applies. A limited examination (including any rhythm strip interpretation in the setting of the limited examination) is billable as a face-to-face encounter if it is medically necessary, e.g. when triggered by an acute patient deterioration, but is not billable as a face-to-face if not medically necessary (e.g. as a routine weekly occurrence). The EKG interpretation performed on a routine rhythm strip is not typically done in the setting of a face-to-face encounter and therefore cannot be so billed. However, it is an RHC service (performed in a clinic on an RHC patient) so the charges can be bundled with a medically necessary visit and the costs recouped through the cost report; Medicare regulations do not allow this to be billed to the Carrier.

Riverbend agrees that a new patient evaluation is a face-to-face encounter, as is routine re-evaluation during and at the conclusion of the program. And exercise stress test (treadmill) is a physician service but may not be a face-to-face encounter (if performed by ancillary personnel under general supervision). However, since the stress test would typically be associated with the initial and final patient evaluations, a total of only 3 face-to-face encounters are assumed to be medically necessary during the course of cardiac rehabilitation. Other physician encounters for evaluation or other reasons may be billed as face-to-face encounters if a face-to-face encounter is provided and if the medical record documents medical necessity (which does not normally exist except in the setting of an unexpected adverse event).

12/30/02: Dressing changes that require the services of skilled personnel are physician services.

In most medical environments physicians do not perform simple dressing changes. Simple dressing changes that are typically performed by a nurse are "incident to" services and do not justify a physician visit in the RHC environment or any other environment. However, this in no way precludes the physician from seeing the patient in a face-to-face visit whenever it is medically necessary for him to evaluate the wound, or prohibits him from providing wound care when the complexity of the care demands the services of a qualified practitioner. It is expected that the documentation would support that complexity.

12/30/02: The LMRP fails to distinguish between noncovered routine foot care and covered routine foot care.

 The LMRP is heavily referenced and cites RHC section 438 for additional discussion of the definition of routine foot care. Although Riverbend attempts to make these "referenced" policies as complete as possible, it is impractical to include all manual citations in their entirety. Cited passages are all available on the CMS website.

12/30/02: Many recurrent services are not simply blood pressure checks but assessments of patients with hypertension and comorbidities.

 The policy states that routine blood pressure checks do not qualify as medically necessary face-to-face visits. However, medically necessary physician reassessment (consistent with usual standards of practice in the other RHC, clinic and office environments) is in no way precluded or restricted. The chart must document that a physician service (evaluation and/or management) was performed and it was medically necessary both on its own and in the context of preceding and subsequent visits.

12/30/02: The LMRP fails to make allowance for the additional "face-to-face interaction" required by physicians employing "disease management" in their practice.

Riverbend anticipates that most RHCs re-evaluate their patients when it is medically appropriate to do so. "Disease management" is not a unique way of delivering medical care; medical necessity does not depend on whether or not the individual physician uses a "disease management" paradigm. Further, since there is no specific disease management benefit, utilization statistics for facilities ascribing to disease management models must be comparable to statistics for the entire constellation of RHCs. Finally, facilities that incorporate preventive care into their disease management model must be careful to exclude those preventive services from coverage, as Medicare does not include a preventive care benefit.

12/30/02: We request that you consider the impact of "high risk" medications on the frequency of physician encounters in the presence of chronic disease.

There is no regulatory impediment to the provider seeing the patient is frequently as is necessary -- even daily or more frequently -- as long as medical necessity exists. Occasional patients may require atypical frequency of visits due to high risk medications, physical impairments, comorbidities were even social considerations. However, the "typical" frequency of visits should not be significantly different across providers and the atypical patient should be both clearly different from the norm and well-documented in the record.

 12/30/02: The LMRP fails to address the fact that patients with chronic illnesses must have periodic lab work that must be discussed with the patient to involve them in their medical care.

 Most lab work is incidental to the physician visit, as the patient is not concerned with his test result but with the disease/prognosis that underlies that result. There are certainly some test results that necessitate a new and distinct face-to-face interaction with the patient, such as a biopsy that uncovers a cancerous condition. Most test results, including those that require a minor change in medication such as a dosage adjustment, do not generally require a new face-to-face interaction. Words such as "generally" and "usually" are purposefully included as every physician will have occasional unique patients with extenuating circumstances. However, in the aggregate RHCs should not need face-to-face visits to discuss laboratory tests with any greater frequency than hospital clinics or physician's offices, so that is the standard to which the RHC should hold itself.

12/30/02: The LMRP fails to define what type of services are subject to the "thirty day bundling rule " and further, fails to define the medical and legal basis for such bundling. Additionally, the 30-day window for bundling injections and other incidental "nurse-only" services into an encounter for billing purposes presents a difficulty if the periodicity of encounters is the more typical 3 month interval used for many chronic diseases. It would be helpful to give consideration to a mechanism for 90-day bundling of some services.

Much of this policy is concerned with distinguishing face-to-face visits from "incident to" services, the legal basis for the billing concept of "bundling."  Riverbend has in the past issued bulletins discussing the necessity for "bundling" incidental services with face-to-face visits occurring within a thirty day time frame. However, no thirty day rule is prescribed in this policy. Rather, providers are informed that incidental services should not be billed in way that would cause them to be paid as face-to-face encounters. If a provider wishes to delineate charges for incidental services on a UB-92, those incidental charges must be included on a claim for a related face-to-face encounter in order to prevent the claims payment system from erroneously generating a separate payment. This represents a "correct billing instruction" to overcome a processing system idiosyncrasy, not a coverage determination. Again, from the "bundling" perspective, there is no time limitation and 90 days (or longer) may sometimes be appropriate.

12/30/02: How does a clinic decide what visits should be bundled?

"Face-to-face encounters" should not be bundled, and in this sense visits (in the RHC sense of the word) should not be bundled. Charges for incidental services should be bundled with the "face-to-face encounter" that engendered them. A "visit" (physical appearance by the beneficiary in the office) solely to obtain incidental services is therefore the only type of "visit" that should be bundled. Examples would be a "visit" solely to obtain a prescription, and injection, a specimen collection or a blood pressure checks.

12/30/02: What services are or will be compared with RHC services to establish utilization norms.

Appropriate utilization norms include first and foremost the normative data from the RHC population as a whole, and secondarily utilization data from outpatient clinics and physician offices. The specific data chosen for comparison depends on the subset of RHC data being analyzed.

12/30/02: "Services commonly performed in a physician's office for outpatient clinic" are evolving; such services include therapies such as physical medicine, cardiac and pulmonary rehabilitation services.

 Part of the definition of "incident to" relies on the phrase "commonly performed in a physician's office." In order to be determined to be "incident to" a physician's service, the services you describe must meet that criterion. Riverbend agrees that these services may be commonly performed in a physician's office, and may be performed "incident to" in outpatient, office and RHC environments. The key distinction is that in the RHC environments, "incident to" services are reimbursed through the cost report not through direct billing of face-to-face encounters.

12/30/02: RHCs psychiatric services (clinical psychologist and L. C. S. W.) should be billed to revenue code 91 X. How should physician psychiatric services, such as a prescription for Prozac, be billed.

When only a minimal level of psychiatric intervention is involved, such as prescribing an antidepressant or an anxiolytic in the normal course of medical care, that should be considered to be no different than any other medical service. True psychiatric services involving psychotherapy and the active treatment of psychiatric disease should be billed under revenue code 91X when performed by a psychiatrist or other physician acting in the capacity of a psychiatrist. This revenue code informs Medicare that limitations on reimbursement for outpatient psychiatric therapy (such as an increased copayment) should be applied. Services such as refilling a prescription should, of course, be considered as incidental to the underlying face-to-face encounter.

12/30/02: We supply our patients with crutches and splints but cannot bill this separately to the fiscal intermediary. Since we do not have a DME billing number, we cannot bill Part B. Can we bill the patient?

No. The DME is a covered Medicare benefit so it cannot be billed to the patient. If the RHC wishes to provide these devices, it may either become an approved supplier (and thereby bill Part B) or it may provide the devices as part of the RHC benefit, in which case the cost of the devices should appear on the cost report and the facility will be reimbursed on that basis.

12/30/02: The Medicare Carriers Manual 2050.1 specifies that a physician must perform an initial service and ongoing services in order for a physician's assistant to be paid. Does the RHC program have similar rules?

Medicare Carriers Manual 2050.1 describe services paid "incident to" the services of a physician. Although in some instances the term physician is used restrictively by Medicare to denote only certain providers typically identified as "doctors," in other instances "physician" is used to include non-physician practitioners such as nurse practitioners and physician assistants. These midlevel practitioners are accorded an intermediate status; they are not reimbursed on the basis of "incident to" but on the basis of services that they individually deliver. In fact services provided incident to the services of nurse practitioners and PAs are covered by Medicare, in contradistinction to other auxiliary and personnel (such as nurses and therapists) who have no incident to benefit. Thus, section 2050.1 is not applicable; the applicable section is Medicare Carriers Manual 2156.C, which follows:

"Physician Supervision.--The PA's physician supervisor (or a physician designated by the supervising physician or employer as provided under State law or regulations) is primarily responsible for the overall direction and management of the PA's professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is being furnished to a patient and may be contacted by telephone if necessary, unless State law or regulations require otherwise."

This does not mandate either an initial visit or a particular frequency of ongoing observation beyond that which is required by the appropriate state law that governs the practice of the PA.

12/30/02: Why are hepatitis B injections treated differently than influenza and pneumonia? Can we bill Part B? Is the patient responsible for a 20 percent copayment regardless of who we bill?

Influenza and the pneumococcal vaccines have separately mandated reimbursement and are therefore treated uniquely. They have their own place on the cost report and are reimbursed separately from the global RHC reimbursement. Other vaccines, including hepatitis B and tetanus, fall under the general reimbursement rules. If they are administered to a patient for a specific medical reason (e.g. following a wound, a needlestick or exposure to the disease), they are covered services. They are not reimbursed separately by Medicare at the time of administration, but the cost of the services is included in the cost report and contributes to the computation of the per visit rate. From a copayment standpoint, the beneficiary is responsible for copayment based on charges. Since the charges for the vaccine can be included in the total charge for the visit that necessitated its administration, the beneficiary is responsible for a copayment. Note that vaccinations that are administered purely for preventive reasons are not covered as Medicare does not cover general preventive services (except for influenza and pneumococcal vaccines which are legislatively excepted); other preventive vaccines can be billed directly to the patient.

12/30/02: How should we bill when a covered and noncovered service are performed at the same visit? For example, a visit may contain some services that are directed at the disease process while other services are entirely preventive.

This is a common occurrence in office practice and represents good medical care. As long as the visit can be justified by the non-preventive services, the entire visit is covered. The only exception is that distinct billable procedures that are exclusively for preventive purposes should be noncovered and may be billed to the beneficiary. Thus, the preventive portion of the examination cannot be "carved out," but a separate procedure such as a "routine" screening EKG may be.

12/30/02: Monitoring and supervision of coumadin therapy should be differentiated from simply drawing blood to check the PT. Most of these patients who have multiple medical problems and are managed monthly do very well and require very infrequent hospitalization. We suggest these patients should be allowed one clinic encounter per month for coumadin monitoring. Even if the coumadin level is adjusted and they have to have their blood drawn again in the same month only one encounter should be billed per month.

There is a distinction between monitoring (checking the INR) and a need to see the patient, which may be based on a need for reexamination or a need for intervention (aggressive education in response to non-compliance or self-administration errors). It is very difficult to pin down a minimum (or maximum) frequency that is applicable in most cases, so this was not specified in the policy.  However, frequency analysis of RHC claims suggest that patients on coumadin require 2 or 3 more visits (for all reasons) per year than patients not on coumadin.  This is consistent with the observation that a visit every 4 to 6 months represents a typical follow-up pattern but that a visit is typically scheduled for this reason only when the patient is NOT being seen for other reasons.  Riverbend's review standard therefore will be that a visit specifically for coumadin management will be regarded as medically necessary only when a) coumadin is first initiated b) medical considerations require a re-examination of the patient or c) it has been at least 6 months since the face-to-face encounter for any reason.  It is expected that ongoing issues (such as coumadin usage) are incidentally addressed with every visit as part of comprehensive patient care.

12/30/02: Elderly patients with difficult veins may require 10 to 15 minutes to draw blood. The nurse has to spend time calling the patient back, sometimes multiple times, and there's also a physician cost of reviewing the lab results. The "drawing fee" is inadequate to cover all these costs.

Although the blood drawing fee, a Part B service, may be inadequate in many instances, there are other instances where the blood drawing proceeds smoothly and the compensation exceeds the incremental costs of the service. On the average, CMS has determined that the physician fee schedule is adequate. Considering that the actual blood drawing is incidental to the visit, excessive overhead costs can also be captured on the cost report, a vehicle not open to other types of providers.

12/30/02: Patients with chronic pain and chronic pain syndromes are typically seen every 30-60 days during which time the physician evaluates the symptoms and response to treatment. The new policy is very vague about how often the frequency of these visits should be. The policy should be well defined in advance so the clinics could decide whether to continue to treat these problematic patients locally or referred into a pain clinic, which is often located in a distant town.

There is an ongoing dichotomy between the need for flexibility to accommodate the diverse circumstances of atypical patients and the need for specific instructions that can be uniformly interpreted.  Additional specificity cannot be included without unduly limiting the flexibility of the provider to respond to unique clinical situations.  As a review standard, however, Riverbend will examine the medical records to determine whether the clinician is making progress toward a therapeutic or diagnostic goal, or whether the clinician is merely continuing an established regimen.  If the physician is continuing an established regimen that requires high utilization (e.g. frequent visits), it would be expected that the record showed some consultation with a pain management center/specialist who had confirmed that this was the optimum course of action.  This is especially true for physician extenders, who are expected to be in close consultation with the supervising physicians in an attempt to constantly improve the patient's status quo.

12/30/02: There are situations where a patient is seen by specialist in the city and advised to get certain injections (e.g. B 12, methotrexate, epogen, allergy shots or hormones) at the local clinic. These patients consume the time of the staff but according to the LMRP this would not result in a net increase in reimbursement to the clinic. The Rural Health Clinic would not be able to absorb the cost of the services. We propose that the clinic should be paid for the nursing encounter or nursing visit at a reasonable rate which may be different than the provider in encounter rate.

Riverbend acknowledges that these patients consume resources, but notes that they do in fact increase the Medicare reimbursement to the clinic. The basis for RHC reimbursement is the cost report. The RHC should not be providing injections to people who are not their patients, so the injection recipients will be having face-to-face visits during the course of the year. The per visit reimbursement rate is based on the total costs of the RHC; as injection visits increase costs (both in terms of supplies and in terms of increased staffing requirements) these costs are reflected in an increased per visit reimbursement rate. Thus, the clinic is in fact paid for nursing encounters and the cost of those encounters (like the cost of administrative services) is included in the costs used to determine the rate of physician encounter reimbursement.

12/30/02: Patients in rural areas are uneducated and are unable to monitor their disease status at home. The standard of care should be different for this kind of population than the well-educated patient population in cities.

All patients in rural areas are not uneducated, nor is the urban population exclusively educated. Urban populations, particularly those represented in hospital clinics, include a large percentage of "inner city" residents with many of the same problems as are seen in rural areas. In fact, many rural residents are particularly inclined to follow physician orders without question. Be that as it may, the primary normative data is expected to come from other RHCs and due consideration will be given to the patient population when other references are used.

12/30/02: The policy may restrict the care of Medicare beneficiaries in the rural clinics. For example, the patient or clinic may assume that a patient with hypertension cannot come to the clinic before a three-month time period even if the patient is having a problem.

Note that this policy is carefully worded to avoid the occurrence of absolutes. Even in a case of hypertension, where national guidelines for follow-up are referenced, individual medical necessity is always overriding. More frequent follow-up visits are always appropriate as long as the medical record clearly justifies the need for a more intensive level of service than is typical. Conversely, there may be certain patients who are particularly stable and require less frequent follow-up; that too is appropriate. However, barring conclusive evidence that a given provider had an unusually atypical patient population, the aggregate of a provider's follow-up pattern should not be significantly different from the norm. Note also that these guidelines refer to scheduled follow-up; patients are never held to a "quota" of visits but are expected to use some level of individual judgment that is qualitatively similar to the population as a whole (the "prudent layperson" standard).

12/30/02: Is a chiropractor a qualified RHC provider, and how is medical necessity for chiropractic services determined?

CFR42CUR 405.2401 notes that physician means (2) "within limitations as to the specific services furnished, a doctor of dentistry or dental or oral surgery, a doctor of optometry, a doctor of podiatry or surgical chiropody or a chiropractor. Therefore a chiropractor can see RHC patients as an RHC service as long as 1) the services are medically necessary (and that includes continued improvement), and the services are within the scope of practice of the chiropractor, and 3) the services are utilized in a pattern that is not inconsistent with utilization patterns in other types of institutions. 

12/30/02: The language that is used in this policy  appears to be in direct conflict to SEC. 1801. [42 U.S.C. 1395] which prohibits supervision or control over the practice of medicine or the manner in which medical services are provided. Our concern is specifically with the extensive definitions the policy makes in defining what constitutes a medically necessary encounter with a physician or extender. 

It seems that it would be more to the point and more effective to state that "using physicians and extenders for services routinely performed by ancillary staff, for the purpose of creating a face-to-face payable encounter, is strictly prohibited and will be pursued as fraudulent claims". 

Although it could be due to misinterpretation of the regulations as well as overt fraud, this sense of your summary statement is exactly the intent of both of these quotes.  The policy is not directed at overt fraud (that is more appropriately handled by the Benefit Integrity department) but at a need to better define some of the regulations in order to reduce the variability in provider interpretation. The policy is extensive not to create a new layer of bureaucracy but to provide a single reference that answers all of the ambiguous questions that come up from time to time. The mainstream provider, such as those that would agree with your general comments, should not have to make any reference to this document as they in all likelihood already have a mainstream interpretation of the relevant Medicare regulations. 

12/30/02: We are concerned with the statement that "Unscheduled return visits are not medically necessary when the patient exhibits a pattern of presenting without a problem or an exacerbation of an existing problem that would cause a prudent layperson to seek medical evaluation and treatment." It appears that your intent is to hold the RHC responsible for ensuring in advance that a patient has a medically necessary reason to be seen. The language gives the reviewer wide leeway in denying visits that, until the provider has evaluated the patient, there is no way of knowing that the patient had no acute complaints.

Please make reference to the sentence that follows your quote, which says "This pattern of behavior constitutes an excessive utilization problem for the RHC primarily when the facility a) does not attempt to educate the patient about the appropriate use of medical resources, b) enables multiple patients to overuse resources or c) maintains a fee structure that inappropriately encourages casual utilization." This is that check to prevent overzealous application during review as it specifies that the RHC is responsible for a) not promulgating an environment that encourages the patient to use resources inappropriately and b) attempting (although success is not required) to educate the patient into a more appropriate pattern of behavior.

12/30/02:  I would agree that injections should not be given without provider presence, because of the risk of adverse reaction. However, in some particularly rural communities, even midlevel providers may be available less than 40 hours a week. It would be a benefit to our patients to be able to provide lab draws, blood pressure checks, strep screens and urinalyses with results called to provider, etc.

The definition of general supervision in a non-hospital environment does rely on the presence of a qualified practitioner. However services that do not generate a discreet "incident to" charge (most specimen collections, follow-up phone calls, and -- typically -- blood pressure checks) as well as services that are not RHC "incident to" services (blood drawing performed in support of a Part B laboratory service) do not require the presence of a physician. Based on your examples, you should be able to operate much as you desire. If the delivery of any services are constrained, regrettably this is due to the Social Security Act itself and cannot be modified by Riverbend.

12/30/02:  I would encourage a policy change in terms of the rule on multiple visits on the same date. In rural areas, transportation can be a significant difficulty. There are no buses; families may have only one working vehicle and may have to plan weeks in advance to get "into town." If a Rural Health Clinic has social work/counseling, primary health care, dental services and podiatry, it may be in a patient's best interest to be dropped off at 10 am, and picked up at 4 pm, and sit in the office all day between appointments so they can get things done somehow. Otherwise, needed services may not be accomplished.

There is no impediment to providing multiple services to the beneficiary on the same day. If some of the services are non RHC services provided by non RHC providers, they may be separately billed as Part B services. Similarly, certain identifiable procedures that are excluded from coverage (e.g. dental services, primary health care) may be directly billed to the patient. Otherwise, though, the RHC benefit is a "general practice" reimbursement scheme that is not comparable to a hospital multi-specialty clinic. Since it is impractical to tease out multiple provider visits for different purposes from multiple provider visits for the same purpose (is a podiatrist evaluation for diabetic foot care a separate problem from the internist evaluation for diabetic complications?) and since the general model of the RHC is that services are provided by multitalented generalists, multiple encounters on the same day are considered to be part of the same "visit" for reimbursement purposes. Note that these high-intensity multiple provider "visits" do raise the overall cost per visit (and therefore the payment per visit) through their impact on the cost report.

12/30/02: There is no allergist practicing in our community, so our patients go anywhere from 1 1/2 to 4 hours to see a specialist. Therefore, to receive allergy injections from these practitioners would require a three to eight hour weekly commute. For our patient's convenience we have been administering injections in our office. In your LMRP you state "The allergy shot...represents a service that is incident to a prior physician visit." True, but not our physicians. As I'm sure you are aware, allergy injections are a potentially hazardous procedure with deaths from anaphylaxis reported. Therefore, our policy is to have a practitioner personally responsible for the patient while he receives his injection, and to see the patient to make sure he is safe for discharge. We believe this constitutes a medically necessary face-to-face visit.

Since you were only administering allergy shots to "your patients", there is some physician visit at which you ascertain the general health of the patient, establish in your own mind the medical necessity of the other physician's order for allergy shots and determine it is both safe and effective for you to administer them in your office. That visits serves as the qualifying visit for the "incident to" service. Allergy shots are typically administered under general, rather than direct, supervision with the physician personally evaluating the patient only when there is some particular medical concern. That standard, typically seen in RHC's as well as hospital clinics and physician offices, has been applied here. Evaluating each allergy shot recipient prior to discharge would constitute a face-to-face visit, but not a medically necessary one. The medical necessity, in the absence of complications that warrant an immediate evaluation, would only be established by the unique circumstances of a given injection, such as the first injection for a new patient or a history of difficulty with the immediately preceding injection.

12/30/02: At present we are managing anti-coagulation in the traditional way: the patient goes to our local hospital for the blood test, we get the results, call the patient and adjust the Coumadin. About a year ago I admitted a patient of mine with a massive stroke which killed her a few days later. She was a lady with chronic atrial fibrillation, who decided on her own to stop taking her Coumadin--the present system has no way of tracking these patients. Since then, I've been interested in other ways of providing this service. We are now looking into a Coumadin clinic involving point-of-service testing. In this model, the practitioner would perform the blood test himself using a hand-held tester. Results would be available immediately, and the practitioner would make the appropriate dosage adjustment. A computer will track all Coumadin patients. We would like to bill this as a face-to-face visit, with the lab test inclusive.

It is true that many Coumadin Clinics use a nurse to adjust dosage, and that is quite appropriate. However, our practice is to have only practitioners make these changes, as we do not have enough volume to fully train an RN. You state in your LMRP "The periodic monitoring of a given test (e.g. INR...) should not be associated with routine follow-up visits to report these results as this does not reflect the practice in physician offices and out-patient clinics." Traditionally, this is correct, but under this new model, the service does require a "provider level of expertise."

The new model that you describe is not a uniform procedure for dispensing medical care but a collection of practices that can be variously combined into a process that aids the physician in managing patients on Coumadin. There are several problems with treating this as a unique service. First, PT testing is not an RHC service but a Part B (laboratory) service. Riverbend cannot consider it to be part of the RHC service, although of course the RHC cannot be prevented from providing it "free of charge." Second, most Coumadin clinics do make extensive use of nurses, even to the extent of allowing them to "direct" changes in medication. However, under the RHC benefit the services of nurses are incident to the service of the physician, and this serves to underscore the difference between physician management and the necessity for physician involvement at every visit. Third, a cited benefit of the Coumadin clinic is the ability to better keep track of results and avoid circumstances such as you described in your opening paragraph. However, the requirement to follow-up on lab tests and convey therapeutic changes to the patient is incumbent upon the physician in all environments; it is assumed that this is addressed in the "traditional" model and therefore it does not serve to justify additional "visits" to a Coumadin clinic. Finally, the RHC is in no way prohibited from incorporating elements of the Coumadin clinic model, but the existence of that model alone is insufficient to justify the medical necessity of visits at a frequency significantly greater than that of the population of large.

12/30/02: This is a comment regarding "Recurrent Services" about blood pressure measurement follow-up frequency medical necessity. The proposal specifies maximum frequencies for follow-up which are supposedly 'consistent with the recommendations' of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. I failed to identify any language in the Committee Report which specifies a limitation on frequency of follow-up visits for purposes of medical necessity. The Report does specify minimum expected frequency of follow-up visits.

Although differences of opinion could exist, the report appears to contain a "recommendation" for the timing of follow-up, not a minimum or a maximum. This recommendation is referenced as a benchmark; more frequent follow-up visits may be indicated in specific instances but the medical record would be expected to document specific medical necessity.

12/30/02: The paragraph on non-covered preventive services is confusing. RHC services do include prenatal and postpartum care, well-child, well-adult (health maintenance) and contraceptive services under Medical Assistance, and I believe that for those rare beneficiaries who are Medicare-eligible younger individuals, are covered by Medicare as well. Moreover, some of those services are exactly the types listed as part of the intent of the RHC legislation. A clearer distinction should be made between services which are "covered by Medicaid", "covered by Medicare under RHC benefit" and "covered by Medicare Part B". The issue of the rare individuals who are Medicare eligible and children, or Medicare eligible and pregnant should not be ignored.

You appear to be referring to RHC Manual 404.1. Note that these preventive services are covered when provided in an FQHC but are not covered services in an RHC. The RHC benefit does not extend to preventive care.

12/30/02: In hypertension management, it is not inappropriate to see patients weekly, or occasionally more often if the pressure is markedly uncontrolled (200/120) and new meds with potential risks or interactions with existing meds are being started or adjusted. Many of these patients have coexisting diabetes, COPD or ASHD, and may be on 6 other drugs. The listed periodicity of "monthly" for uncontrolled hypertension should not be applied to the truly unstable patient. Obviously, once improved control is established, the periodicity should appropriately decrease. The definition or criteria for "accelerated hypertension" is unclear; perhaps you could substitute "unstable" or "severe".

Accelerated hypertension (strictly high blood pressure accompanied by retinal changes without the presence of papilledema) more generally represents hypertension that does not represent an immediate danger to the individual but which nonetheless must be rapidly corrected to avoid permanent end organ damage. Both unstable and severe are reasonable approximations and is added in the policy.

 Thus the "uncontrolled" and "unstable" patients you describe may well have a medical necessity for more frequent visits. It is reasonable to assume that the documentation of the high blood pressure combined with the documentation of ongoing physician intervention (e.g. medication change) would justify that medical necessity during an audit of the medical record.

12/30/02: Using the criterion "reason for visit not documented or listed only as f/u or checkup" as a reason to deny medical necessity is inappropriate for chronic disease management. When patients are being managed for chronic disease, particularly multiple diseases, it is time-consuming to write or dictate the list of conditions in the "subjective" part of the documentation, particularly when the diseases are usually listed in the "assessment" portion. It merely adds verbiage, not content. In addition, often the nursing staff will write the initial phrases of the history in the written chart, and to most patients with chronic diseases, the appropriate periodic visits for management are "checkups" and "follow-ups". The medical necessity should take into account the entire service, and not be based upon an interpretation of the initial statement.

In evaluating the documentation for evidence of the reason the patient was asked to return, the entire submitted chart (preceding note, nurses notes, and entire physician note) serves to justify the medical necessity for the visit. Therefore, specific phrases do not need to be copied by the nurse or the physician; rather, it must simply be apparent in reviewing the documentation that there was a reasonable medical indication for requesting patients follow-up at the scheduled time. "Follow-up or checkup" does not provide that information, but that does not preclude the possibility that the information can be obtained elsewhere.

12/30/02: Just as in the hospital record, many notes may be initialed or signed in a form, which although clear and unique within the facility, may not be self-evident as identity to external reviewers. The statement "inability to identify the signatory by provider" is confusing, since an individual's signature may be perfectly identifiable to all individuals using the record, but may not be so to a particular reviewer. If a facility has a log or register of signatures and names, submitting a copy of that should be sufficient to clarify the identity for any questioning reviewer. Claims should not be denied for this reason, but questioned. Item #1 should be modified to specify that the signature of a handwritten note should be uniquely identifiable within the facility (as noted above). If unclear, a log or register of "signatures" can be furnished.

Riverbend agrees that claim should not be denied for this reason; the wording in the policy is not an attempt to create a reason for denial but an attempt to decrease denials that are already occurring by "asking the question" upfront. A log or register is certainly a reasonable idea. Riverbend would not want to require that additional documentation in all instances, but it offers a reasonable option for the facility if it is concerned that the validity of the signature may be challenged. 

12/30/02: The date of service should be listed, but asking for the date of signature is a foolish, wasteful additional burden of physician time.

The date that should be present on the medical record should be the date of service; the only instance where a separate date of signature would be indicated would be the rare instance in which the physician writes the note or signs the note on a date well after the service was rendered. This is no more than good record keeping, and represents the usual practice of most physicians.

12/30/02: Documentation requirements: Item #3 (dictated entry) should only require a validation by the provider, since the name has been furnished by the transcriber. The validation should be able to take whatever form the provider wishes: a signature stamp (under appropriate security), initials, an "ideographic" mark, or a signed name, since it is only necessary for validation, not identification.

This is exactly the intent of the policy. 

12/30/02: Electronic signatures on electronic-only, as well as computer-generated records should be governed by appropriate security, which is globally imposed by the vendors of such software, and is subject to HIPAA, which should obviate the necessity for any additional attestation. If there were questions about a particular facility's records, an attestation could be requested.

Historically a problem area with frequent denials has been the review of claims generated by automated systems which vary from the manually typed signature at one extreme to the totally paperless computer-generated record at the other. The request for a photocopy of a simple signed statement by the provider attesting that the security of the system is sufficient such that only he can generate his typed "signature," is a mechanism whereby the facility can send a single photocopy and thereby eliminate the risk of "signature" denials. The copy of a filed document will be sufficient to verify security in those instances where it is not evident from the format of the computer generated records.

12/30/02: Tele-health: It is unclear if the tele-health originating facility fee is to be billed to the RHC intermediary (Riverbend) or the Part B carrier. It may become common for RHC's to serve as the "distant consultant", particularly for RHC's who have specialty practitioners among their number, or when the services of a physician, as opposed to a physician extender, is necessary. In our practice, there are multiple RHC's - a main central one, and satellite facilities. Billing the RHC carrier for the originating site fee and the part B carrier for the tele-consult is confusing, but viable.

The Tele health originating facility fee is not an RHC service in accordance with PM-01-0 69; therefore, although it is paid outside the RHC inclusive rates, it should be billed to the carrier not the intermediary. 

12/30/02: Will the creation of a digital image for diabetic retinopathy per retinal digital scope be separately payable in a RHC environment? The RHC physician creates the image, and sends it to an ophthalmologist for a diagnostic reading.  Will the RHC physician be reimbursed for the technical component (making the image) and the ophthalmologist be reimbursed by the carrier for the professional component (interpreting the image)?

The creation of an image for a physician to use is an incidental service not a physician service (like a telemedicine consultation).  If it is created in conjunction with a medically necessary physician assessment, the entire visit constitutes a face to face.  If the patient is brought back solely to obtain the image, it is an incidental service and does not constitute a medically necessary face to face even if performed by the physician/extender.

12/30/02: We have a transcription system that sends transcribed documents back to the provider electronically for review and E-signature. Once signed, the documents print out and are placed in our paper record. We do not have an electronic medical record.

It appears that we are somewhere between number 5 and number 6. The provider reviews the transcription, authenticating it, and then e-signs it. But then it is printed for our paper record. Only our providers have passwords that allow for dictating or altering their dictated word. All other employees have a " view only" security level if they have it at all. Medical staff knows that their numbers cannot be shared with employees. I find it cumbersome that we would need to send an attestation statement each time you review a record.

The Fiscal Intermediary is charged with insuring that Medicare regulations are followed, and one of the regulations is the requirement that electronic signatures are appropriately password protected. Since there is no reasonable way for the FI to do that, practitioners are asked to affirm that appropriate protection, such as you described, is in place. This does not need to be (and should not be) on a case-by-case basis. Rather, if the practitioners sign a statement verifying that the system is secure -- such that, if a practitioner sees his electronic signature on a page, he knows that he is the one that put it there -- then the facility can enclose a photocopy of that statement with any records. This would help insure that records are not inappropriately denied due to "lack of physician signature." Note that legal conventions such as notarization are not required; the statement of the provider is sufficient.  

12/30/02: Do lab, x-ray and other diagnostic tests need to be initialed by the ordering provider? We do now initial. The hospital is looking at software that would electronically allow providers to view results and produce an exception report for all those not viewed. But it has no capability to have the provider electronically sign the paper document.

There is no Medicare requirement for lab results to be initialed by the provider. Many certifying agencies do like to see a procedure that ensures that the physician has reviewed all relevant clinical information, in this type of procedure is an excellent quality initiative. However it is not required for Medicare reimbursement.

12/30/02: Monthly nursing visits are crucial to maintain good patient care. You must realize that physician/extenders are responsible for the care of nursing home patients 7/24/365, and are required to remain within a distance of a fifteen (15) mile radius of the nursing home. Additionally, we are called at all hours of the night to take care of problems. Making monthly rounds allows physician/extenders to take care of problems on a timely basis and give better care. There's no way you can expect to recruit young physicians to take care of nursing home patients when they now average 7-9 cents per hour and this will be reduced to 3.5-4.5 cents per hour ($60.00/30/24). Many problems are taken care of by the physician/extender on rounds, that would, in many instances would have to be taken care of in the middle of the night. I think making nursing home rounds every 60 days would be unfair to the patient and physician/extender. Many patients and others thinks the fee the physician/extender receives is only for the actual nursing home visit, while patient care is an ongoing problem requiring the physician/extender being available 7/24/365. I feel that seeing patients routinely on a monthly basis may be cost effective in that problems could be taken care of in a timely fashion obviating a hospitalization or prolongation of a medical problem.

For Medicare purposes (and, indeed, for reasonable medical purposes) a nursing home patient in an unskilled bed is no different from a homebound patient in his personal domicile. Physicians are equally on-call for their patients at home, yet do not compute an "hourly rate" based on 24 hours a day. If the patient has medical problems that require frequent visits, there is no impediment to seeing the patient as often as is medically necessary. On the other hand, if a nursing home resident has no active medical problems to require a physician visit, then there's actually no medical necessity for even a bimonthly visit -- fulfilling the requirements of a nursing home bylaw is not a medically necessary task. However, visits to fulfill Medicare and Medicaid requirements can in some instances be deemed to be medically necessary, hence the allowability of the bimonthly visit.

01/30/03: We normally bill pregnancies with a global code after delivery.  There is no charge for prenatal office visits.  Under Rural Health, would we bill for the prenatal visits as a Rural Health visit then bill Part B for just the delivery?  Or would the prenatal visits still be no charge visits and bill the global to part B?

Routine pre-natal visits are not an RHC service, just as annual physicals are not.  RHC Manual Section 404 lists prenatal/postpartum care as a primary preventive service payable to FQHCs (over and above services payable to RHCs).  The delivery global is paying for routine pre-op and post-op care, so billing the global to part B and not billing any of the visits to Part A would be the most appropriate.  However, the RHC would have to be certain that it complied with 408.2 regarding the separation of RHC and non-RHC services.

01/31/03: Are routine Pap smears and sigmoidoscopies covered RHC benefits and how should they be billed? In "Medicare & You 2002, Physician Edition" page 35 there is a list of Medicare Part B covered preventive services. This includes sigmoidoscopy, pelvic exam (includes a clinical breast exam), and a digital rectal exam. Are any of these covered under the RHC benefit? If these are non-RHC services, can I bill them to Part B carrier?

 Preventive services are RHC services. A service that requires face to face visit should be billed as an RHC visit.

Services that do not require face to face visit with a practitioner (e.g. stool guiac) are ancillary services and are covered RHC expenses but do not generate a face to face visit.

03/07/03: We have a question regarding the coverage of TB testing for both intradermal (86580) and tine (86585).  According to Medi-939-01 dated 03/19/01, RHC providers were instructed to bill Part B for laboratory services.  TB testing is grouped with the 80000 codes in CPT, but it is not a true lab service.  Do you feel TB testing should be billed to Part B, Riverbend, or the patient? 

I don't think TB testing is a CLIA-waived test.  I think it is an office procedure. If it is done due to signs or symptoms or as a consequence of exposure to the disease, it would be an RHC service that does not require a separate face to face encounter (i.e. it would be part of the encounter during which the signs or symptoms were evaluated). 

If it is being done for routine screening or preventive care or for employment, it would be billable to the patient as non-covered by Medicare.

05/28/03: Can LCSW do Group Therapy? Does this qualify as a face to face encounter for each individual in the group?

Group therapy is NOT consistent with a face to face visit.  The group therapy would be reimbursable on the cost report only (as an "incident to" service).