Updated: 3/2/2006
Frequently Asked Questions- Billing
Click here for "How does a RHC bill for surgeries?"
Click here for "How to bill for laboratory services in a RHC?"
How does a RHC bill for the "Welcome to Medicare" Physical?
Click here to go to the Texas Assoc. of RHCs FAQClick here to go to the RAC Online FAQ
FAQ From Healthcare Business Specialists on Certification Issues
What is the best way to get your RHC billing Questions answered?
The best way to get your questions answered is to ask the payer and ask in writing. In most cases that would be the Intermediary. Under provisions in Section 903 of the MMA of 2003; if you write your intermediary with the question and the appropriate billing facts - the carrier or intermediary must respond in writing (electronic) with the answer. If you follow that guidance; they can not penalize you or the clinic in any way; however, they could still take the money back if they determine their interpretation was incorrect. Here is the language from the MMA of 2003:
"a provider of services or supplier follows the written guidance (which may be transmitted electronically) provided by the Secretary or by a Medicare contractor (as de-fined in section 1889(g)) acting within the scope of the contractor’s contract authority, with respect to the furnishing of items or services and submission of a claim for benefits for such items or services with respect to such provider or supplier; ‘‘(ii) the Secretary determines that the provider of services or supplier has accurately presented the circumstances relating to such items, services, and claim to the contractor in writing; and ‘‘(iii) the guidance was in error; the provider of services or supplier shall not be subject to any penalty or interest under this title or the provisions of title XI insofar as they relate to this title (including interest under a repayment plan under section 1893 or otherwise) relating to the provision of such items or service or such claim if the provider of services or supplier reasonably relied on such guidance. ‘‘(B) Subparagraph (A) shall not be construed as preventing the recoupment or repayment (without any additional penalty) relating to an overpayment insofar as the overpayment was solely the result of a clerical or technical operational error.’’.EFFECTIVE DATE.—(1) shall take effect on the date of the enactment of this Act and shall only apply to a penalty or interest imposed with respect to guidance provided on or after July 24, 2003."
Local Coverage Determination (LCD)
Most of your questions regarding billing can be answered if you refer to the Local Coverage Determination (LCD) (On 12/28/2005 Riverbend converted from Local Medical Review Policies (LMRP) related to Rural Health Clinics into a Local Coverage Determination (LCD) and changed some of the language from the previous LMRP.) All rural health clinics that are serviced by Riverbend should review the document by going to the Riverbend website at LCD-4874. If you can not find the answer in the LCD; I would look in the FAQ section of the LCD. It is over 20 pages in a question and answer format. To review the FAQ follow the link to it.
Local Coverage Determination (LCD-4874) dated 12/28/2005
FAQ from Riverbend regarding Local Coverage Determination
Can a Rural Health Clinic bill for an office visit and a hospital admission on the same day?
Riverbend GBA will allow an office visit and a hospital admission in the same day; while other intermediaries may not allow this. In a response to an email in the summer of 2005, Trailblazer in Texas indicated that this was allowable as well. This policy is somewhat contrary to what most professionals who have been working in the Medicare Part B billing system for years are used to (only one visit per day). The Office of Inspector General did take exception to this treatment in the Review of Hutchinson Rural Health Clinic and click here to read the report:
Review of the Hutchinson Rural Health Clinics, A-07-00-00118
The best answer on this question is to ask the payer what their policy is on this issue.
How does a Rural Health Clinic bill for Hospice patients?
RiverbendGBA instructs providers to code ALL Hospice patients with a Condition Code 07 and Riverbend will pay the claim. If you have another intermediary you should check with them on their policy toward hospice billing; however, it will most likely read something like the following:
Hospice is never a RHC covered service. If a Hospice patient is treated by a rural health clinic physician for services not related to the patient’s terminal condition; the rural health clinic should include condition code 07 in Form Locators 24 through 30 and the claim should be paid by the RHC intermediary. However, most intermediaries are very broad in their determination of what is attributable to the terminal condition and I would expect to receive a request for additional information before the claim is paid.
If the service is an attributable to the patient’s terminal condition it is the responsibility of the Hospice to contractually pay the attending physician as well as the RHC physician.
If the RHC physician and the Hospice Attending physician are the same physician; Medicare has recently changed procedures to allow the attending physician to include a modifier and receive Medicare Part B payments for specific Hospice patients. See the Medicare Carriers Manual, Part 3, Chapter IV Claims Review and Adjudication Procedures for the new procedures for billing Medicare Part B.
4175.1 Processing Claims for Attending Physicians Who Treat Hospice Patients.--When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, not employed by the hospice, in addition to receiving care from hospice-employed physicians. The professional services of a non-hospice affiliated attending physician for the treatment and management of a hospice patient’s terminal illness are not considered "hospice services". These attending physician services are billed to Part B, provided they were not furnished under a payment arrangement with the hospice. The attending physician codes services with the GV modifier "Attending physician not employed or paid under agreement by the patient’s hospice provider" when billing his/her professional services furnished for the treatment and management of a hospice patient’s terminal condition. Make payment to the attending physician or beneficiary, as appropriate, based on the payment and deductible rules applicable to each covered service.
When services related to a hospice patient’s terminal condition are furnished under a payment arrangement with the hospice by the designated attending physician, the physician must look to the hospice for payment. In this situation the physicians’ services are hospice services and are billed by the hospice to its intermediary.
4175.2 Services Unrelated to a Hospice Patients Terminal Condition--You may receive claims from physicians and suppliers for services not related to the hospice patient’s terminal condition. These services are coded with the GW modifier "service not related to the hospice patient’s terminal condition." Process services coded with the GW modifier in the normal manner for coverage and payment determinations. If warranted, you may conduct prepayment development or post payment review to validate that services billed with the GW modifier are not related to the patient’s terminal condition. (Note: RHCs use Condition Code 07 to indicate that the services were not related to the terminal diagnosis).
Home Care Oversight - Question
I am unable to find any guidance on the rules of home health oversight codes G0179, G0180, G0181, and G0182. In the past, if the services were provided by the RHC physicians at a time when the RHC was not operational but the physicians were seeing nonRHC patients, it was possible to bill these services to Part B, PGBA carrier. However, now PGBA instructs us to file this service as an integral part of an office visit and to include it with our charges to Riverbend. Have I missed something or are these charges now RHC, even if the work is performed when the RHC is closed or even if the physician is not on RHC duty but is working in the hospital that day.I am unable to get a straight answer from PGBA or Riverbend. There is no reason to keep on logging all this home health if there is no charge allowed for it.
Home Health Oversight can not
be billed as a rural health clinic service during RHC hours as there is no
face to face visit.
Skilled Nursing Home - Question
Do you have any information on SNF visits and as of January 1, 2005 should all be billed to RHC? Are there any guidelines on the number of visits and how often?
All nursing home visits are billable to rural health
clinics effective 1/1/2005. (you may choose to bill them to Medicare B
on the Part B fee schedule if you exclude the cost on the cost report). The LMRP for Riverbend says 1 every 60 days for
routine visits at level 1 nursing home and 1 every 30 days for routine
visits at skilled nursing homes. As always medical necessity overrides all
numeric guidelines so visits should be carefully documented.
Since many of our clients are interested in Skilled Nursing
Home and NF visits. The Local Coverage Determination (LCD) from
12/28/2005 specifically addresses this issue as
follows: "A
physician/extender visit to a beneficiary in a skilled SNF bed or a
swing bed is medically necessary on a monthly basis to evaluate the
patient status as it relates to the skilled service. A
physician/extender visit may constitute a medically necessary
face-to-face more often than monthly only if the medical record
supports the necessity of more frequent evaluation. (For the
purposes of medical review, monthly shall mean no less than 21 days
between visits.)
In order for a patient to be in a covered Part A stay in a SNF they
must have a 3 day acute qualifying stay (3 midnights) and then they
can be admitted to a SNF under Pt A IF they meet criteria of having
a skilled service performed at the SNF, i.e. PT, OT, ST, wound
cares, tube feedings, etc. The resident is given a maximum of 100
days in each benefit period, and they only get those 100 days
renewed when they have either not received skilled services for 60
days or they are discharged for 60 days and without any skilled
services being paid for by Pt A. All services must be certified by
their physician at 5 days, 14 days, 30 days, 60 days and 90 days (if
the patient still qualifies for skilled pt A services).
In response to the question
regarding the Medicare Secondary Payer forms required by Medicare;
this is the guidance that CMS provided in April, 2005 regarding this
form. Here are a few facts regarding MSP. Medicare Secondary Payer
(MSP) Summary
You do not have to use the specific
8-page form that Medicare prescribes and can use a shorter
version . - Here is a link to a form designed by one of the
list-serve members that is very good: Medicare
Secondary Consent form
Here
is a written response from CMS regarding the Medicare Secondary
Payer form:
CMS Policy (April, 2005)
Medicare law and regulations require that any entity
that bills Medicare for services rendered to Medicare beneficiaries
must determine whether Medicare is the primary payer for those
services. Section 1862(b)(6) of the Social Security Act (the Act)
(42 USC 1395y(b)(6)) requires all entities seeking payment for any
item or service furnished under Part B to complete, on the basis of
information obtained from the individual to whom the item or service
is furnished, the portion of the claim form relating to the
availability of other health insurance. Additionally, 42 CFR
489.20(g) requires that all providers must agree "… to bill other
primary payers before billing Medicare..."
Therefore, any provider, physician, and other
supplier that bills Medicare for services rendered to Medicare
beneficiaries must determine whether or not Medicare is the primary
payer for those services. This is accomplished by asking Medicare
beneficiaries, or their representatives, questions concerning the
beneficiary's MSP status.
While the law and regulations apply to all providers,
physicians, and other suppliers, CMS has issued explicit MSP
information collection requirements for
hospitals
only. You many find these instructions online in the MSP Manual in
chapter 3, section 20.1 and 20.2 at:
http://www.cms.hhs.gov/manuals/105_msp/msp105index.asp
Although CMS does not have explicit MSP information collection
requirements for other providers, physicians, and other suppliers,
it is in their best interest to collect MSP information as
frequently as possible
to ensure they are filing proper claims. A helpful tool that
may be used to collect MSP information is the "MSP Questionnaire"
found in the MSP manual, Chapter 3, Section 20.2.1, "Admission
Questions to Ask Medicare Beneficiaries." Please keep in mind that
the "MSP Questionnaire" is a model. You may add questions you feel
would be helpful in identifying other payers that may be primary to
Medicare.
If providers, physicians, and other suppliers fail to
file correct and accurate claims with Medicare, Medicare can recover
its conditional payments and, in cases where an entity knowingly
bills incorrectly, pursue civil monetary penalties or damages under
the False Claims Act.
Source: Suzanne Ripley, CMS Here is a response from the NARHC List serve
which is pretty typical of an on site review for MSP.
"We just had a Tri Span Medicare Secondary On Site Review at our
Facility here in Louisiana. They were very clear that the MSP form
was to be completed on each patient for each visit and each question
answered. (paper or electronic is acceptable) However, Tri Span said
no signature is required of the Beneficiary on any document, just
the name of the person who is giving the information. They actually
pulled our files at the hospital and checked for the MSP and did and
education which did include the RHC that is provider based."
Source: NARHC List-Serve
A physician/extender visit to a beneficiary in a non-skilled bed,
intermediate care facility or nursing home is not medically
necessary on a routine basis even if the nursing facility requires
it as a condition of patient residence. However, Medicare does
"presume" visits to be medically necessary if they are used to
satisfy Federal Regulations. Based on these requirements, detailed
in the Code of Federal Regulations [42 CFR 483.40], a visit to a
patient in a non-skilled bed, ICF or nursing home will be considered
medically necessary if it has been approximately 60 days (for the
purposes of medical review at least six weeks) since the last visit.
At frequencies greater than this the encounter is only medically
necessary if it occurs in response to a patient complaint or in
follow-up to an established medical condition; in both instances the
visit is medically necessary only if an office visit would be
medically necessary under the same circumstances."
The only way a clinic is going to know if that person is on a PT A
stay is to ask the SNF and the patient's doctor that certified the
skilled days. Janet Lytton
Rural Health Development
Medicare Secondary Payer Rules (MSP)
No specific regulations for RHCs
Hospitals do have specfic regulations
and guidance they must follow.
RHC's should collect the information
"as frequently as possible" (Riverbend said every 90 days on
April 1, 2004; however, CMS has since indicated that the 90
day rule does not apply to RHCs and RHCs should collect the
information "as frequently as possible". - It would seem
that we would go back to "obtain the information every
visit" standard.
The patient does not have to sign the
form.
It can be maintained electronically.
It must be maintained for 10 years.
(that's the hospital guideline)
FAQ from Riverbend Government
Benefits Adminstrator
These FAQs are from the Riverbend Part A Intermediary website.
1) When I receive my all-inclusive rate of payment from RGBA, do I begin billing UB-92 claims using that rate as my charge?
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The all-inclusive rate of payment provided by RGBA pertains to your payment per visit only. You may begin billing your claims to RGBA after your all-inclusive rate of payment is established; however, your facility should already have a fee schedule established detailing what charges are applicable to the services you provide. RGBA uses the all inclusive rate to calculate your payments per visit only. Your all inclusive rate only reflects the amount paid to your facility per encounter, not the amounts you should charge for your services. |
2) Do I bill Flu/PPV to RGBA on a UB-92 claim form?
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RHCs do not bill Flu/PPV on a UB-92 form. Each facility should maintain a log of these services to be submitted to Riverbend GBA along with your year-end cost report. These injections are not subject to coinsurance or deductible application, and should not be billed on a UB-92. If you are billing the face-to-face encounter when the injection was administered, the Flu/PPV vaccine diagnosis, example V0481, should not be shown on the UB-92 form. |
3) If I do not have the Direct Data Entry (DDE) system, is there a way I can locate the reason codes indicated on my 201 reports, “Summary
of Returned Claims” report?
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Yes. The RGBA web site has the reason codes listed for your review at www.riverbendgba.com. Click on the words “Reason Code Listing” to view the entire list of codes available. |
4) What about the remark codes indicated on my remittance advice from RGBA? Are those codes listed anywhere on the web site?
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MS is the national maintainer of the remittance advice remark codes list. The complete list of remark codes is available at http://www.wpc-edi.com/codes/Codes.asp. If you have DDE capability, the remarks codes are also maintained on that program under option sixty-eight (68) on the Inquiry Menu. |
5) How does an RHC bill if the patient presents for services and does not have a face-to-face encounter with the RHC physician
or practitioner?
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The
General Billing Requirements section of Publication 100-4,
located on the CMS web site, describes form locator 46 examples
of Medicare billing. RHC charges for services performed on days
in which there was no face-to-face encounter should be billed as
outlined in the following example: |
6) How do I bill for covered injections?
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Medicare covered injections, such as B12 or allergy, are billable on the UB92 to Riverbend GBA as long as the face-to-face requirement has been met. Please refer to question number five on the previous page for further information regarding billing for services without a faceto-face encounter on that same date. Another source of information regarding this is the RHC Courier dated December 2001. The article on page five contains information regarding “Medically Reasonable and Necessary Face-to-Face Encounters.” The RHC Couriers are listed on our web site at www.riverbendgba.com. |
7) If an RHC employs a new provider in the facility, do I need to complete paperwork before I submit claims for that provider?
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No. Riverbend GBA pays the facility rather than the individual physician; therefore, you only need to indicate the UPIN of the attending provider when submitting your claim to us. You may want to contact your Part B carrier to determine what information is required prior to submitting claims for services to that payer. |
8) I have several claims on a patient that have been returned numerous times referencing an error in
the name indicated on the claim form. How can I be certain I am submitting the correct information
regarding the patients name and HIC number?
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When submitting claims to Riverbend GBA for services provided to a Medicare beneficiary, be certain that the name entries in form locators 12, “Patient Name”, and 58A (or 58B if Medicare is the secondary payer) “Insured’s Name”, matches exactly what is printed on the patients Medicare card. Close attention should be given to patients bearing Jr. or Sr. at the end of their names. When entering this information on the claim form, if a space is indicated on the Medicare card, then a space should also be entered on the UB-92 claim form where applicable. |
As an RHC facility, a patient comes in for a face to face encounter leaves and returns that afternoon is the second visit considered a face to face billable encounter?
The RHC guide section 504 states: "Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit, except for cases in which the patient, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment". (12/30/2002)
When preparing the cost report and counting total face-to-face visits, do we count the number of wellness exams performed on Medicare and non-Medicare beneficiaries in the total number of visits.
Yes, you will count the number of wellness exams performed in your facility in the total number of visits. (6/12/2003)
When a Medicare patient comes in for a yearly physical and also has a valid E & M on the same day, how do we bill the patient?
Your facility should bill the face-to face encounter to RGB You may choose to include the yearly physical, however the charges for the physical will be in non-covered charges. Routine exams are statutorily excluded services. The diagnosis code should represent the face-to-face encounter. You will not want to show a diagnosis code for the physical. (6/12/2003)
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http://www.ashp.org/reimburse/docs/Suppl%206_Mitchell.pdf
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What to do if your NP or PA Resigns?
Answer - You need to report the loss of a mid-level to the State as soon as possible and start recruiting someone. Document your efforts to find someone and you can apply for a waiver in 90 days if you do not find someone. The State will then grant you one year to find someone if they approve your waiver.