| LMRP Database ID Number |
L4874 |
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| LMRP Title |
Rural Health Clinic |
| |
| Original Policy Effective Date |
For services performed on or after
12/27/2002 |
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| Original Policy Ending Date |
|
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| Revision Effective Date |
For services performed on or after
03/11/2003 |
| |
| Revision Ending Date |
|
| |
| Contractor's Policy Number |
083-02 |
| |
| AMA CPT / ADA CDT Copyright Statement |
CPT codes, descriptions and other data
only are copyright 2003 American Medical Association (or such other
date of publication of CPT). All Rights Reserved. Applicable
FARS/DFARS Clauses Apply. CDT-4 codes and descriptions are ? 2003
American Dental Association. All rights reserved. |
| |
| CMS National Coverage Policy |
Title XVIII of the Social Security Act,
Section 1862 (a)(1)(A). This section excludes coverage of items or
services that are not reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member.
Title XVIII of the Social Security
Act, Section 1862 (a)(7). This section prohibits Medicare payment
for any expenses on items and services incurred for routine physical
examinations.
Title XVIII of the Social Security Act, Section
1833 (e). This section prohibits Medicare payment for any claim
which lacks the necessary information to process the
claim.
Title XVIII of the Social Security Act, section
1861(aa). This section sets forth the rural health clinic services
and defines the requirements imposed on RHCs.
|
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| Primary
Geographic Jurisdiction |
NJ
TN
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| Secondary
Geographic Jurisdiction |
AK
AL
AR
AZ
CA
CO
CT
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
NC
ND
NE
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
TN
TX
UT
VA
VT
WA
WI
WV
WY
|
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| Oversight Region |
Region IV |
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| CMS Consortium |
Southern |
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| LMRP Description |
The Least You Need to Know
Rural Health Clinics provide
covered services that can be divided into RHC services and
non-RHC services; RHC services are further subdivided into
physician services (evaluation and treatment by a physician
or physician extender) and services that are
"incident to" a physician service.
When a patient presents with
a problem or an exacerbation of an existing problem requiring
an evaluation and diagnosis by a qualified RHC practitioner,
this constitutes a visit. The documentation must support that
physician services (as defined above) were performed by that
qualified practitioner. Patients that present to the clinic
for services that do not require the expertise of a qualified
RHC practitioner are receiving services "incident to" a prior
physician/extender service (face-to-face visit). This does not
require a new face to face encounter. If the
physician/extender does not personally perform the service,
the episode does not constitute a face to face encounter.
However, even if the provider of the service is a qualified
RHC practitioner, the episode still does not constitute a
"visit" unless physician/extender services are provided in
addition to the "incidental" services. Further, the face to
face encounter is not medically necessary because the service
does not require a practitioner level of expertise.
Thus there are situations in
which the provider of the service (e.g. the person giving an
injection) may be a qualified practitioner and the service
(e.g. the injection) may be medically necessary but it is not
medically necessary to have the practitioner re-examine the
patient to deliver the service. In these cases it is the
physician/extender services that are medically
unnecessary; using
physician/extenders for services routinely performed by
ancillary staff does not create additional face-to-face
encounters as Medicare is specifically prohibited from
reimbursing medically unnecessary services [Section
1862(a )(1) of the Act]. Riverbend
is further charged with ensuring that RHC utilization patterns
do not diverge from hospital outpatient and physician office
patterns [Program Integrity Manual 83-2-2.4.3.1], as would be
the case here.
Note that the services that do not require
physician/extender expertise (and are "incidental" services)
are medically necessary incidental services and are
reimbursable through the cost report.
Many specialty services,
such as PT, cardiac rehab, and coumadin clinics, provide
primarily non-physician services and therefore generate a high
level of costs per face to face visit. These services
are not prohibited in the RHC environment, but the RHC may
find that excluding them into a non-RHC provider type creates
a more appropriate reimbursement model. [Refer to
27-501ff]
This is neither a new
limitation on medically necessary services nor a new
interpretation of policy; rather it represents a compendium
and explication of Riverbend's longstanding interpretation of
the various CMS regulations that govern RHC services. Specific
billing instructions and documentation requirements are
included. |
Rural
health centers (RHCs) provide primary care services to beneficiaries
in rural physician shortage areas. To assist them in that mission,
Congress created a special reimbursement mechanism. Independent RHCs
are paid a flat rate for each face-to-face encounter based on the
anticipated average cost for direct and supporting services, with
reconciliation of costs occurring at the end of the fiscal year.
This policy applies specifically to independent (free-standing) RHCs
but also applies to facility-based institutions except where certain
filing instructions are obviously inapplicable due to the different
mechanism of reimbursement.
The services provided
at a rural health center can be divided into four categories:
1. Face-to-face encounters (or
"visits")[27-500.A].
2. RHC services incident to a
face-to-face encounter. These services are not directly billed but
are reimbursed through the cost report. [27-502] Incidental
services are typically provided by non practitioners under general
physician/extender supervision, although practitioners
(particularly therapists who are directly employed by the RHC)
frequently also provide incidental services.
3. Non RHC
services. RHCs can provide part B covered services that do not
fall within their congressional mandate. Examples include
physician services to hospital inpatients and physical therapy by
contracted therapists. Non RHC services are not reimbursed under
the all inclusive rate; rather, they must be billed separately to
the appropriate carrier. [27-501.1]
4. Noncovered services.
Noncovered services may be provided and billed directly to RHC
patients. However, in no instance can Medicare beneficiaries be
billed for services that would be covered under Medicare.
[27-321]
The correct assignment of charges into these
categories is the crucial element of correct Medicare
billing.
RHC "visits" are defined by Medicare as a
face to face encounter between the patient and a physician,
physician assistant, nurse practitioner, nurse midwife, specialized
nurse practitioner, visiting nurse, clinical psychologist, or
clinical social worker during which an RHC/FQHC service is rendered.
[27-504] (Hereinafter the term physician/extender will be used to
refer to the list of physician, PA, NP/NM, CP and CSW.) RHC services
are limited to physician/extender services, services incident to
those physician/extender services and (under limited circumstances)
visiting nurse services [MIM 3191.1]. Physician/extender services
are further defined as those professional services performed by a
physician for a patient including diagnosis, therapy, surgery, and
consultation [27-405.1], thereby codifying the distinction between a
visit and a non-visit incidental service.
Incidental
services are those services that are commonly rendered in a
physician's office without charge. Ancillary services are those
which are customarily provided with an additional charge. [42 USC
1395f(d)(3), later applied to outpatient services] Due to the wide
variation of billing practices the distinction is not absolute.
However, the significance of the distinction is that RHC services
include only a) face-to-face encounters that deliver physician
services and b) services that are incident to those encounters; all
non-incidental ancillary services, such as encounters with a
contracted physical therapist, are c) non-RHC services. Any service
provided by an RHC will fall into one of these three
categories.
|
| |
| Indications and Limitations of Coverage
and/or Medical Necessity |
Physician Services
A
face to face visit is an encounter between a clinic patient and a
physician, PA, NP, nurse midwife or (for visiting nurse services) a
visiting nurse.[42 CFR 405.2463(a)] Clinical psychologist and social
worker encounters are visits in both an FQHC environment and an RHC
setting. [42 CFR 405.2463(a)(2) and (a)(4) as modified by OBRA 1987
Section 6113] Podiatrists, optometrists, dentists and chiropractors
are physicians for certain procedures; however they are not licensed
to provide general medical care. An encounter with a podiatrist,
optometrist, dentist or chiropractor MAY constitute a valid face to
face visit if the provider is acting within the limits of his
specialty and no other coverage and medical necessity restrictions
apply [42 CFR 405.2401]. However they are not able to supervise
physician extenders in the provision of RHC services, nor do they
qualify as physicians for the purpose of determining physician
coverage (i.e. an MD or DO must be present to consider the hours
"physician covered").[27-123]
A face-to-face encounter
requires direct interaction between the practitioner and the patient
for the purpose of providing evaluation and management services at a
skill level that requires the assessment, clinical reasoning, and
judgment of a qualified RHC practitioner (i.e. the metaphorical
"laying on of hands"). The condition of the patient must warrant the
specialized skills of the qualified RHC practitioner. It is expected
that either:
1) The patient will initiate the visit with a new problem
or an exacerbation of an existing problem that a prudent layperson
would believe requires evaluation and/or diagnosis by a qualified
RHC practitioner OR
2) The patient has been rescheduled by
the practitioner for a follow-up visit under circumstances in
which the specified frequency of follow-up is customary,
reasonable and necessary.
Medical necessity is required for
Medicare services to be reimbursable. This includes a necessity for
a physician or physician extender level of care in the case of a
face-to-face encounter. Services that do not medically require
active physician/extender involvement during any given trip to the
facility lack medical necessity for a face-to-face encounter even
though the services themselves may well be medically necessary
ancillary or incidental services. As a corollary, a visit solely to
obtain an ancillary or incidental service does not constitute a
medically necessary face-to-face encounter.
Since the RHC
benefit is a primary care benefit, 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 in the unusual instance
in which a patient develops a new condition or complication that
medically necessitates a second evaluation on that same day [42 CFR
405.2463(a)(3) and 27-504].
RHC face to face visits are
covered when furnished to a patient at the clinic, a skilled nursing
facility or other non-hospital medical facility, the patient's place
of residence, or elsewhere (e.g., at the scene of an accident),
subject to MIM 3642.B [27-401]. Note that visits performed outside
of the RHC physical plant have specific limitations as discussed
below.
Although a service may be considered to be a
covered physician service as long as the physician/extender is able
to visualize some aspect of the patient's condition without the
interposition of a third person's judgment [27-405.1], all physician
services do not equate to face to face encounters. Such non
face-to-face services (e.g. review of an X-ray, EKG or tissue
sample) may be non-RHC Part B services billed to the carrier (such
as the review of a tissue sample) or they may be integral to a prior
face to face encounter. Covered services that do not qualify as face
to face encounters and that cannot be billed to the carrier are
still reimbursable through the cost report.
Medical
services that do not follow usually accepted standards of current
medical practice are not medically necessary. This includes
experimental and investigational treatment, unproven applications of
existing technology, and diagnostic/treatment plans outside the
mainstream of the practice of medicine. In these instances the
service is not medically necessary, as is any visit whose primary
purpose is to order, render or evaluate the non-covered
service.
Incidental ("Incident to")
Services
Services and supplies incident to a
physician's professional services consist of those services that are
commonly furnished by employees in an office setting under general
physician supervision as an incidental, although integral, part of a
physician's professional services. This includes all routine
services performed by the clinic staff, e.g., nurses, therapists,
technicians, and other aides. [27-406] Incidental services are not
limited to the same day as a face to face visit; rather they must
merely be tied to an actual physician/extender service (either a
face to face or a non face-to-face covered service such as a
telephone consultation). For example, non-physician services are
incidental when performed during a course of treatment in which the
physician/extender performs an initial evaluation and remains
actively involved (directs) that course of treatment. [27-406.1] The
physician supervision requirement is satisfied as long as the
physician/extender is on the premises and immediately available
during the services. [27-406.3]
Services that fit this
description of incidental services do not establish medical
necessity for a face to face encounter. Services that are routinely
provided by ancillary personnel such as nurses, therapists, aides,
etc.--i.e. incidental services--should not be billed as face to face
encounters even if provided by a physician/extender, unless specific
documented medical necessity exists to require a physician/extender
level of expertise to render the service. However, medical necessity
does exist for periodic physician/extender evaluations to manage the
incidental services; only those intermittent evaluation and
management encounters should be billed as face to face visits. For
the purposes of determining whether a service is customarily a
physician service or an incidental/ancillary service, the FI will
look at the usual practices of the RHC for non-Medicare patients,
the usual practice of other RHCs, and the usual practice of
outpatient clinics and traditional physician offices. [PIM Chapter 2
Section 2.4.3.1.A]
Mental Health Services
A clinical
social worker may provide services that are typically physician
services as well as services that are typically provided incident to
physician services. [27-419.2 and 27-500 .A] An encounter with a
clinical social worker may be billed as a face-to-face visit by the
FQHC or the RHC [42 CFR 405.2463 as modified by OBRA 1987, Section
6113] only when the CSW is providing a medically necessary physician
service. Services that are entirely incident to a contemporary or
prior physician visit may not be billed as face-to-face visits
although they are covered services and are reimbursed on the cost
report. This includes all CSW services in the
RHC.
Encounters with a clinical psychologist should be
billed as a face-to-face visits by the FQHC or RHC. [27-419.1 and
27-500.a] Medical necessity will be assessed, and the visit must
show evidence that the psychologist's expertise was required and
that the visit was providing more than an incidental service in
support of a prior physician visit. (The latter case constitutes an
"incident to" service that is cost report reimbursed; this applies
to all clinical psychologist services in the RHC.)
Therapy Services
Therapy (PT, OT and
ST) can be incidental, ancillary (non-RHC) or physician/extender
(face to face) services. [42 CFR 410.60(e)(2)(iv)] When performed by
a therapist, therapy sessions are incidental (cost report
reimbursed) if the therapist is an employee of the clinic and
ancillary (separately billed under Part B as a non-RHC service) when
the clinic arranges sessions with an independent therapist.
[27-406.6 and 13-3-3191.3]
When personally performed by a
physician/extender, therapy services are valid physician services
[42 USC 1395l(g)(1)]. One on one therapy services with a
physician/extender may be billed as face to face visits. However,
for the purposes of determining whether a given service is a
physician service or an incidental/ancillary service, the FI will
look at the usual practices of the RHC for non-Medicare patients and
the usual practice of other RHCs. Further, utilization patterns will
be compared with outpatient clinics and traditional physician
offices. Face to face therapy encounters that are
uncharacteristically shorter or less intensive than their
traditional ancillary service counterparts (i.e. typically less than
30 minutes) will be denied as not medically necessary. [PIM 2.4.3.1]
Group therapy sessions are not consistent with a traditional
physician-patient visit, are appropriately treated as incidental
(cost report reimbursable) services, and are not medically necessary
for the physician/extender level of expertise. Only one-on-one
therapy sessions may be treated as face to face visits; group
sessions are covered RHC services and are reimbursed through the
cost report.
Cardiac and Pulmonary rehabilitation (CR/PR)
are NOT therapies [CIM 35-25 and c.f. RGBA LMRP-079-01].In
accordance with the Medicare benefit structure, these services must
be provided incident to physician services in the outpatient
environment, making them cost report reimbursable for the RHC. Based
on utilization patterns in other outpatient environments [PIM
2.4.3.1], up to three physician contacts ("face-to-face visits")
will be considered medically appropriate to monitor the course of
cardiac or pulmonary rehab.
Typically the first
CR/PR visit will consist of the new patient comprehensive
examination and associated stress test, while the remaining two
visits consist of examinations needed to monitor patient progress
(and effect routine medication and treatment changes) and/or a
post-service evaluation and stress-test. Additional face to face
visits only demonstrate medical necessity when precipitated by a
sudden deterioration or acute event that necessitates a physician
evaluation. A rhythm strip interpretation would be covered (charges
bundled) along with the face to face in the setting of a physician
evaluation following an acute event, but the routine review of
strips generated during CR/PR is typically done after the fact, so
additional face to face encounters are not medically necessary.
Similarly, routine changes in treatment regimens are usually done
based on reported progress, not a face to face exams, so again
medically necessary face to face encounters do not
occur.
Monitoring and medically supervising
rehabilitation is not within the scope of practice of physician
extenders. Physician extenders can and do provide the individual
services, but the individual services themselves do not require a
physician/physician extender level of expertise. Therefore the
individual rehabilitation sessions are "incident to" and do not
represent medically necessary face to face encounters even when
rendered by a physician/extender.
Injections
A visit solely to receive
an injection does not constitute a medically necessary face-to-face
visit if the need for the injection was previously determined. This
is true even if a face-to-face contact is made. [MIM 11-3660.7, MCM
14-3-15050.C, RHC 27-406, MCM 14-5202, PIM
83-2.4.3.1]
Allergy shots. A visit solely to
receive an allergy shot does not constitute a medically necessary
face-to-face visit even if a face-to-face contact is made. The
allergy shot is generally administered by ancillary personnel and
represents a service that is incident to a prior physician visit.
However, if the patient has an adverse reaction that necessitates a
physician/extender evaluation (and that examination, assessment and
plan is appropriately documented), the encounter may then be
appropriately billed as a face-to-face
visit.
Methotrexate. Methotrexate in immunomodulating
doses does not require a physician visit beyond the frequency
necessitated by the underlying disease.
Vitamin B12.
The IM administration of B12 may be transiently necessary in any B12
deficiency state but is only medically necessary chronically
following a definitive diagnosis of pernicious anemia (Schilling
test, radiolabeled B12 uptake and/or other standard diagnostic
criteria). However, even when appropriately administered, a face to
face encounter is not medically necessary with each injection. In
the setting of newly diagnosed B12 deficiency with symptoms, patient
evaluations may be required weekly times four and then monthly times
twelve. In the absence of symptoms attributable to B12 deficiency,
two or three visits within the first six months may be necessary for
patient education and re-evaluation . Following this initial period,
annual visits may be necessary (whether or not the patient is
continuing injections) if the patient is not being otherwise seen
for chronic problems. More frequent physician/extender encounters
are not medically necessary due to the slow rate of relapse
following B12 repletion.
Flu shots and vaccinations
(influenza, hepatitis B and pneumonia vaccines) do not necessitate a
face to face visit. They are administered incidental to a
contemporary or prior physician service. Note that whereas the
administration of influenza and pneumococcal vaccine is a non-RHC
service reimbursed outside the all-inclusive rate while hepatitis-B
is an incidental RHC service covered under the rate, neither are
specifically reimbursed on a claim by claim basis; both are cost
report reimbursable. [27-614 and MIM 3660.7.G]
Other
injections (such as epogen) also usually represent incidental
services when the need for the injection is previously established,
even if the physician/extender specifies a change in dosage. This is
because the physician/extender is merely responding to a lab test; a
re-evaluation of the patient is not indicated with each adjustment.
Conversely, a face to face encounter is medically necessary when it
is the accepted standard of practice in physician offices and
outpatient clinics, generally because a clinical re-evaluation of
the patient is also indicated (e.g. 24 hours after an initial dose
of IM antibiotics but not routinely after each subsequent
dose).
Dressing changes
There may be instances
when a caretaker is unable to adequately perform dressing changes or
where the level of complexity of the care requires the skills of a
nurse. These dressing changes do not constitute medically necessary
face to face visits solely because the service was provided by a
physician/extender if similar services could be provided by nurses
or other designated office staff. Except in the special case of
visiting nurse services, medical necessity for a face to face
encounter is based on:
1) The need for a physician/extender to monitor the
underlying wound at a frequency that does not differ from the
usual patterns of utilization in an office or outpatient clinic
OR
2) An exacerbation or complication that would trigger an
examination in those environments OR
3) Sharp debridement
requiring the skills of a physician/extender.
Lab tests
An encounter expressly
for the purpose of obtaining blood for lab tests does not constitute
a medically necessary face-to-face visit even if a face-to-face
contact with the provider is made. To be considered as a
face-to-face visit, there must be some additional medically
necessary evaluation or management component. All laboratory
services, including venipunctures that are not integral to a
face-to-face visit, are non-RHC services that must be billed to the
part B Carrier (or the FI for provider-based RHCs only). [PM A-00-30
as amended]
The process of reporting a lab result to the
patient, even if a medication is changed as a result, is also
usually incidental to the initial visit. A visit for the purpose of
reporting the lab result is only medically necessary (in the absence
of a separately indicated evaluation) when the information being
reported to the patient is of sufficient complexity or gravity to
demand an additional extended physician/extender discussion with the
patient. Examples of this would include (but are not limited to) a
complex metabolic profile with multiple abnormalities, an evaluation
for cancer, and a finding of a new disease (e.g. diabetes). The
periodic monitoring of a given test (e.g. INR, CBC, etc.) should not
be associated with routine follow-up visits to report the results as
this does not reflect the practice in physician offices and
outpatient clinics. The routine use of a visit to discuss lab
results is not medically necessary.
Prescription Services
Visits for the
sole purpose of obtaining or renewing a prescription, the need for
which was previously determined (so that no examination of the
patient is medically indicated), are not covered face to face
services but are incident to the visit at which the
physician/extender determined the need for the prescription.
[27-405.3] Incidental services such as intermittently dispensing
medications (oral or injectable) to psychiatric patients or drug
abusers and counting/filling pill dispensers for disabled or
demented beneficiaries may be performed, but these services do not
require a face to face evaluation. Thus the need for a prescription
refill or medication disbursement will not contribute to
establishing medical necessity for the face to face
encounter.
Pain management is a covered RHC service but
the enabling of a drug addiction (either within or outside of a drug
rehabilitation program) is not. Frequent medication refills for
narcotics do not represent medically necessary face to face
encounters, but they nonetheless indicate a potential quality of
care issue and the overall pain management strategy should be well
documented in the chart. Frequent visits for the injection of
narcotics usually require an evaluation and thus a face to face
visit, but they should also be part of a well documented pain
management strategy that includes diagnostic investigations and/or
pain specialty consultations that attempt to minimize addiction and
maximize patient well being. A pattern of over-utilization of the
RHC for multiple patients in the absence of pain management
strategies is not medically necessary and may be an indicator of
more serious problems.
Paperwork
The paperwork involved in
maintaining records, documenting encounters for third parties and
completing forms for patients is an incidental part of medical
practice. These services (when provided in support of an activity
not otherwise excluded from coverage, such as disability
examinations) are reimbursed by Medicare through the cost report as
services incidental to the covered encounter. A period of time spent
solely in record keeping cannot be considered as a face to face
visit. An actual face to face encounter solely for the purpose of
creating paperwork is not a medically necessary visit; the visit
must be justified by a medically necessary evaluation or
treatment.
Visit for Non-covered Service
Face
to face encounters primarily to receive services that are not
covered by Medicare (such as acupuncture) are themselves not
covered.
Routine Services
Routine
physician/extender examination, vision exams and examinations for
hearing aids are not Medicare covered services. The routine physical
checkup exclusion applies to all examinations performed without a
relationship to the treatment or diagnosis of a specific illness,
symptom, complaint, or injury; it also applies to examinations
required by third parties (such as employment or insurance
evaluations). Eye examinations are not covered for the purpose of
prescribing, fitting or changing eyeglasses (e.g. refractions). Eye
examinations are only covered in conjunction with a medically
necessary evaluation to diagnose or treat an eye disease, and
hearing exams must be directed to uncovering a specific
pathology.[27-437] Routine foot care is not covered except in the
setting of a systemic disease that requires care to be performed by
a skilled practitioner in order to avoid the risk of injury to the
patient.[27-438.C]
Most primary preventive services are
not covered under the RHC benefit even when provided by RHCs. These
include medical social services, nutritional assessments, preventive
health education, prenatal and postpartum care, routine physicals
(including well child care), immunizations, eye and ear screening,
family planning, routine screening procedures (urine dipstick, stool
guaiac, serum cholesterol, weight and BP), risk assessment
(including undirected history taking and physical exam to ascertain
risks), and thyroid screening. Group presentations, educational
activities and dental services are never covered.
[27-404.1]
Certain screening and/or preventive services
such as mammography have a special benefit delineated by Congress.
The professional portion of theses services are considered covered
RHC services in accordance with PM A-00-30. If a face-to-face visit
is medically necessary, it is covered and may be billed on that
basis; if not, the services are still covered as "incident to" costs
but the charges must be billed in such a way that a 'visit" is
neither reported nor paid. Thus, the professional component of a
sigmoidoscopy would be covered and would support a face to face
encounter, while the technical component can be billed to the Part B
Carrier. The professional components of bone mass measurement and
mammography are always covered as RHC services, but should only
generate a face to face visit if the physician personally performed
the service; the preparation of the report is not a face to face
visit by itself although charges could still be included on a claim
as a covered physician service but only in association with another
visit. Stool guaiac for cancer screening would similarly not support
a face to face (unless the digital rectal exam benefit was being
provided) and thus would create only a Carrier (lab) claim.
Conversely, a pelvic exam would only generate a face to face visit;
lacking a technical component, there would be no Carrier claim
(unless the RHC interpreted its own Pap
smears).
Two services never should be billed
as face to face visits. Medical nutritional therapy, in accordance
with BIPA 105, must be provided by a registered dietician or
nutrition professional; it is therefore an "incident to" service for
which costs are reported but no visit. Diabetes self management
(DSM) represents a similar situation. PM-A-00-30 identifies DSM as
an RHC service, but MIM 3619 specifies that G0108/9 codes are not
payable for beneficiaries receiving services in an RHC. Although DSM
(as defined in Section 4105 of the BBA of 1997) must be certified as
medically necessary by a physician/extender, the actual educational
intervention is usually provided by other professionals, typically
nurses. A face-to-face service beyond that which occurred when the
intervention was ordered (certified) is not medically necessary.
Therefore it too is an "incident to" service for which costs may be
reported but no visit reported. Lacking technical components,
neither of these services would generate Carrier claims either.
Recurrent Services
1. Blood
Pressure Measurement: Follow-up visits to monitor blood pressure
can take two forms. Some visits include physician/extender
evaluation and management services and are therefore appropriately
identified as encounters. The documentation should reflect the
performance of these services over and above the simple measurement
of a blood pressure. The frequency of follow-up is medically
necessary when consistent with the recommendations of The Sixth
Report of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure.
[http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm]
Specific medical necessity must be clearly documented to support
frequencies greater than:
New diagnosis (first 6 months);
lifestyle modification: monthly (q 30 days)
New diagnosis
(first 6 months); pharmacological management: monthly (q 30
days)
Established diagnosis; lifestyle modification;
controlled: quarterly (q 90 days)
Established diagnosis;
pharmacological management; uncontrolled: monthly as long as at
least every other visit supports active intervention (change in
therapy)
Established diagnosis; pharmacological management;
controlled: quarterly (q 90 days)
Accelerated or unstable
hypertension with a need for rapid control of pressure: medically
necessary as long as each visit supports ongoing direct and active
intervention (change in therapy) during the period of frequent
follow-up.
Other visits may be solely to obtain a BP
measurement as a data point for the diagnosis or tracking of the
hypertension. Visits solely to obtain BP measurements are incidental
to the primary E&M visit, and any follow-up at a frequency that
is not supported by current standards of care is not medically
necessary.
2. Disease Management Clinics: Disease
Management clinics do not represent a special Medicare benefit
category. Visits to clinics of this type are subject to the same
requirements for medical necessity as all other face-to-face
encounters: namely, there must be a requirement for a
physician/extender level evaluation, re-evaluation or therapeutic
intervention at each visit. Routine visits, i.e. visits at a
frequency greater than that which is supported by current standards
of care in physician offices and outpatient departments, are not
medically necessary and are not covered.
3. Lab
Follow-up Clinics: Visits to lipid clinics, prothrombin
(Coumadin) clinics and other lab-based follow-up clinics generally
do not demonstrate a need for physician/extender face-to-face
discussion of results other than in the two or three visits
following diagnosis. Exceptions are expected to demonstrate a
well-documented and unique need for the face to face interaction.
The routine use of a visit to discuss lab results is clearly not
medically necessary; medical necessity for this is discussed
above.
4. Specially Clinics: Diabetes clinic
visits are medically necessary when medical complications of the
disease are addressed, or when monitored at a frequency consistent
with recommended standards of care. Routine Foot Care clinics are
always not medically necessary and non-covered [RHC Manual 438.C]
except in the setting of diabetes with loss of protective sensation
[CIM 50-8.1]. Pain Management clinic visits demonstrate medical
necessity for a given frequency of visits when supported by the
immediate pain management needs at the time of each visit and by the
documentation of progress with respect to the overall pain
management strategy.
5. Chiropractic clinics:
Coverage of chiropractic services is specifically limited to
treatment by means of manual manipulation of the spine for the
purpose of correcting a subluxation that has been demonstrated by
x-ray or physical examination. The patient must have a significant
health problem (neuromusculoskeletal condition) necessitating
treatment, and the manual manipulative services rendered must have a
direct therapeutic relationship to the patient?s condition and
provide reasonable expectation of recovery or improvement of
function. Once the functional status has remained stable for a given
condition, further manipulative treatment is considered maintenance
therapy and is not covered. Continued or repetitive treatment
without an achievable and clearly defined goal is also considered
maintenance therapy and is not covered. No other diagnostic or
therapeutic services furnished by a chiropractor or under his/her
order are covered by Medicare. Any additional conditions of coverage
imposed by the local Carrier for office based chiropractic care will
be applicable, and chiropractic care must augment (not replace) the
primary care nature of the RHC.
Off-site Services
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.) Visits to
patients who are covered under Part A may not be billed by the RHC
as they are bundled into the SNF Consolidated Billing. The RHC can
bill visits only for patients whose stay is not covered under Part
A. [PM a-00-30] (The physician/extender may directly bill the
Carrier for these services if not compensated by the RHC under
agreement.)
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.
Note that a physician/extender may provide
RHC services in one professional capacity and may provide SNF or
nursing home medical services in a different professional capacity.
In that case a patient visit that is provided under the auspices of
the RHC should be billed as an RHC visit if separate billing is
allowed. A visit provided by the physician/extender in his private
(non-RHC) capacity has nothing to do with the RHC and should
therefore neither generate an RHC claim nor impact the cost report;
this visit would be billed by the physician/extender to the Carrier.
The determination that a physician/extender is acting under the
auspices of the RHC as opposed to acting independently is based on
such factors as the physician/extender's contract with the RHC, his
malpractice coverage, and the consistency of clinical
responsibilities for other RHC and non-RHC patients. For example, it
would not be appropriate if patients covered under Part A were seen
in an independent capacity while patients covered under Part B were
seen as RHC visits. More importantly, in no instances should
services be reflected in RHC claims or cost reports and be billed to
the Carrier as independent services.
Visiting Nurse Services
Under certain
conditions visiting nurse services are covered as RHC services and
are billed as face to face encounters. There must be documentation
that the RHC is located in an area where CMS has determined that
there is a shortage of home health agencies, and the patient must be
homebound. The care must be performed by a registered nurse,
licensed practical nurse or licensed vocational nurse operating
under a written plan of treatment. [27-412.1] A physician/extender
home visit to perform services typically rendered by home health or
visiting nurses is only covered when the criteria for VNS are met.
When VNS criteria are not met, the home visit is subject to the same
medical necessity requirements as an office-based face to face
encounter, and a physician/extender home visit solely to perform
home health services will be denied as not medically necessary for a
physician level of expertise.
Home Visit
The RHC home visit is an RHC
physician service that is qualified in the same manner as an office
visit. It must have the same face-to-face component with history,
physical exam, assessment and disposition. There are no special
requirements (e.g. homebound status) on a home visit, nor are there
any unique exemptions. Medical necessity for the home visit is
identical to medical necessity for office visit -- i.e. the fact
that the patient is homebound does not confer any additional
necessity for a physician/extender level of care. A home visit is
not medically necessary if an office visit would not be medically
necessary for the same patient condition.
Telephone services
Services by means
of a telephone call between a physician/extender and a beneficiary
(including those in which the physician provides advice or
instructions to or on behalf of a beneficiary) are Medicare covered
services that are included in the payment made to the RHC. However,
such services do not constitute face to face encounters and may not
be billed as visits. Reimbursement for these services are made
through the cost report. [27-405.2]
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| CPT/HCPCS Section |
Rural Health Clinic |
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| Benefit Category |
Rural Health Clinic
Services
|
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| Coverage Topic |
Doctor Office
Visits
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