RHC Billing Information

This page include information on Billing for RHC Services and links related to RHC billing.

The RHC Billing 101 Seminar Workbook (400 pages) went to the printer last night and will be ready to mail early next week if you would like to purchase one. The cost is $125.00 and includes a CD that is completely full of recent RHC Billing information. We will have a limited number of these left over from the seminar and once we sell them all they are gone. If you want one, just email me at la_vita_nouva@hotmail.com with your information and I can invoice you for the Workbook.

Medicare has released new information for providers that infrequently bill Medicare, RHCs, and FQHCs as it relates to PECOS. This is a very important document for rural health clinics and you should review this information closely if you are a rural health clinic.

Highmark Medicare Services has a really nice document on PECOS this morning that should answer so of your questions regarding the process.

This first link has an interesting answer on Medicare Secondary Payment requirements. Some Medicare Administrative Contractors indicate this information should be collected each visit; however, Trailblazer indicates that it can be obtained quarterly. Here is the link for 5 pages of questions and answers on RHC Billing.

Highmark Medicare Services is having two webinars on Medicare billing on July 13th which may interest you.

This is the 283 page document that Medicare produced on preventive services last year.

In May, 2010 the Muskie School of Public Service through the Maine Rural Health Research Center produced a report on Mental Health Services. Here are the reports related to this work:

Second, is a 21 page Powerpoint presentation that was presented at the National Rural Health Association annual meeting this May.

Third, is the 63 page complete report if you want the complete details on mental health services.

We updated the summary of PECOS that we prepared last month with the latest information and it can be found as follows:

June 30, 2010: CMS released a press release on PECOS indicating that they would not enforce the provisions of the regulation effective July 6, 2010. Here is a link to the CMS press releases.

We completed a 10-page newsletter today with lots of information on the PECOS regulations that become effective on July 6, 2010. If you have questions about what your need to do to comply with the regulations, this is a must read.

Here are the slides from our Billing presentation in Robinson, Illinois on June 17, 2010. We will update these and use some of the basics for our Billing 101 Seminar in Hilton Head, SC on July 16, 2010. Here are the slides and the signup page for the seminar.

June 28, 2010: I am back in the office after a week of vacation in Hilton Head, SC. Trying to get caught up on lots of emails and work that backed up during the week off. Here is a presentation on Medicare Bad Debts that I emailed to one client today. It was helpful in explaining Medicare Bad Debt reporting.

June 16, 2010: Ok, lets give this a try. These are really large files. I broke them down into 4 sections hoping they would upload. This is my handout for the RHC Billing Seminar in Robinson, Il on Thursday. A similar; but even more comprehensive handout will be provided for our Billing seminar in Hilton Head on July 16th.

This is an excellent resource as well from Highmark Medicare Services on how to file a Medicare Part A claim. It has 34 pages of great tables and lists that will be very helpful to anyone who bills Medicare for services.

First is a document related to Georgia rural health clinics and Medicaid. It was published in April and is pretty comprehensive on billing and coding.

The next document is tips for completing the UB04 form. Its 18 pages and has lots of tables.

The last one is if you are from Texas, this document relates to billing and coding of Medicaid claims.

This document contains frequency guidelines for the management of hypertension patients.

I am working on the Medicare Secondary portion of the presentation and this is where the headache starts. A good document from Cahaba to get us started:

June 2, 2010. RHC Cost Reporting season is over and we completed 51 rural health clinic cost reports. Now, it is time to move on annual evaluations, startups, and seminars. Thanks to everyone for getting their information in on a timely basis and making this a relatively stress-free cost reporting season. I have emailed a newsletter dated June 1, 2010 and have attached the PowerPoint presentation from Cahaba's webinar on Understanding RHC Billing on May 27, 2010.

May 6, 2010. I prepared a newsletter today with information on a Technical Assistance Phone Call by the NARHC, a Webinar on RHC billing by Cahaba, and a couple of RHC Billing 101 Billing seminars. To be placed on our email distribution list email "subscribe" to la_vita_nouva@hotmail.com. Here is the link to the newsletter:

May 5, 2010. A couple of updates. One of the MACs was reminding RHCs to get your credit balance report in. They were due on April 30, 2010 for the first quarter. Remember those are different from the cost reports and are due quarterly. There will be a technical assistance call on Tuesday May 11th from 3:00 to 4:00 PM Eastern time regarding becoming a National Health Service Corp approved site and changes to MUA and HPSA designation. I would check the HRSA website for slides or sign up for the NARHC Listserve to receive information on this phone call. The phone number is 866-237-3252 and the access code is 673020.

At last week's RHC Update Seminar, I mentioned several excellent presentations on the South Carolina Office of Rural Health website including one by Marsha Marze with lots of Cahaba, Palmetto, and Medicaid names and phone numbers on it. Here is a link to all the presentations:

April 20, 2010: Today I finished the RHC Update Billing PowerPoint Presentation and sent the 295 page RHC Update Notebook to the printers. Here is the link for the Billing Slides. If you see anything interesting or have comments on any of the slides; please email me. If you are interested in us coming to a town close to you; let us know as well; since after all this work of getting everything up to date; I would like to schedule a summer or early Fall seminar series.

A quick note from the PQRI Teleconference and E-Prescribing for physician offices. To obtain the additional funding you must e-prescribe 25 different times and use G8553 on 25 claims to qualify. You can not resubmit a claim just to add the G8553 code and rural health clinics and FQHCs are not eligible for these bonus payments. Additionally, the clinic must have 10% of its patients from primary care. Previously, a physician practice had to have at least 75% of its visits e-prescribed before it qualified for the bonus; so it will now be much easier to qualify for these payments.

Cahaba and all MACs are instructed to withhold payments from RHCs and physicians (Part B) if the Medicare deductible is in excess of the reimbursement rate. For example, if your charge is $155 (the current Medicare deductible) and your RHC reimbursement rate is $77.76 (the current maximum independent RHC cost per visit), Medicare will not pay you and withhold an extra $77.24 from your remittance whether or not you collect the deductible up front or not.

If you have not collected the deductible and it becomes uncollectible; it is reimbursable as a Medicare bad debt on the cost report if you follow the Medicare Bad Debt reporting guidance. There is nothing that can be done about this withholding except to stop billing Medicare during the first few months of the year and hope someone else gets stuck with the deductible. That’s not an ideal situation; but giving the government an interest free loan for up to 18 months is not either.

This has always been the case; however, the problem is worse in recent years due to the Medicare deductible increasing from $100 (it was always this amount for many, many years) to $155 over the past few years. The problem will continue to get worse as the Medicare deductible increases every year.

Additionally, there is some question about if Cahaba is handling this differently than Riverbend. Some clients indicate that Riverbend only withheld payment if you actually collected the deductible and others indicate that they withheld it whether it was collected or not. I’m not sure what the right answer is on that except that Cahaba indicates that their guidance from the Medicare Contractors manual is clear and they are doing it correctly by withholding the payment whether the Medicare deductible was collected or not.

March 1, 2010: The following link is to the HBS Newsletter as of March 1, 2010. This newsletter includes information on RHC Billing, the NARHC and HRSA teleconference scheduled for 4:00 PM Eastern on March 4, 2010, RHC Cost Reporting and information on Negative reimbursement.

We are updating our site to include policies regarding the training of your staff on billing procedures. We are including some documents that will be a part of the policies and procedures. The first document is a 10 page PDF that includes a Table of all Medicare MACs, an RHC Billing Cheat Sheet, listings of upcoming Medicare training programs for billing, and a sample of negative reimbursement and why you having more of this in previous years.

This notice may be the reason some of you are having problems with Medicare secondary payments and crossovers. Every MAC has been having problems lately, so its not just Cahaba.

Here are a couple documents that we have been working on for the Update Seminars

This first link is to a Highmark Medicare Services Webinar that will be conducted on February 10, 2010. It sounds like a good idea to sign up for this one if you have someone new to billing or need to train someone. This looks like invaluable training for your staff. To register for the seminar called Introduction to Medicare Part A which will start at 10:00 am Eastern ST on February 10, 2010 follow this link:

Also, if you like the information above; the link below has an Update that Highmark presented on January 12th, 2010 that is filled with valuable information for rural health clinics. Here is the link:

This one is a little old; but if you are fighting with your Medicare Advantage plans it never hurts to be able to whip out a CMS memorandum supporting your position that you should be receiving your cost per visit instead of the Medicare fee schedule. Here is the link:

Next is a link to the Missouri Rural Health Clinic Association website. They have a transcript from the December, 2009 meeting with Cahaba. Cahaba answers some billing questions; however, is pretty inconclusive on most of the questions. Hopefully, we can start getting something in writing on how RHCs will get paid and how to get Medicare to pay when they are the secondary payor.

Trailblazer Health Enterprises, LLC updated their UB-04 RHC billing examples on January 28, 2010 and provides an excellent example of how the UB-04 should be completed for a number of situations including billing on-site off-site, home visit, covered Part A SNF visit, non-covered Part A SNF visit, psychiatric, two visits, Medicare Secondary Payer (MSP) conditional, MSP liability conditional and MSP primary paid.

In the 2010 final Medicare Physician Fee Schedule the Centers for Medicare and Medicaid Services (CMS) announced that Medicare will no longer recognize consultation codes for Medicare Part B fee for service payment. CMS directs providers to report other evaluation management (E/M) codes in lieu of the consultation codes. In place of the consultation codes, CMS increased the work relative value units (RVUs) for new and established office visits, increased the work RVUs for initial hospital and initial nursing facility visits, and incorporated the increased use of these visits into the practice expense (PE) and malpractice calculations. CMS also increased the incremental work RVUs for the E/M codes that are built into the 10-day and 90-day global surgical codes.

Rural Health Clinics tend to not worry as much about coding as they should due to Medicare and Medicaid paying the same cost per visit regardless of the code; however, the proper assignment of HCPCS/CPT codes will lead to more accurate and in most cases improved overall reimbursement due to an improvement in collections of copayments. Most RHCs dramatically under code as compared to physician offices that are not RHCs. The following table is derived from the fiscal year 2008 Part B Physician/Supplier data from CMS. The first column has the Established Office patient codes, the second column has the average Medicare allowable charge (not the actual charge, but, the Medicare allowable), and the third column has the percentage that each established office code is used in comparison to the total established office codes. The average Medicare allowable per visit was $66.70 for 2008 for physician offices. (Divide Total Medicare allowable charges by total established office encounters.)

HCPCS/CPT Code	Average Medicare Allowable Charge	Percentage Of Total

99211	$19.25	4.3%
99212	$35.76	9.7%
99213	$58.23	48.9%
99214	$88.88	33.1%
99215	$120.03	4.0%

If you think your clinic is not coding correctly, The American Academy of Family Physicians has a tool that enables physicians to easily compare their coding frequencies with one another and with national benchmarks. Here is the link to download the Excel worksheet:

In fact there are over 150 free tools in the FPM Toolbox related to physician management, coding, and administration. Here is a link to the tools:

Many of the tools are downloaded and are included on the RHC Update Seminar CD and are printed in the RHC Update Seminar Notebook.

Average charges in all physician offices are increasing at a dramatic rate; however, rural health clinics continue to lag behind other providers as reflected in a 1.2% increase in the most recent RHC reimbursement cap (from $76.84 in 2009 to $77.76 in 2010). The RHC rate increase is directly tied to the Medicare Economic Index which is influenced by provider charges. According to a presentation at the NARHC annual meeting in 2009 the average charge per visit for RHCs was $101 for Part A services. (This excludes services billed to Part B including laboratory and technical components.)

One easy way to determine if your Medicare charges are reasonable is to take the P S and R report that is used to prepare your RHC cost report and divide total Medicare charges by total Medicare visits. This number represents the average charge per Medicare visit (excluding services billed to Medicare Part B). This number should exceed $100 per visit and the most recent cost report I prepared has an average Medicare charge of $144 for 2009. Charges will become more and more important as long as Medicare continues to increase the Medicare deducible ($155 in 2010) and RHCs are not subject to Medicare limiting charges. Keep in mind that this significant advantage is being taken away in the proposed RHC regulations published June 27, 2008 in which case RHC collections will be limited to their cost per visit, or the Medicare maximum cost per visit whichever is less.

While it is difficult to obtain charge information from competitors due to FTC rules regarding price-fixing; data or price analyzers from companies such as Ingenix or St. Anthony’s can be invaluable in helping rural health clinics to establish fair and reasonable charges.

One of the most common areas of questions related to RHC reimbursement relates to payments additions that Medicare offers physicians. The question is always “As a rural health clinic do I qualify for the add on payment?” and unfortunately the answer is a resounding “no” in most cases. Let’s look at three of the most common add-ons in some detail.

RHCs are not eligible for this additional payment of 10% on their RHC cost-based business that is billed to Medicare Part A. However, services billed to Part B may be eligible. The HPSA payments are administered through the MAC, which may be the same or different than the RHC intermediary. It depends on which region you are in. When filing the CMS 1500 claim, you must include:

1) the name, address and zip code of the location where the service was rendered

The 10% bonus will be paid to you in a quarterly remittance check by the MAC. The bonus is only for geographic HPSA's and is available to any physician billing Medicare for Medicare eligible patients. Eligible services are professional services such as hospital and nursing home visits. Medicare Advantage and Tricare plans pay HPSA bonuses as well.[1]

PQRI incentive payments of 2% are linked to the Medicare fee-schedule payments. Because RHCs are not paid using the fee-schedule, there is no mechanism for RHCs to obtain the PQRI incentive payments.[2]

Medicare e-prescribing incentive payments (2%) are also linked to the physician fee schedule. Again, because RHCs are not paid using the Medicare fee-schedule, there is no way for them to receive this benefit either.[3]

Due to the number of add-ons that RHCs do not receive; some have considered dropping out of the program or want to know exactly the benefit of being in the program as it relates to Medicare (most clinics benefit much more from increased Medicaid reimbursements). Anyway, let’s compare the RHC and RBVRS reimbursement mechanisms using 2008 data (since we have a good number for Medicare RBRVS reimbursement per our Table on page 1 of this report).

Description	RHC	RBRVS	Comments

Average Charge	$100	$100	Charge per visit

Medicare Reimbursement	$75.63	66.70	RHC Cap/Limiting

Medicare Actual Payment	60.50	$53.36	80% of Rate

Copayments	$20.00	$13.34	20% of charge for RHC
Add-on Payments
HPSA	$0	$6.67	10% of limiting charge
E-Prescribing	$0	$1.33	2% of limiting charge
PQRI	$0	$1.33	2% of limiting charge

Total Payments	$80.50	$76.03	$4.47 or 5.9% advantage to RHC

As we had suspected the gap between rural health clinic payment and RBRVS payment has narrowed substantially over the years and now the RHC payments exceed RBRVS by only $4.47 per visit or 5.9%. As with any government financed program, the future of this argument is in the details. If RHCs, can no longer collect the full 20% of charges for copayments they will lose most of their reimbursement advantage over RBRVS clinics; however, if RBRVS clinics are impacted by the proposed 21.2% reduction in the physician fee schedule (currently frozen until March 1, 2010) then RHCs will again offer a much more favorable reimbursement option. Just a reminder, most of the RHC benefit is derived from an improved Medicaid rate, so that should be kept in mind when you are considering any change of status. Additionally, if a clinic codes well it may find the RBRVS schedule more advantageous. This simplified study did not take into account procedures and other lost revenue from professional components as well. Individual clinic results will vary based upon:

If you are considering a change of status, you should contact a rural health clinic reimbursement specialist to determine the impact of any changes to your practice.

Subject

Description of Change

Encounters

That take place with more than one health professional

Updated

Explanation

Encounters with more than one health professional which take place on the same day and at a single location constitute a single visit except:

A) after the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment

B) the patient has a medical visit and a clinical psychologist or clinical social worker visit.

Mental Health Limitation Phase-out

Medicare is phasing out the mental health limitation effective 1/1/2010 per a Memorandum dated 10/30/2009:

2009 62.5%

2010 68.75%

2012 75.00%

2013 81.25%

2014 100%

This will make providing mental health services more attractive for rural health clinics in the future.

Initial Preventive

Physician Exam

(IPPE)

Effective 1/1/2009: Use revenue code 052X and HCPCS code G0402 for professional component of examination. RHC Deductible is waived for the exam; however, coinsurance is still applicable.

Subject

Description of Change

Diabetes and Medical Nutritional

Therapy

Diabetes self-management training and medical nutritional therapy are not RHC services. Report these services on the cost report as it is included in the computation of the all-inclusive rate. Do not submit claims with G0108 or G0109 HCPCS Codes.

Cahaba is the MAC

For most existing RHCs

Per Section 911 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 on January 7, 2009, Cahaba Government Benefits Administrator was awarded the Jurisdiction 10 A/B MAC contract for Alabama, Georgia, and Tennessee.

Effective August 3, 2009 Cahaba started processing RHC claims for all independent RHCs that had been processed by Riverbend GBA.

If you are an AL, GA, or TN RHC both your Part A (cost-based) and Part B (fee for service) will be processed by Cahaba.

If you are an out-of-jurisdiction provider[5] (an RHC located in a state other than AL, GA, TN) then your Part B (fee for service) claims will be processed by your local MAC.

If you are a new RHC apply to your MAC that is assigned for your region. There are 15 different regions. See attached map for specifics.

One of the frustrating things about RHCs is the number of rules that must be followed and the exceptions to the rules. Knowing when to stray away from rules is important for proper payment.

Rule	Exception
The Part B deductible applies to RHC services.	Do not apply the deductible to the Initial Preventive Physical Exams (IPPE) (G0402) or the Abdominal Aortic Aneurysm (AAA) Ultrasound Screening (G0389)
Do not place HCPCS Codes on the UB-04 form.	For preventive services that are subject to frequency limitations HCPCS coding is required.
Only one visit per day.	1. An encounter in addition to the payment for the IPPE visit may be appropriate. 2. A medical visit and psychiatric visit on the same day (Revenue Code 900) are allowable. 3. More than one clinical visit in one day is allowed if appropriate. (See new guidance in Chapter 9 of RHC billing guide.) 4. Some states allow an EPSDT (wellness) screen and a medical visit on the same day. Check with Medicaid.
Only a physician, NP, PA or Nurse Midwives must have a face to face for a visit to be billable.	1. LCSW or CSW for a psych or social worker visit 2. visiting nurse if approved by CMS 3. Telemedicine visit
Visit must occur in the clinic or patients home (home includes SNF, NF, or assisted living facility)	A visit may occur at the scene of an accident. (Revenue Code 0528)

The RHC upper payment limit per visit is increased from $76.84 to $77.76 effective January 1, 2010, through December 31, 2010 (i.e., CY 2010). The 2010 rate reflects a 1.2 percent increase over the 2009 payment limit in accordance with the rate of increase in the Medicare Economic Index (MEI) as authorized by the Social Security Act (Section1833(f)). Here is a link to the Medlearn article implementing the payment increase:

Most RHC services for the treatment of mental, psychoneurotic, and personality disorders are subject to the outpatient mental health treatment limitation (the limitation) in Section §1833 of the Act. Certain diagnostic services and brief office visits for monitoring or changing drug prescription(s) are not subject to the limitation.

The limitation has been 62.5 percent since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010. However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:

The mental health treatment limitation amount is applied before application of the coinsurance.

This will increase the opportunity for RHCs to provide mental health services to the Medicare population. If you think that providing outpatient mental health services could benefit your patients please contact Dave Jolly at Solution Pointe Healthcare, LLC at dwjolly@aol.com for more information.

The Medicare annual Part B deductible has increased from $135 in 2009 to $155 in 2010 or 14.8% per annum. At that rate, the deducible will be $1,414 in 17 years when at 67 (Social Security has moved back the eligibility dates back for baby boomers), I am eligible for Medicare. The hospital deductible which is due on every hospitalization is now $1,100 for 2010 which is a 2.9 percent increase from 2009 deductible of $1,068. Medicare is sounding more and more like private insurance every day. They also plan on cutting physician payments (Part B) by 21.2% in 2010. Medicare is sounding more and more like private insurance every day. Our premiums keep going up; but, all we get for it is a discounted fee from the medical community and the insurance company never pays anything.