Rural Health Clinic Billing Cheat Sheet
Effective: April 1, 2005
This form=
is
designed to provide general guidance regarding the billing of Rural Health =
Clinic
services to Medicare (Medicaid & Insurance rules are different in most
cases) as of April 1, 2005. T=
hese
guidelines change frequently and have different interpretations depending on
the intermediary paying the claim.
There are also some variances between provider-based and independent
RHCs. Provider-based clinics are no longer required to use HCPCS codes and =
bill
Non/RHC, Medicare services using the hospital provider number instead of
billing to the Part B Carrier.
Examples of Non-RHC/Medicare services are as follows:
&=
nbsp; • =
All
laboratory services including the six required tests
• &nb=
sp; Technical
components of procedures (ie. Radiology)
• &n=
bsp; Hospital
services
• &nb=
sp; Hospice
services
Before
billing any claim using this form, you should review guidance from your
intermediary to determine if our prescribed billing method is appropriate in
your situation.
RHC billi=
ng
and UB-92 requirements changed on April 1, 2005 based upon guidance from
Medicare (CMS). This 31-page document simplifies billing for RHC services b=
y no
longer requiring RHCs to report additional line items when billing for
preventive services. Except for the telehealth originating site facility fee
reported using revenue code 0780, all charges must now be reported on the
following revenue code line for the encounter or the claim will be returned=
to
the provider. RHCs must now only use one line o=
n the UB-92
and must bundle charges into one of the following revenue codes:
0900 &n=
bsp; Behavioral
Health Treatments (subject to the 37.5% psychiatric reduction
Three new sources of information for rural
health clinics regarding billing have been published by CMS over the last
several months. Those sources=
have
been listed with the appropriate hyperlink listed in the table. These documents are a good starting
place to help you understand the billing requirements for rural health clin=
ics.
|
Date |
Description |
Hyperlink |
|
11/12/2004 |
Instructions for completion of UB=
-92 (93 pages) |
|
| 11/19/2004 |
Updated RHC Billing Instructions<= o:p> (31 pages) |
|
|
1/2005 |
The
Medicare Guide to Preventive Services (167 pages) |
General Billing Guidelines for RHCs=
The follo=
wing
table is a summary of information related to the billing of services under
Medicare RHC regulations.
A billable encounter is between a physician, NP,=
PA
and a patient where a medically necessary service RHC covered service is
provided. For example, a nurse drawing blood, or taking blood pressure would
not be considered a billable encounter.&nb=
sp;
A rural health clinic encounter must meet all of the following to be
billable to the RHC intermediary:
=
1.&n=
bsp;
Must be a
Medicare covered service
=
2.&n=
bsp;
Must be a=
RHC
covered service (not laboratory, hospital, or technical component for examp=
le)
=
3.&n=
bsp;
Must have=
a
face to face with a physician, NP, PA
=
4.&n=
bsp;
Must be a
medically necessary service
=
5.&n=
bsp;
Must be a
service that requires the skill of a physician, NP, or PA (scope of practic=
e)
Additionally encounters will be denied as not
medically necessary if the frequency of visits is not consistent with norms=
in
other outpatient venues, such as:
1. &n=
bsp; other patients in your practice
2. &n=
bsp; other rural health clinics
3. &n=
bsp; other physician clinics
4. &n=
bsp; other hospital outpatient clinics
The deductible is the same as Part B which incre=
ased
to $110 in 2005.
The co-insurance percentage is 20% of actual cha=
rges
for RHC services versus 20% of the Medicare allowable for Medicare Part B
services.
The actual charge should be billed to Medicare. =
(not the reimbursement rate – Note: Some Medicaid programs require you=
to
bill your rate.)
Professional Components are RHC services &
included on the UB-92.
Technical Components are paid fee-for-service by
Medicare Part B.
The maximum RHC cost per visit is $70.78 in 2005=
and
68.65 in 2004.
RHC services are reimbursed on a cost per visit
basis from the Medicare Part A Intermediary (
Non-RHC services (laboratory, technical comps,
hospital visits) are paid Fee-for-Service by the Medicare Part B Carrier.
RHCs do not use CPT codes when billing RHC services =
to
Part A.
RHCs should review the Local Medical Review Policies
(LMRP) for billing guidelines.
The Bill Type is 711 when billing charges to Med=
icare
Part A.
A Provider should be present in the office suite=
any
time patients are treated under RHC Conditions of Participation regulations=
.
RHC Reimbursement Table - Visits
RHC Covered Services
|
|
|
|
|
|
|
|
|
|
|
Off= ice Visit (Do not use 99211-n= urse only) |
Yes |
UB-92 |
521 |
|
|
|
|
|
|
NF
(Level) 1 - Nursing Home LMRP – (1 routine every 60 days) |
Yes |
UB-92 |
520 |
|
|
|
|
|
|
SNF (Level II) Skilled NH (as of
1/1/2005) LMRP – (1 routine every 30
days) |
Yes=
|
UB-92 |
520=
|
|
|
|
|
|
|
Hospital Swing-Bed (SNF) |
Yes |
UB-92 |
520 |
|
|
|
|
|
|
Welcome to Medicare Physical (IPPE) 2005 – One physical during the 1st 6
months a person has Medicare |
Yes[1] |
UB-92 |
521 |
|
|
|
|
|
|
Pap Smear–Professional Comp. No Medical Necessity required |
Yes |
UB-92 |
521 |
|
|
|
|
|
|
Home
Care Oversight |
Yes |
None |
NA |
|
|
|
|
|
|
Home
visits |
Yes |
UB-92 |
522 |
|
|
|
|
|
|
Therapeutic Psychia=
tric
services by a physician, NP, PA, Clinical social worker or Clinical
psychologist. (subject to 37.5% reduction) |
Yes |
UB-92 |
900 |
|
|
|
|
|
|
Notes |
|
|
|
|
|
|
|
|
Non-RHC Services
|
|
|
|
|
|
|
|
|
|
|
Hospital Visit |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Hospice |
No |
Bill Hospice[4]<=
/a> |
NA |
|
|
|
|
|
|
Emergency Room |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Obs=
ervation
Room (Hospital) |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Nur= se Only Visits (99211) |
No[5] |
None |
NA |
|
|
|
|
|
|
EPS= DT/Well Baby Visits |
No[6] |
Medicaid |
Medicaid |
|
|
|
|
|
|
Phy= sicals (Not “IPPE”) |
No[7] |
None |
NA |
|
|
|
|
|
Serv=
ices
Provided during Non-RHC Hours
A rural health clinic can designate certain hours during the week to be a private practice or non-RHC time. During this time all services woul= d be billed to Medicare Part B and paid Fee-for-service including Medicaid servi= ces and the cost of the time would be excluded from the cost report. Likewise, = some services that are normally RHC services if performed after normal RHC worki= ng hours can be billed to Medicare Part B (1) if the visit or service occurs o= utside the RHC hours, (2) it is documented in the physician compensation agreement= and (3) the cost is excluded from the cost report. Some examples of such services are Skilled Nursing visits, Home Care Plan Oversi= ght and Home visits.
RHC Reimbursement Table - Ancillary Services
|
|
|
|
|
|
|
|
|
|
|
Laboratory
(including 6 required tests) |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Rad=
iology
(TC only) |
HCFA- 1500 |
NA |
|
|
|
|
|
|
|
Pap Smears (TC Only) |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Bone Density Scans (TC only) |
No[9] |
HCFA- 1500 |
NA |
|
|
|
|
|
|
Hol=
ter
Monitor (setup) & TC |
No |
HCFA- 1500 |
NA |
|
|
|
|
|
|
B-1=
2 & other Injections=
|
Yes |
UB-92 |
521 |
|
|
|
|
|
|
Rad=
iology
(Professional Component) |
Yes |
UB-92 |
521[10] |
|
|
|
|
|
|
All=
ergy
Shots |
Yes |
UB-92 |
521 |
|
|