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1. Billing for Rural Health Clinics March 20, 2008Jeff Bramschreiber, CPAWipfli LLP920.662.2822jbramschreiber@wipfli.com WIPFLI.COM

2. How are Rural Health Clinics (RHCs) paid?RHCs are paid a flat rate for each face-to-face encounter based upon the anticipated average cost for direct and supporting services, with a reconciliation of costs (i.e., cost report) occurring at the end of the fiscal year.

3. RHC Reimbursement Limits* * Only applies to independent RHCs and provider-based over 50 beds.

4. There are two types of RHCs—billing and payment is slightly different:1. Independent RHCs bill RHC services to one of five regional fiscal intermediaries.2. Provider-based RHCs bill RHC services to the fiscal intermediary of the host provider (usually a hospital).

5. Diagnostic services provided outside the scope of RHC services are also billed differently:1. Independent RHCs bill non-RHC diagnostic services (e.g., lab, X-ray) to the Medicare Part B carrier. 2. Provider-based RHCs bill non-RHC diagnostic services (e.g., lab, X-ray) to the fiscal intermediary of the host provider.

6. Professional services provided outside of the scope of RHC services are billed similarly:1. Independent RHCs bill non-RHC professional services (e.g., hospital visits) to the Medicare Part B carrier. 2. Provider-based RHCs bill non-RHC professional services (e.g., hospital visits) to the Medicare Part B carrier.

7. There are four general categories of services provided at or by a RHC:1. RHC encounters (face-to-face visits) 2. RHC services “incident to” encounters3. Non-RHC services4. Noncovered services

8. 1. RHC encounters:Face-to-face with a RHC practitioner (physician, NP, PA, CNM, CP, CSW)Medically necessaryNecessity for physician or midlevel practitioner professional serviceIn the RHC or patient’s place of residence

9. 2. Incidental “incident to” RHC services:Services and supplies commonly rendered by clinic employees under general supervisionIncidental part of professional service (e.g., injections, BP check, prescription renewals, dressing changes, etc.Tied to a visit, but not separately billable

10. 3. Non-RHC services:Performed outside RHC setting, (e.g., hospital o/p, i/p, or ER)Technical component of diagnostic services (lab, X-ray, EKG, etc.)Specifically excluded - Ambulance, DME, screening mammography

11. 4. Noncovered services:Never paid by MedicareExperimentalRoutine examinationsPrescription drugs

12. Coverage and separate payment available for certain services:Flu vaccinesPneumococcal vaccinesNot separately billed, but paid in lump sum through the cost report

13. General Billing Guidelines:

14. RHC Payment Example #1: The customary charge for 99212 is $60. The Medicare encounter rate is $70. Deductibles have already been met.

15. RHC Payment Example #1:

16. Standard Part B Payment Example (not RHC):

17. Comparison between RHC and Part B Payment Example #1:

18. RHC Payment Example #2: The customary charge for 99215 is $160. The Medicare encounter rate is $70. Deductibles have already been met.

19. RHC Payment Example #2:

20. Standard Part B Payment Example (not RHC):

21. Comparison between RHC and Part B Payment Example #2:

22. RHC Billable Services (Encounters):Must be a medically necessary, face-to-face encounter with RHC practitioner.One RHC visit per patient per day (limited exceptions).Use standard fee schedule and E/M coding (includes procedures).Bill to fiscal intermediary; UB-92 claim form.Revenue codes revised as of July 1, 2006.

23. Expanded Revenue Codes for RHCs: Effective for dates of service on or after July 1, 2006 Change Request 4210, February 1, 2006 MedLearn Matters Article MM 4210

24. Expanded Revenue Codes for RHCs

25. RHC Incidental Services:Examples include allergy injections, vitamin B-12, supplies, etc.Not separately billable; combined with RHC encounterCannot be billed to Part B carrier!Cost of services bundled into encounter rate through cost report

26. Non-RHC Services:Examples include services rendered in hospital and other diagnostics (lab, X-ray, EKG)Professional component of hospital services billed to Part B carrierTechnical component of diagnostic services billed to Part B carrier for independent RHCs or hospital FI for provider-based RHCs

27. Laboratory (Non-RHC Service):All labs, including six basic labs, are billed to Part B carrier for independent RHCs or to hospital FI for provider-based RHCs.Includes venipuncture.Costs for lab services performed in RHC are reported in nonreimbursable cost center on the independent RHC cost report or in the hospital lab department for provider-based RHCs.

28. Radiology (Non-RHC Service):The technical component of all radiology, including EKGs, are billed to Part B carrier for independent RHCs, or hospital FI for provider-based RHCs.The professional component is billed with encounter, unless a non-RHC physician interprets.Costs for X-ray services performed in RHC are reported in nonreimbursable cost center on independent RHC cost report or in the hospital radiology department for provider-based RHCs.

29. Billing Guidance:Local Coverage Decision (LCD) L4874 for Rural Health Clinics from Riverbend Government Benefits AdministratorIncludes Frequently Asked Questions (FAQs) as a separate document.http://www.riverbendgba.com/vlmrp/4874.html

30. Special Billing - Preventive Services:The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care ProfessionalsThis guide provides information on Medicare’s preventive benefits including coverage, frequency, risk factors, billing, and reimbursement (167 pages).http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf

31. Table of Contents - Guide to Medicare Preventive Services 1. "WELCOME TO MEDICARE" PHYSICAL EXAMINATION 2. CARDIOVASCULAR SCREENING BLOOD TESTS 3. DIABETES SCREENING TESTS, SUPPLIES, SELF-MANAGEMENT TRAINING, AND OTHER SERVICES 4. MAMMOGRAPHY SCREENING 5. SCREENING PAP TESTS 6. PELVIC SCREENING EXAMINATION 7. COLORECTAL CANCER SCREENING 8. PROSTATE CANCER SCREENING 9. INFLUENZA, PNEUMOCOCCAL, AND HEPATITIS B VACCINATIONS 10. BONE MASS MEASUREMENTS 11. GLAUCOMA SCREENING

32. Special Billing - Welcome to Medicare Visit: Split between Part B service and RHC service Part B service:− Bill technical component of EKG using G0367 (EKG) to Part B carrier ($16 reimbursement) or hospital FI RHC (professional) service: − Follow normal RHC billing Rev code 52x Paid as RHC encounter

33. Special Billing - Cardiovascular Screening: Includes blood tests for cholesterol and triglycerides Part B service:− Bill lab tests to Part B carrier (or hospital FI) using appropriate diagnosis codes RHC (professional) service - None performed

34. Special Billing - Screening Pap/Pelvic Exam: Split between Part B service and RHC service Part B service:− Bill technical component of Pap Screen to Part B carrier or hospital FI RHC (professional) service:− Follow normal RHC billing Rev code 52x Paid as RHC encounter

35. Special Billing - Flu/PPV:Flu and pneumococcal vaccines have “special” treatment for cost-based reimbursementDo not file claims for Flu/PPVMaintain a log with the patient’s name, HIC number, and date of service Reported and paid separately on the RHC cost report

36. Special Billing - Multiple Visits:Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day at a single location constitute a single visit.Exception: When one of the following conditions exist: (a) After the first encounter, the patient suffers illness or injury requiring additional treatment. (b) The patient has a medical visit and a clinical psychologist or clinical social worker visit.

37. Jeff Bramschreiber, CPA Partner, Health Care Practice Wipfli LLP 469 Security Blvd. Green Bay, WI 54313 920.662.2822 jbramschreiber@wipfli.com Speaker Information

38. Questions and Discussion