Rural Health Clinic Billing & Coding

1. Rural Health Clinic Billing & Coding By Janet Lytton, Director of Reimbursement Rural Health Development janet.lytton@rhdconsult.com April 24, 2019

2. Overview • RHC Billing Overview • “How To’s” of Problem Claims • MSP Requirements

3. 2019 Medicare Patient Deductible = $185 per year IRHC Rate = $84.70/visit PBRHC PPS Hospital Rate = $84.70/visit PBRHC <50 bed hospitals = No limit ** New Medicare cards have all been issued in 2018 with numbers not associated with beneficiary social security numbers. All billers should be using the new numbers.

4. Billing Overview • RHC Billing Regulations • CMS RHC Internet Only Claims Manual http://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/clm104c09.pdf

5. What is a Visit? Face-to-Face with the Provider Physician, PA, NP, CNM Clinical Social Worker or Clinical Psychologist Medically necessary Does it require the skills of a Provider? Payer Class All payer classes are counted in the total visit count Place of Service Clinic, Home, NH, SNF/SW B, Scene of Accident Level of Service All levels apply, to include procedures To include all services “incident to”

6. CPT Procedure Codes All Procedure Codes that are normally performed in a physician’s clinic are applicable in the RHC If your coder is also your biller, the knowledge of what service to bill to which payer is imperative Some CPT codes will have to be “split” billed, i.e. EKG tracing and interp, xray prof & tech comp

7. Medicare Covered But Nonbillable Services Nurse service w/o face-to-face visit or “incident to” visit I.e. allergy injection, hormone injection, dressing change, venipuncture Provider MUST be onsite to have “incident to” Service MUST be “previously” ordered CMS Manual 100-02 Chapter 13 Section 120 & 140 Telephone services CMS Manual 100-02 Chapter 13 Section 120 Prescription services CMS Manual 100-02 Chapter 13 Section 120

8. Examples of no medical necessity Routine INR visit for lab Simple suture removal Dressing change Results of normal tests Blood pressure monitoring B12 injection Allergy Injection Lab tests for screening w/o med necessity Prescription service only Chief Complaint: “here for refills”

9. RHC UPDATED REGULATIONS Global Billing All procedures in the RHC are not subject to Globals If RHC sees PT for the surgical DX of another provider, must assure the proc was billed w/54 mod If RHC provperforms hospproc, bill w/54 mod, and then bill each visit at clinic level as not in global Services never included in global surgical package Initial visit to determine surgery required Visits unrelated to DX for surgical procedure Treatment for underlying condition or an added course of treatment which is not part of normal recovery 3-Day Payment Window RHC services are not subject

10. MODIFIER -25 Significant, separately identifiable E/M service by same provider on the same day of a procedure or other service. Append to E/M code , I.e. 99214-25 (in system only) Use Modifier 25 when: Visit for a problem unrelated to the procedure Visit for a new problem or a problem that has changed significantly and requires re-evaluation before performing the procedure. Visit for the same problem in different sites; one treated surgically and one treated medically. (DO NOT use -25 on claim as it means there was a separate visit on the same day for unrelated diagnosis, effective 10/1/16)

11. EXAMPLES OF MODIFIER -25 Visit for a problem unrelated to the procedure or service Preventive AWV = patient seen for annual wellness visit E/M service = Patient also c/o leg pain, swelling and hot spot. Evaluated for phlebitis Supporting Documentation E/M documentation identifiably distinct from procedure documentation Must meet ALL requirements for E/M visit along with documentation of procedure. Can only count “bullets” of documentation once in setting the level. DO NOT SHOW THE -25 ON YOUR MEDICARE OR MEDICAID CLAIMS

12. Medicare Part A Billing RHC Services UB 04 form or 837i electronic format Bill Type 711 52X and/or 900 Revenue Code(s) with CPT code of face-to-face visit with CG modifier and the bundled charges minus any preventive service charges All other revenue codes listed on separate lines with CPTs of the “bundled” charge line items Charges on subsequent lines must be $.01 or more Sent to MAC Claims for all RHC visits Office, Skilled Nursing Home, Swing Bed, Nursing Home, Home, Scene of an accident

13. Medicare Part A “QVC” Revenue Codes– That can Have The CG Modifier 521 Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient Only prof service as labs, drugs, x-ray TC, EKG tracing gets billed to the SNF. 525 Visit to a Pt in a SNF, NF, ICF, AL Patient not on a Part A SNF Stay 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 900 Mental Health Services

14. Rev Codes, HCPCS Codes, & CG modifier 052X and/or 0900 Rev Code w/Qualifying Visit code and the CG mod, HCPCS of QVC, total bundled charges of all service lines except preventive codes; separate line for each bundled service with charge > $.01, list each preventive service w/code and applicable charge. Any stand alone preventive code or primary code of several preventive codes requires CG modifier. ALL RHC claims MUST have a CG modifier to receive payment Detail of Revenue codes except the following are allowed: 002X-024X, 029X, 045X, 054X, 056X, 060X, 065X, 067X-072X, 080X-088X, 093X, 096X-310X

15. Rev Codes, HCPCS Codes, & CG modifier Some common allowed Revenue codes may be: 052X, 0250, 0300, 0636, 0780, 0900 (this is not an all inclusive list) All HCPCS codes must match Rev code used; 0250 should not have a CPT code on the line item Currently, QVC list is not updated and RHCs are allowed to bill for a service that is deemed as a provider service If providing a service on the QVC list, suggest using that code as the one that has the CG modifier QVC List https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf * References are CMS CR9269 and SE1611

16. Timely Filing MEDICARE: Must file claims within one year from date-of-services—effective 3/23/10. I.e. January 1, 2019 must be filed by Dec 31, 2019 NE MEDICAID: Must file claims within 180 days from date-of-service I.e. January 1, 2019 must be filed by Jun 29, 2019 Any adjustment must be completed w/I 90 days MCD MCOs may have longer timely filing; Heritage Health began 1/1/17 *If any Xover payments are not received, these can be put on your Medicare Bad Debt log for your cost report

17. Medicare RHC Provider Number RHC office visit services Excludes all labs, x-ray TC & EKG Tracing, any TC Includes venipuncture effective 1/1/14 Billed to the MAC, UB04 Form or electronic Paid on the clinic’s “all inclusive rate” All Medicare coverage rules apply Reasonable & necessary Allowed preventive is covered, I.e. pap, PSA, AWV

18. Medicare Part B Provider Number (IRHC) All labs, x-ray TC, EKG tracing, any technical components (venipuncture is part of the office visit bundled services) All hospital services (IP, OP, ER, OBS) Billed to MAC, HCFA 1500 Form Paid on the Medicare Pt B fee schedule

19. Medicare Part B Provider Number (PBRHC) All hospital services (IP, OP, ER, OBS)* Billed to WPS MAC, HCFA 1500 Format Paid on the Medicare existing fee schedule * The only exception is if the CAH is Method II reimbursement

20. PBRHC - Hospital OP Provider Number ALL Laboratory performed in the RHC, including 6 basic tests (venipuncture is part of the office visit bundled service) Billed as would have been if provided at the hospital Technical Component X-ray EKG Holter Monitor placement All TC’s Billed as would have been if provided at the hospital Paid on the Medicare Pt B Fee Schedule

21. PBRHC - Hospital OP Provider Number CAH Method II Hospital bills for both the professional and technical component when performed in the hospital setting: X-ray EKG Holter Monitor ER OP/OBS/ASC Must have separate line item for the prof service Paid on the Medicare Pt B Fee Schedule + 15%

22. State Medicaid RHC/nonRHC Billing Each State Medicaid is specific as to their State requirements—50 states, 50 plans May use either the 1500 or UB04 Managed Care Plans have choice as well Coverage is specific to each state Most States require both RHC and nonRHC Medicaid provider numbers Paid on the RHC rate or a PPS rate NE has transitioned to Managed Care Payers Heritage Health began 1/1/17 http://dhhs.ne.gov/medicaid/Pages/med_medcontracts.aspx

23. NE Medicaid Each Managed Care Payer (MCP) can require either/both—UB04 or 1500 All Services for the Managed Care patients are sent to the MCP—nothing sent to DHHS (w/few except.) Nebraska Total Care UnitedHealthcareCommunity Plan of Nebraska WellCareof Nebraska MCP can determine how to bill and how to pay claims MCPs are given RHCs facility specific payment rates to assure MCP is paying the most current rate—RHC Medicaid year is 7/1 through 6/30 each year

24. NE Medicaid Must have RHC and nonRHC number Form for each is per the Managed Care Payer NE Plans use the UB04 for RHC services Use the 1500 for the nonRHC services Ailments are RHC services Preventive services are nonRHC services IRHCs receive 100% of their Medicaid PPS rate PB of <50 bed hosp receive 100% of their actual charges PB of >50 bed hosp receive 100% of MCD PPS rate Must send in a copy of your Medicare CR annually as is a Federal Requirement With PPS payments there are no cost report settlements

25. NE Medicaid IRHC RHC services—UB04 Detailed line items on UB04 w/RHC Provider # Lab, X-ray TC and EKG tracings (nonRHC) are billed on the nonRHC provider # on the 1500 Professional components are part of the visit All preventive, IP, OP, ER, OBS are nonRHC services, billed with nonRHC Provider # on1500 OB is global with exception of first visit (1500) If only visits, then nonRHC# and list visit dates Global Period will depend on the MCO—anywhere from 2 weeks (Wellcare) or more

26. NE Medicaid PBRHC RHC services —UB04 Detailed line items on UB04 with RHC Provider # Lab, X-ray TC, EKG tracing billed with Hosp OP # Professional components are part of the visit All preventive, IP, OP, ER, OBS are nonRHC services, billed with the nonRHC # on 1500 OB is global with exception of first visit (1500) If only OB visits, bill nonRHC# and list visit dates Global Period will depend on the MCO—anywhere from 2 weeks (Wellcare) or more

27. NE Medicaid “Incident to” services without a face-to-face visit are billed on the nonRHC # i.e. injection only Must have both the administration CPT code and the NDC of the drug administered If VFC is used, Vaccine CPT is billed on the nonRHC # with charge of $19 and SL modifier nonRHC services paid using the fee schedule and not your RHC rates Are allowed to have an RHC visit at the same time as a nonRHC visit, i.e. ailment and preventive

28. Private Pay or Private Insurance Billed as in fee-for-service clinic No changes in reimbursement Must not discount charges at time of service RHC rule that all patients be charged the same fees no cash discounts no professional discounts given All discounts given should be based on finances of patients i.e. sliding fee scales can be developed to as high as 400% of poverty guidelines per Federal Regulations

29. Medicare Advantage (MA) Two types of plans PFFS – Private Fee for Service Send Claims on UB04 with Medicare Rate letter Regional/PPO Plans Must provide service to the entire region per CMS Send Claims on UB04; you negotiate payment When patients switch to MA, they are on your “Private” section of your visit counts You may want to keep them separate as they will count as Medicare patients if you need to figure the % of Medicare utilization.

30. Behavioral Health Services Clinical Psychologist (PhD) Doctoral level of education Clinical Social Worker (CSW) Masters level with at least 2 years experience Use 900 revenue code to bill therapeutic behavioral health After 10/1/16 will require a CG modifier on the bundled line item The first visit to determine services by a Physician/PA/NP is an RHC visit, then behavioral health services apply Reimbursement in 2014> changed to 80/20 Can be only service on claim or can also have 521 rev code If both the 900 and 521 rev codes on claim, both will have the CG mod.

31. QVC required; AIR paid with copay and deductible applied. 900 Rev code is for Behavior Health Providers

32. More Than One Visit Per Day Only allowed if a different unplanned illness or injury If same diagnosis, accumulate to set E & M level 1st visit must have a CG modifier; 2nd visit is to be billed with a -59 modifier; or after 10/1/16 also can use -25 Visit by physician and then the mental health provider both are billable—2 visits—Each bundled 521 and 900 will have a CG modifier effective 10/1/16 IPPE and an ailment visit—is 2 visits, only ailment visit requires CG modifier IPPE, ailment and mental health visit—is 3 visits, ailment visit and mental health visit require CG modifiers Visit in clinic, then hospital admit (MAC determines); generally both not billable Visits by two different specialties on same day—is 1 visit CMS Manual 100-02 Chapter 13 Section 40.3

33. Effective 10/1/16, the -25 or -59 will only be attached to the RC line item that is the second visit on the same date-of-service for an unplanned different ailment of the patient. 2 AIRs paid

34. Example of claim after 10/1/16, with both 521, 900 and preventive services on the claim. Note the CG modifier is attached to the “bundled” 521 line, and to the “bundled” 900 line with the 521 preventive service charges not included in either of those lines. (2 AIRs). Since the Preventive service is AWV, there is not additional payment.

35. Example of claim effective 10/1/16, with a Medical Visit 521, 900 Mental Health Visit and IPPE on same DOS. Note the CG modifier is attached to the “bundled” 521 line, and to the “bundled” 900 line. (3 AIRs pd); the Preventive service is NOT included in the bundle.

36. The CG modifier must be attached to the main preventive service with all the other services listed on subsequent lines. 1 AIR is paid, unless there was an IPPE (G0402), then 2 AIRs are paid; no lines are bundled.

37. BILLING NONCOVERED CHARGES How do you bill noncovered charges? If all charges are noncovered, send 710 TOB with all charges as noncovered and condition code 21. If only some of the charges are noncovered can use: Modifier GY = noncovered by Medicare Statute or Modifier GX = ABN Issued, Beneficiary liable. Can use one or both on Medicare claim but the charge for the item must be shown as noncovered and will not be bundled in the CG line.

39. Claim when only partially noncovered

40. INFUSION THERAPY Infusion with an Office Visit In your system 9920X or 9921X for OV, J-Code for Infusion med, CPT for Infusion subcutaneous or intravenous 96365 Intravenous infusion, for therapy, prophylasis or diagnosis; initial up to 1 hr. 96369 Subcutaneous infusion for therapy or prophylaxis, initial up to 1 hr, including pump set-up Add charges bundled to the E/M code and line item entry of each bundled service (Medicare)

41. Laboratory Services All coded with the accurate CPT code Don’t forget to charge the venipuncture with OV effective 1/1/14 is part of the office RHC services If more than one of the same test is done on the same day, a -91 modifier is added to the CPT code IRHCs—All Labs, to include the required basic 6 tests, are payable through Medicare Part B PBRHCs—All labs, to include the required basic 6 tests, both Medicare & Medicaid are payable through the Hospital OP provider number

42. Radiology Services All coded with the accurate CPT code for each the technical component (TC) and the professional component(PC) if provider interprets Effective 1/1/18, some x-ray codes are both the TC and PC but no list given as yet, i.e. Chest x-ray = 71046 Two views frontal & lateral has no splits Interpretation is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health; then listed separately Technical Component is billed to Medicare Pt B or for PBRHC, billed using the hospital OP provider number Medicare reg on nonRHC service billing, TCs & EKG tracing: CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.

43. EKG Services Coded using the tracing only for the TC & the interpretation only if provider interprets. EKG Tracing only = 93005 EKG Interpretation and report = 93010 (521 rev code) Interp is billed with the office visit and included in the total charges that are submitted to Medicare Rural Health, then listed on separate line Tracing only is billed to Medicare Pt B for IRHC or PBRHC bills using the hospital OP provider number Medicare reg on nonRHC service billing, TCs & EKG tracing: CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.

44. Note xray reading is -26 modifier and CPT for EKG interp; all bundled with the OV on the CG line; 1 AIR pd, $36 copay

45. “Incident to” Services Direct supervision by provider required Must be in clinic, not in same room being in the hosp when attached to clinic is NOT “incident to” Exception is the Chronic Care Management services Part of provider’s services previously ordered integral, though incidental covered as part of an otherwise billable encounter I.e. dressing change, injection, suture removal, blood pressure monitoring Medicare (Medicaid if State requires) services should be billed under the provider that performed the service—NE Medicaid does require

46. Services Rendered on non-visit days—“Incident To” Services Can be combined on claim with a visit within “a medically appropriate” timeframe (30 days pre/post) NEVER considered a separate visit or sent to Part B List only the date of the FTF visit as date-of-service Charges should reflect all services bundled (CG line) Added charges will be on subsequent lines of UB04 When added, additional reimb is the 20% copay Adjustments OK—717 Type of Bill; CC=D1; remarks “changes in charges” Otherwise, the costs are included on the cost report and claimed indirectly CMS Internet Manual 100-02, Ch 13, Sec 120

47. MEDICARE INJECTIONS Injections with Office Visit Charge All CPT codes in system Bundle all charges with the QVC; list the RC 0250 w/no CPT code, or RC 0636 with the J-code & submit claim to RHC MCR If it is a Pt D drug, it must be sent to Pt D plan or Patient Can participate with the transactrx.com site for Pt D payments Injections only—nurse service (Incident to service) Charge in system Either DO NOT bill (write off) as there is no f-t-f visit OR can be bundled with a visit within “a medically appropriate time” generally 30 days pre or post nursing service and submitted with the f-t-f visit If injectable is a Part D drug it MUST not be on RHC claim; only billable to the patient or to Part D

48. PART D - INJECTIONS Injectable/Vaccine as a Part D drug – 1/1/08 Injections, i.e. Gardasil, Zostavax, Varivax, Tetanus (as immunization update), DTAP (90697 check your MCR payer as it may have a LCD to be under Pt B; WPS allows to be Pt B for an injury, effective 1/1/16 LCD L34596) The injectable/vaccine is payable only through Pt D Exception is flu and pneumonia is payable through the RHC cost report; Hepatitis B is Pt B covered if indicated Pt high risk and billed on the visit claim If injectable/vaccine is obtained at the clinic level, then the patient is to pay for the injectable/vaccine and the administration privately and then they have to submit that claim to their Part D company to be reimbursed for the services. Clinics can link to: www.mytransactrx.com and bill the Pt D drug and get payment to include administration of the drug and the system will let you know the copay amount. (an electronic system for the clinic to bill is suggested by CMS)

49. NonRHC Services MCR excluded services, i.e. dental, hearing & eye tests = Patient payable Lab Services; Technical components of an RHC service = Billable to Pt B for IRHCs; PBRHC billed by parent hospital DME, Prosthetic devices, Braces = Must have DME provider # to bill items If no provider #, build the cost of the item in the procedure code being billed Ambulance Services = Ambulance company bills Hospital Services ER, OP, IP, ASC, MCORF = Billed to Pt B; if CAH Method II, ER, OP, ASC billed by CAH Telehealth distant-site services = Billed on the RHC claim with 780 RC with Q3014 and charge Hospice Services (if for DX of hospice); Auxiliary Services, i.e. language interpretation, transportation, security = not billable to anyone

50. How Do We Bill:OV, Lab, EKG, Xray Medicare: Bill OV, EKG interp, xray read (if provider does the interp/read) to RHC Medicare on UB 04 (use E & M with bundled charges w/CG and subsequent lines of the 71046-26 & 93010 with charge); Bill labs, EKG tracing & Xray TC to MCR Pt B for IRHCs & PBRHCs bill with Hosp OP # on UB04 NE Medicaid: IRHC follows Medicare guidelines w/CPT; PBRHC list all line items and paid total charges. Private/Commercial: Bill as in FFS clinic