What’s new in RHC billing?
Charles A. James, Jr.
President and CEO
North American Healthcare Management Services
www.northamericanhms.com
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What is an RHC?
Rural Health Clinics were established by the Rural Health
Clinic Service Act of 1977 to address an inadequate supply of
physicians serving Medicare beneficiaries in underserved
rural areas, and to increase the utilization of nurse
practitioners (NP) and physician assistants (PA) in these
areas. RHCs have been eligible to participate in the Medicare
program since March 1, 1978, and are paid an all-inclusive
rate per visit for qualified primary and preventive health
services.
(Medicare Benefit Policy Manual. Chapter 13. Section 10.1.)
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The RHC Encounter Rate
“In general, the all-inclusive rate (AIR) for an
RHC or FQHC is calculated by the MAC/FI by
dividing total allowable costs by the total
number of visits for all patients. Productivity,
payment limits, and other factors are also
considered in the calculation.”
(Medicare Benefit Policy Manual. Chapter 13. Section 70.)
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RHC Productivity Standard
1 FTE Physician – 4,200 Visits
1 FTE NP or PA – 2,100 Visits
If the RHC or FQHC has furnished fewer than
expected visits based on the productivity standards,
the MAC/FI substitutes the expected number of
visits for the denominator and use that instead of
the actual number of visits.
(Medicare Benefit Policy Manual. Chapter 13. Section 70.4.)
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RHC Claims - Medicare Part A
• Rural Health Clinic claims are administered
by Medicare Part A.
• It is a Part B (Physician Service) benefit,
using the structure of Medicare Part A.
• This is why we deal with UB04, Cost
Reports, Revenue Codes, etc.
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Medicare Part B (FFS)
In the RHC world, the term ‘Medicare
Part B’ typically indicates those claims
which will continue to be paid ‘fee-forservice’ and billed on a CMS-1500.
Non-RHC claims fall in this category.
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Qualified RHC Providers
An RHC encounter can be billed for the
following providers:
• Physicians (MD, or DO)
• Nurse Practitioners, Physician Assistants, and
Certified Nurse Midwives
• Clinical Psychologists (PhD)
• Clinical Social Workers (CSW or LCSW)
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Rural Health Services
• Physicians' services, as described in section 100;
• Services and supplies incident to a physician’s
services, as described in section 110;
• Services of NPs, PAs, and CNMs, as described in
section 120;
• Services and supplies incident to the services of
NPs, PAs, and CNMs, as described in section 130;
(Medicare Benefit Policy Manual Chapter 13)
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Rural Health Services (Continued)
• CP and CSW services, as described in section 140;
• Services and supplies incident to the services of
CPs and CSWs, as described in section 150; and
• Visiting nurse services to the homebound as
described in section 180.
(Medicare Benefit Policy Manual Chapter 13)
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The RHC Encounter is:
“An RHC or FQHC visit is defined as a medically-necessary,
face-to-face (one-on-one) encounter between the patient
and a physician, NP, PA, CNM, CP, or a CSW during which
time one or more RHC or FQHC services are rendered. An
Initial Preventive Physical Examination (IPPE) or an Annual
Wellness Visit (AWV) can also be considered an RHC or FQHC
visit.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.)
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Physician Services
The term “physician” includes a doctor of medicine,
osteopathy, dental surgery, dental medicine,
podiatry, optometry, or chiropractic who is licensed
and practicing within the licensee’s scope of
practice, and meets other requirements as
specified.
(Medicare Benefit Policy Manual. Chapter 13. Section 100.)
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Physician Services
“Physician services are professional services furnished by a
physician to an RHC or FQHC patient and include diagnosis,
therapy, surgery, and consultation. The physician must either
examine the patient in person or be able to visualize directly
some aspect of the patient’s condition without the
interposition of a third person’s judgment. Direct
visualization includes review of the patient’s X-rays, EKGs,
tissue samples, etc.
(Medicare Benefit Policy Manual. Chapter 13. Section 100.)
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Incident-to Services Defined
• Commonly rendered without charge or included in the RHC or FQHC
bill;
• Commonly furnished in a physician office or clinic;
• Furnished under the physician’s direct supervision; and
• Furnished by a member of the RHC or FQHC staff.
• Drugs and biologicals that are not usually self-administered, and
Medicare-covered preventive injectable drugs (e.g., influenza,
pneumococcal);
• Bandages, gauze, oxygen, and other supplies; or
• Assistance by auxiliary personnel such as a nurse, medical assistant,
or anyone acting under the supervision of the physician.
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Incident-to Services Defined
• Incident-to services are considered covered and paid
under the RHC.
• They must be bundled with the RHC encounter. They are
not separately billable or payable.
• Services that do not occur on the same date as the
encounter can be bundled if they occur 30 days before or
after.
• The effect on payment is an increase in the charge, and
therefore in the co-insurance.
• The cost for these services are included in the cost report,
but are not separately payable on claims.
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Provision of Incident-to Services
• Incident to services and supplies can be furnished
by auxiliary personnel.
• More than one incident to service or supply can
be provided as a result of a single physician visit.
• Incident to services and supplies must be
provided by someone who has an employment
agreement or a direct contract with the RHC or
FQHC to provide services
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Provision of Incident-to Services
• Services and supplies furnished incident to
physician’s services are limited to situations in
which there is direct physician supervision of the
person performing the service.
• Direct supervision does not mean that the
physician must be present in the same room…the
physician must be in the RHC or FQHC and
immediately available.
(Medicare Benefit Policy Manual. Chapter 13. Section 110.1)
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Examples of incident-to services
•
•
•
•
•
•
Injections
Suture Removal
Dressing Changes
Prescription Services
Blood Pressure Monitoring
Billing the NP/PA using the physician’s
name and NPI!!
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Commingling
• For RHCs commingling is fraud.
Commingling is getting paid twice from
Medicare.
• Submitting incident-to services to Medicare
Part B, since they are covered under the
RHC benefit, is fraudulent billing.
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Multiple Encounters
“Encounters with more than one RHC or FQHC
practitioner on the same day, or multiple
encounters with the same RHC or FQHC practitioner
on the same day, constitute a single RHC or FQHC
visit, regardless of the length or complexity of the
visit or whether the second visit is a scheduled or
unscheduled appointment.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Multiple Encounters are allowed when:
• The patient, subsequent to the first visit, suffers an illness
or injury that requires additional diagnosis or treatment
on the same day (2 visits), or
• The patient has a medical visit and a mental health visit on
the same day (2 visits), or
• The patient has his/her IPPE and a separate medical
and/or mental health visit on the same day (2 or 3 visits).
The IPPE, also known as the “Welcome to Medicare Visit”,
is a one-time exam that must occur within the first 12
months following the beneficiary’s enrollment.
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Global Billing
• Surgical procedures furnished in an RHC or FQHC by an
RHC or FQHC practitioner are considered RHC or FQHC
services.
• The RHC is paid based on its all-inclusive rate and is not
subject to the Medicare global billing requirements.
• Surgical procedures furnished at locations other than
RHCs or FQHCs may be subject to Medicare global billing
requirements.
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Modifier - 25
• This modifier indicates a significant, separately
identifiable service and an office visit which occur
on the same day by the same provider.
• Documentation requirements must be met for
both services.
• Reasons for usage in an RHC may be for:
 Same day sick visit and preventive service
 Same day sick visit and minor surgery
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99495 - Transitional Care Mgmt
• Communication (direct contact, telephone,
electronic) with the patient and/or caregiver
within 2 business days of discharge.
• Medical decision making of at least moderate
complexity during the service period.
• Face-to-face visit, within 14 calendar days of
discharge.
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99496 - Transitional Care Mgmt
• Communication (direct contact, telephone,
electronic) with the patient and/or
caregiver within 2 business days of
discharge.
• Medical decision making of high complexity
during the service period.
• Face-to-face visit, within 7 calendar days of
discharge.
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Non-Rural Health Services
Non-Rural Health Services can be billed to the
fee-for-service carrier (or hospital FI). These
services include:
• Diagnostic testing - X-Ray, EKG, etc.
• Laboratory services - Venipuncture
• Professional services rendered in the
hospital
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Diagnostic Testing and Lab:
Independent
• The professional component for X-Ray,
EKG, and other diagnostic testing is
bundled with the RHC encounter.
• The technical component of these tests are
billed to the Medicare Part B carrier using
the fee-for-service provider number.
• All lab services are also billed to the Part B
carrier.
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Diagnostic Testing and Lab:
Provider-Based
• The professional component for X-Ray,
EKG, and other diagnostic testing is
bundled with the RHC encounter.
• The technical components for X-Ray, EKG,
ultrasounds, etc. are billed to the FI using
the parent entity’s billing number.
• Lab services are also billed to the FI using
the parent entity’s billing number.
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Hospital Admit and RHC Encounter
• Some MACs will pay the Hospital admit and
an RHC encounter on the same day.
(Trailblazers, WPS, Cahaba).
• Other’s won’t.
• Check with yours to confirm.
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Hospice
• RHCs and FQHCs can treat hospice beneficiaries
for any medical conditions not related to their
terminal illness.
• If a Medicare beneficiary who has elected the
hospice benefit receives care from an RHC or
FQHC related to his/her terminal illness, the RHC
or FQHC cannot be reimbursed for the visit.
(Medicare Benefit Policy Manual. Chapter 13. Section 200)
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Non-Hospice Related
• When the RHC provider DOES see a hospice
patient for non-hospice related condition:
• Occurrence Code ‘07’
• Enter ‘Non-Hospice Related Service’ in
remarks
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Influenza, Pneumococcal Injections
• Flu and pneumonia shots are covered
under the RHC program. These are the
only injections that are separately payable.
• These are not billed on a claim, but are
submitted on the cost report.
• They are paid with the clinic’s annual cost
report reconciliation.
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Prevnar - 13
• Cahaba will not cover Prevnar on the cost
report.
• Most other MACs will allow Prevnar.
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Visiting Specialists in an RHC
Any qualified provider (MD, DO, NP, PA) can
see patients in an RHC.
The only stipulation is that the RHC must
provide primary care services fifty-one
percent of operating hours. (FP, IM, Peds, OB)
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Two Scenarios for Visiting Specialists
Scenario #1: A specialist rents space from the
RHC one morning per week, brings his own
staff, and does his own billing.
Configuration: The RHC carves out the cost
of the space and removes all associated
costs from the cost report.
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Visiting Specialists
Scenario #2: A general surgeon comes to the
RHC once per week. She sees RHC patients
and they are billed as RHC encounters.
Configuration: In-patient surgeries should be
billed with modifier 54 (surgery only).
Follow-up visits can then be billed as
encounters.
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Mental Health Services
• Mental Health Services performed by a
qualified provider are billed using revenue
code 900.
• Diagnostic services are paid as an
encounter.
• Therapeutic services are subject to a
limitation which is being phased out.
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Mental Health Providers
• Medicare RHC providers are:
 Clinical Psychologist (PhD)
 LCSW
 LCPC or CPC is not payable by Medicare
(Check with your own state to see if LCPC
or CPC are eligible – in most states they
are not)
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Mental Health Billing
• Diagnostic visits are fully payable.
• Therapeutic visits are subject to limitation.
 Medicare pays 81.5% of RHC rate.
 Patient pays 18.5% of rate plus coinsurance/deductible on charge amount.
 This limitation will be phased out by
2015.
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Mental Health Payment Limitation*
Period
Limitation %
Medicare Pays/ Pt. Pays
Through Dec. 31, 2009
62.5%
50% / 50%
Jan. 1, 2010 – Dec. 31, 2011
68.5%
55% / 45%
Jan. 1, 2012 – Dec. 31, 2012
75%
60% / 40 %
Jan. 1, 2013 – Dec. 31, 2013
81.5%
65% / 35%
Jan. 1, 2014 – onward
100%
80% / 20%
* www.cms.gov/MLNMattersArticles/downloads/MM6686.pdf
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Telehealth
• RHCs are statutorily required to be the
‘originating’ site for telehealth services.
• The RHC cannot be remote site.
• Must report on UB04 with Q3014. ($23.17)
• Can accompany an E/M service or be
reported alone.
• ‘Remote’ physician bills an E/M code with
modifier.
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Preventive Services (MPS)
• Initial Preventive Physician Examination
• Annual Wellness Visit (AWV) and
Personalized Prevention Plan Services
(PPPS)
• Subsequent Annual Wellness Visit
• Medicare Preventive Screenings
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Preventive Services - Billing
• The IPPE and AWV are Medicare covered
preventive services.
• These are RHC encounters.
• They should be billed with the HCPCS code
on a UB04.
• There is no cost sharing (i.e. no patient
deductibles or co-ins.) for IPPEs and AWVs.
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Preventive Services – Cost Reporting
• Medicare pays 80% of the RHC Encounter
rate, but no co-insurance or deductible.
• Track Medicare Preventive Services (MPS)
charge amounts.
• These are to be entered on the cost report.
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IPPE – Initial Preventive Physician Exam
• Otherwise known as the ‘Welcome to Medicare Visit’.
• Payable once per lifetime.
• Must be rendered within 12 months of the beneficiaries’
Medicare coverage date.
• Co-Insurance and deductible do not apply.
• Is payable as a separate RHC encounter. One occasion
where two encounters on the same day are payable.
• Any preventive diagnostic screenings are billed to
Medicare Part B.
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IPPE Billing
The total charge for the IPPE is $175.00. The line items
would be reported as follows:
Rev Code
HCPCS
DOS
Charges
052X
G0402
3.22.2013 $175.00
One encounter rate will be paid. Patient co-ins and
deductible are waived.
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Annual Wellness Visit and PPPS
• The patient is eligible if they are no longer in the first 12
months of Medicare coverage and have NOT had the IPPE
in the last twelve months.
• Co-Insurance and deductible do not apply.
• When rendered during an RHC encounter, only one
payment is made.
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Annual Wellness Visit Billing
The total charge for the Annual Wellness Visit is $175. The
line items would be reported as follows:
Rev Code
HCPCS
DOS
Charges
052X
G0438
3.22.2013 $175.00
One encounter rate will be paid. Patient co-ins and
deductible are waived.
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MPS Visit and ‘Sick’ Visit Same day
• There will be two line items on this claim:
 One line with the RevCode/MPS HCPCS Code/charge
 One line with the RevCode/Charge Amount for the sick
visit.
These will be paid as one encounter. The MPS have no coinsurance/deductible applied.
The ‘sick visit’ WILL have a co-insurance and deductible
amount.
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MPS with ‘Sick Visit’ Billing
The MPS is $175.00 and the ‘sick visit’ charge is $150, the
line items would be reported as follows:
Rev Code
HCPCS
DOS
Charges
0521
0521
G0438
3.22.2013 $175.00
3.22.2013 $150.00
Two encounter rate will be paid. Patient co-ins and
deductible are waived on the $175.00.
Co-insurance will be based on $150.00 ($30.00).
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Breast Pelvic Exam/ PAP
• G0101: Cervical or vaginal cancer screening;
pelvic and clinical breast examination – Part of
the RHC Encounter.
• Q0091: Screening Papanicolaou smear; obtaining,
preparing and conveyance of cervical or vaginal
smear to laboratory.
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Registered Dietician
• Registered dietician services are covered in
a RHC.
• They are not separately payable and do
NOT constitute an encounter.
• These are bundled with an otherwise
payable RHC encounter.
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Hepatitis Vaccines and Medicare
Hepatitis vaccines and their administration are
included in the RHC visit and are not separately
billable. The cost of the vaccines and administration
can be included in the line item for the otherwise
qualifying visit. A visit cannot be billed if vaccine
administration is the only service the RHC provides.
(Medicare Benefit Policy Manual. Chapter 13. Section 210.1.2)
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Medicare Preventive Reference
MPS Chart:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads//MPS_QuickReferenceChart_1.pdf
CMS Preventive Services Center:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html
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Non-Payable but Covered Services
• These services are bundled and are not
separately payable as encounters:
 Nursing Visits/Injections
 Telephone Consultation
 Diabetic Nutrition Counseling
 Zostavax (can be billed to Part D)
 Hepatitis
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CMS Websites - www.cms.gov
MedLearn Catalog www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
Medicare Claims Processing Manual – Chapter 9
www.cms.gov/manuals/downloads/clm104c09.pdf
CMS Medicare Secondary Payor Manual:
www.cms.gov/manuals/downloads/msp105c03.pdf
Preventive Services www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf
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CMS and Medicare Resources
CMS Rural Health Center – www.cms.gov/center/rural.asp
Online Manuals www.cms.gov/Manuals/IOM/list.asp?listpage=1
Cahaba – www.cahabagba.com
Cahaba MSP Flow Sheet and Information
http://www.cahabagba.com/documents/2012/02/part-aquick_msp.pdf
WPS RHC FAQ!!!
http://www.wpsmedicare.com/j5macparta/resources/provi
der_types/rhc-billing-qanda.shtml
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Preventive Service Links
IPPE (MM6445)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/mm6445.pdf
Annual Wellness Exam (MM7079)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/mm7079.pdf
MPS Chart:
http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_QuickRefer
enceChart_1.pdf
CMS Preventive Services Guide:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/mps_guide_web-061305.pdf
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More CMS Resources
Medicare Claims Processing Manual – UB04 Completion
www.cms.gov/manuals/downloads/clm104c25.pdf
Medicare Claims Processing Manual – Chapter 9 RHC/FQHC
Coverage Issues
www.cms.gov/manuals/downloads/clm104c09.pdf
!! NEW !! Medicare Benefit Policy Manual – Chapter 13
RHC/FQHC
www.cms.gov/manuals/downloads/clm104c09.pdf
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Contact Information
Charles A. James, Jr.
North American Healthcare Management Services
President and CEO
888.968.0076
cjamesjr@narhsinc.com
www.northamericanhms.com
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888.968.0076