Annual Conference
Accurate Coding for the
Rural Health Clinic
Janet Lytton, Director of Reimbursement
Rural Health Development
308-647-6455 janet.lytton@rhdconsult.com
Indianapolis, Indiana
June 2012
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 Understand what CPT codes are split
and why within the RHC
 Assure clinic is not missing any
chargeable codes
 Assure clinic is coding preventive
services correctly
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 Independent Rural Health Clinic
 Provider Based Rural Health Clinic
 Coding does not change for the various
provider types
 RHC is a payment methodology and not a
difference in coverage
* ICD-10 delayed implementation to 10/1/2014
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DOES IT MATTER HOW WE CODE A VISIT?
Patient payment is affected
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Medicare considers OVER CODING as a
violation of the fraud and abuse regulations
because of the additional reimbursement
Medicare considers UNDER CODING as a
violation of the fraud and abuse regulations
because it encourages patients to overuse the
clinic
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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
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Better documentation does not mean MORE
documentation
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checklists are not always a good practice
just because a system is checked it doesn’t mean it
was examined
if it isn’t documented, it didn’t happen
if audited, the record must stand alone; many times
work is done, but no documentation
Providers tend to undercode their cognitive
services
Levels coded accurately = correct
reimbursement
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Note Review of Systems
List patient complaints and concerns
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Document history taken
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Describe exam accomplished
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Note any injection to be given and nurse giving
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List and number diagnoses pertinent to visit
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Review lab findings
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Note prescriptions or samples given and/or
requested tests
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List plan and follow-up
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Definitions:
• New Patient
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Patient who has not had any professional services
from that provider or any provider in the same
specialty who are part of the same group practice
within the past 3 years.
If seen in the hospital and then in the clinic and if
billed under a different tax ID number then the
patient is considered new, if same tax ID number
then established.
Established Patient
•
Patient who has received professional services from
the provider or any other provider of the same
specialty in the same group within the past 3
years.
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Definitions:
• Consultation—Medicare does not recognize this code
and code used should be changed to an OV E & M
A service provided by a provider whose opinion or advice
regarding a specific problem is requested by another
provider. There must be a REQUEST (written or verbal, but
documented in the chart), the consultation must be
RENDERED and there is a written REPORT that must be
given to the requesting provider. All are required to be in
the patient chart.
• Even if in the same practice, there must be a report given.
• A consultation and a procedure can be coded separately on
the same day with the modifier -25 on the consultation.
•
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Definitions:
• Preventive CPT codes
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CPT codes for physical exams based on age
Use when patient has no significant complaints or
follow up of ailments
Medicare does not pay for Preventive CPT codes
Medicare will cover the Initial Preventive Physical
Examination, paps, pelvic, Annual Wellness Visit,
PSA, etc. (those listed in the Medicare beneficiary
handbook) Medicare preventive services generally
begin with “G”
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Definitions:
• Time
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Used to determine E & M Level when counseling
and/or coordination of care is more than 50% of
the encounter
Outpatient time is face-to-face time
Inpatient time is unit/floor time
Must document total time spent in minutes
document what the counseling was about and/or
what coordination of care was provided
State “Counseling or Coordination of care greater
than 50%”
Counseling can be visiting about ailments,
teaching, etc.
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Definitions:
• Concurrent Care
•
Similar services i.e. inpatient subsequent care, to
the same patient by different providers of
different specialties on the same day but must be for
different problems.
•
Example: Orthopedist seeing patient after knee
surgery; family physician seeing patient in
hospital for diabetes. As long as different ICD 9
Diagnosis codes, both are allowed when
different specialty.
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Most Common used in RHC:
Office Visits
NF/SNF
New
Est.
Initial
Subseq.
99201
99211
99304
99307
99202
99212
99305
99308
99203
99213
99306
99309
99204
99214
99310
99205
99215
Many other E & M Codes, refer to CPT Coding
manual
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Significant, separately identifiable E/M service by
same provider on the same day of a procedure
or other service.
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Append to E/M code , I.e. 99214-25
Use Modifier 25 when one of the following criteria
is met:
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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.
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Visit for a problem unrelated to the procedure or
service
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Preventive Care Visit = patient seen for annual physical
E/M service = Patient also c/o leg pain, swelling and hot
spot. Evaluated for phlebitis
Supporting Documentation
E/M documentation separate from procedure
documentation
 Must meet ALL requirements for E/M visit along with
documentation of procedure.
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 521
 522
 524
Office visit in clinic
Home visit
Visit to a Part A SNF or SW patient
 525
Visit to a Pt in a SNF, NF, ICF MR, AL
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527
528
780
900
Only prof service as labs, drugs, x-ray TC, EKG
tracing gets billed to the SNF.
Patient not on a Part A SNF Stay
Visiting Nurse Service in a HHA shortage
Visit at other site, i.e. scene of accident
Telehealth site fee
Mental Health Services
 All other revenue codes, i.e. 250 drugs, 270 supplies, are
bundled with the visit code charges
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Injections with an Office Visit
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Add charges to the E/M code when submitting claim
Code all services in Practice Management system
Injections only—nurse service
Charge out all services with correct CPT codes
 Either DO NOT bill as there is no face-to-face visit
 OR if it was in the plan of treatment at the last visit,
add charges to that visit and submit total charges with
the face-to-face visit date for payment (after all services
performed)
 If injectable is a Part D drug it MUST not be a part of
the RHC claim as it is only billable to the patient or to
Part D
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Injectable/Vaccine as a Part D drug – 1/1/08
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The injectable/vaccine is payable only through Pt D
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.mytrnsactrx.com (used to be
eDispense) and bill the Pt D drug and get payment to
include administration of the drug and let you know
the copay amount.
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• All coded with the accurate CPT code
• Don’t forget to charge the venepuncture
• CPT 36415
• If more than one of the same test is done on the
same day, a -91 modifier is added to the CPT
code
• All Labs, to include the required basic 6 tests,
are payable through Medicare Part B
OR
• If PBRHC, they are payable through the
Hospital OP provider number. No more
than one 851 TOB can be submitted each day
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• All coded with the accurate CPT code for
each the technical component and the
professional component if provider
interprets
•Chest x-ray = 71020-TC Two views frontal & lateral;
71020-26 x-ray interpretation
• Interpretation is billed with the office visit and
included in the total charges that are
submitted to Medicare Rural Health
• Technical Component is billed to Medicare Pt B
or for PBRHC, billed using the hospital OP
provider number
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• Coded using the tracing only for the TC & the
interpretation only if provider does the
interpretation.
• EKG Tracing only = 93005
• EKG Interpretation and report = 93010
• Interp is billed with the office visit and
included in the total charges that are
submitted to Medicare Rural Health
• Tracing only is billed to Medicare Pt B or for
PBRHC, billed using the hospital OP
provider number
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 Bundled with a face-to-face encounter within a 30day period
 Direct supervision by provider required
 Must be in clinic, not in same room
 being in the hospital when attached to clinic is
NOT incident to
 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
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 When added to the f-t-f visit, the
additional reimbursement is the 20%
copay for the additional charges
 Otherwise, if not on a claim, all costs
are part of your cost report and are
included in your rate
 If the clinic costs are above the capped
rate, the clinic will not get any
additional dollars for these services
through their cost report.
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• No global charges for Medicare in the RHC
• Each visit in the clinic is a billable visit
• Code the surgical procedure with -54 (surgical
procedure only) and bill to Part B
• Bill the pre and post visits as RHC visits as it is
the RHC facility billing the services, not a
specific provider
• Any procedure in the Hospital should be the
procedure only, not the aftercare involved
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Assure documentation as to why the second
visit and time seen i.e. patient seen in
a.m. for X and presents again at XX p.m.
due to X
Only allowed if a different illness or injury
or a different medical specialty.
If same diagnosis, accumulate to set E & M
level
If seen in clinic and then admitted
•
Bill hospital admission
25
 Keep a log of injections, or have your computer
track
 Medicare paid on your Medicare Cost Report
 Flu payable once per season; pneumo once lifetime
 Medicaid is paid only if in your State benefits at
the time of service
 Keep track of vaccine and supply costs
 Determine average nursing hours per week
 Determine average provider hours per week
 Generally allow 10 minutes per injection on Cost
Report, but do a time study
 Must verify that there are NO Medicare Advantage
on log
 LOGS MUST BE LEGIBLE
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Clinical Psychologist (PhD)
Clinical Social Worker (CSW)
Use 900 revenue code to bill therapeutic
behavioral health
The first visit to determine services by a
physician/PA/NP is an RHC visit, then
behavioral health services apply
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 Allowed Medicare Preventive Services
are billed through the Rural Health
Clinic on the UB04
 Technical Components, labs, EKG
tracing are billed on the non-RHC
side, either through the Hospital OP
provider number (PBRHC) or to
Medicare Pt B (IRHC)
 Examples to follow later
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Preventive physical
Medicare: Does not pay for physicals, except for
the Introduction to Medicare Physical. If the
visit is only for a physical and not for the
ailments, then bill the patient.
Effective 1/1/11, Medicare will pay for an
“annual wellness” visit per year; This IS NOT
a physical
Medicaid: Covered for kids and billed as an
RHC Visit with the T1015 code w/U6 mod.
Private/Commercial: Bill as in FFS clinic
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Charges for Preventive Services
NOTE: Section 4104 of ACA eliminates co-insurance and
deductible for preventive services, effective for dates of service on or
after January 1, 2011. RHCs and FQHCs must provide detailed
healthcare common procedure coding system (HCPCS) coding for
preventive services to ensure coinsurance and deductible are not
applied. Providers will need to maintain this documentation in
order to apply the appropriate reductions on lines 16.03 and 16.04.
(per instructions for Form CMS-2552-10 dated August 2011)
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•
When seen for the hospice condition and if the
physician is the attending physician of the
patient and not employed by the hospice
company
Bill Medicare Part B with the GV modifier
Any TC is billed to the Hospice Co if required
Medicare Claims Manual 100-04 Sec. 40.1.3
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•
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When seen for a condition other than the
reason for being on hospice
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Bill the FI as an RHC visit, RC 521
Use Condition Code 07
Use diagnosis for ailment not the hospice DX
**Cares should be coordinated with the Hospice Entity
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Documentation !!!
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Must use either 1995 or 1997 documentation guidelines
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Required at time of each visit
Develop policies as to which guidelines used
Develop billing policies and assure claims are sent
correctly
Develop Collection policies and assure RHC is
following policy when determining RHC bad
debt
Support Billing?
Are lab tests warranted by diagnoses?
If not, do we have an ABN signed?
Does the Chart, Claim and Encounter form
match for services and level of care?
Have we asked the MSP questions?
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All practices that accept Medicare & Medicaid
dollars are required to have a Clinic
Corporate Compliance Policy
Hosp/Clinic Corporate Compliance Policy
Do we have consents signed?
Are we getting ABNs (Advanced Beneficiary
Notices) when appropriate (must be CMSR-131 03/11)
Keep copy of ABN
Are we asking the MSP (Medicare Secondary
Payer) questions?
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www.cms.gov
www.cms.gov/MLNMattersArticles/
http://www.in.gov/isdh/20118.htm
www.wpsmedicare.com (IN MAC, 7/23/12 start date)
www.cahabagba.com
www.trailblazerhealth.com
www.narhc.org
www.aap.org
www.hrsa.gov
www.bhpr.hrsa.gov/shortage/
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www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads// MPS_QuickReference Chart_1.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads//MPS_QRI_IPPE001a.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads//AWV_Chart_ICN905706.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads//qr_immun_bill.pdf
Make sure you are a part of your MAC listserve for updated info!
Rural Health Development Website & my e-mail: www.rhdconsult.com
janet.lytton@rhdconsult.com
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