Iowa Association of Rural Health Clinics
RHC 101 & Legislative Update for RHCs
October 1, 2014
9:05 a.m. - 10:30 a.m.
or subtitle
JeffDate
Bramschreiber,
CPA, Partner
Wipfli Health Care Practice
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Discussion Topics
I.
RHC Overview/Becoming a RHC
II. Legislative Update
III. RHC Policy Manual
IV. RHC Billing Information
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RHC Overview/Becoming a RHC
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I. Rural Health Clinic Overview
What Is a Rural Health Clinic?
The rural health clinic certification is a designation that
clinics providing primary care in certain rural, underserved
areas can obtain from the Centers for Medicare & Medicaid
Services (CMS), which provides an alternative, cost-based
reimbursement system for treating Medicare and Medicaid
beneficiaries.
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I. Rural Health Clinic Overview
Rural health clinics were established by law in 1977
under PL 95-210

Amended the SSA by adding Sec.1861(aa) to extend Medicare and Medicaid
entitlement and payment for primary and emergency care services furnished
at an RHC by physicians, NPs, and PAs for services and supplies incidental
to their services.

Authorized CMS and states to pay qualifying clinics on a cost-related basis
for these services.

Required that certified clinics be located in an area that is designated by the
Census Bureau as non-urbanized and designated or certified by HRSA as a
shortage area. Contained a “grandfather” clause that enabled an RHC to
remain in the program even if it no longer met the location requirements.
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I. Rural Health Clinic Overview
After a slow start, popularity in the RHC program grew
significantly in the 1990s.
There are over 4,000 RHCs throughout the United States.
Over 50 percent are provider-based, mostly to Critical Access
Hospitals.
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I. Rural Health Clinic Overview
Certified Rural Health Clinics by State
• Total RHCs
grew from 482
in 1989 to
4,014 in 2014.
• Largest number
of RHCs
located in
Missouri; grew
from 2 in 1989
to 380 in 2014.
• 145 RHCs in
Kansas.
1989 2006 2013 2014
Alabama
5
61
81
85
Alaska
16
6
0
0
Arizona
5
12
21
19
Arkansas
0
63
74
73
California
54
246
295
282
Colorado
13
37
61
57
Connecticut
0
0
0
0
Delaware
0
0
0
0
Florida
18
132
149
151
Georgia
21
87
99
95
Hawaii
0
2
2
2
Idaho
8
42
45
45
Illinois
7
197
215
215
Indiana
0
54
60
63
Iowa
13
130
143
145
Kansas
6
165
176
170
Kentucky
7
113
158
170
Louisiana
0
64
117
122
Maine
24
40
40
39
Maryland
1
0
0
0
Massachusetts
0
1
1
1
Michigan
0
143
176
183
Minnesota
4
73
86
87
Mississippi
8
127
176
170
Missouri
2
270
387
380
Latest Update: 11/19/2013
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Viriginia
Wisconsin
Wyoming
Totals
1989
2006
2013
2014
0
41
53
55
0
99
133
136
5
6
11
11
2
17
13
13
0
0
0
0
21
12
10
10
24
9
10
10
43
95
90
89
0
60
59
55
17
16
22
22
0
33
47
50
13
49
65
63
28
40
67
70
1
1
0
0
2
91
115
117
24
56
59
59
25
40
66
68
1
296
306
307
8
15
19
18
6
20
15
15
2
50
42
41
13
98
119
117
32
60
49
52
2
56
61
65
1
16
17
17
482
3341
4010
4014
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I. Rural Health Clinic Overview
What Is a Rural Health Clinic?
The rural health clinic certification is a designation that
clinics providing primary care in certain rural, underserved
areas can obtain from the Centers for Medicare & Medicaid
Services (CMS), which provides an alternative, cost-based
reimbursement system for treating Medicare and Medicaid
beneficiaries.
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I. Rural Health Clinic Overview
 Must be primarily engaged in providing primary care
services: majority of the services provided by the clinic
are for the “treatment of acute or chronic medical
problems which usually bring a patient to a physician’s
office.”
 Rural is defined as an area “that is not an urbanized area
as defined by the Bureau of the Census.”
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I. Rural Health Clinic Overview
Underserved areas include:
Governor-designated shortage areas.
Geographic Medically Underserved Areas (MUA).
Geographic Health Professional Shortage Area (HPSA).
Population-Based Health Professional Shortage Area.
*Population-Based Medically Underserved Areas (MUP)
do not qualify.
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I. Rural Health Clinic Overview
 Underserved area designation must be current, meaning
the designation is made or updated within 4 years.
Note: Health Care Safety Net Act of 2008 (H.R. 1343)
amended title XVIII (Medicare) of the Social Security Act to
revise the definition of "rural health clinics" to extend from three
years to four years the time frame for making certain
designations related to a shortage of health services in an
area.
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I. Rural Health Clinic Overview
 Cost-based reimbursement is determined on the average
cost per visit. A visit is defined as a medically necessary
face-to-face encounter between a physician, nurse
practitioner, physician assistant, certified nurse midwife,
clinical psychologist, or clinical social worker and a
patient.
In general, if there is no “visit,” there is no RHC payment
(exceptions for flu/pneumo vaccines).
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I. Rural Health Clinic Overview
Located in a rural area.
Current underserved designation.
Primarily outpatient primary care services.
Midlevel practitioner at least 50% of time clinic is open.
Operate under medical direction of a physician.
Physician must be present at least once every 2 weeks.
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I. Rural Health Clinic Overview
Ability to perform (furnish) 6 basic lab tests:
Chemical examinations of urine
Hemoglobin or hematacrit
Blood sugar
Examination of stool specimens
Pregnancy tests
Primary culturing for transmittal to a certified
laboratory
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I. Rural Health Clinic Overview
Compliance with Federal, State, and Local Laws (42
CFR 491.4).
Location of the Clinic (42 CFR 491.5).
Physical Plant and Environment (42 CFR 491.6).
Organizational Structure (42 CFR 491.7).
Staffing and Staff Responsibilities (42 CFR 491.8).
Provision of Services (42 CFR 491.9).
Patient Health Records (42 CFR 491.10).
Program Evaluation (42 CFR 491.11).
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I. Rural Health Clinic Overview
Example - Interpretative Guidelines (Appendix G SOM):
Physical Plant and Environment (42 CFR 491.6) (cont.)
C. Non-medical Emergencies–Review written documentation
and interview clinic personnel to determine what instructions
for non-medical emergency procedures have been provided
and whether clinic personnel are familiar with appropriate
procedures. Non-medical emergency procedures may not
necessarily be the same for each clinic.
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I. Rural Health Clinic Overview
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Determine Eligibility
Calculate Financial Potential
Complete Enrollment Application
Policy and Procedures
Prepare for Survey
Notification of Survey Readiness
Survey Conducted
Approval
Payment Determination
Determine Initial Payment Rate
Begin Claims Process
First RHC Payment
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I. Rural Health Clinic Overview
Compare current reimbursement from Medicare with RHC rate.
CPT
Code
Medicare
Volume
Medicare
Fee
Total
Medicare FFS
Reimburs.
10
5
104.57
57.95
1,000
300
10
5
79.80
79.80
800
400
19.35
42.02
70.46
104.12
139.61
43.47
66.97
1,400
13,400
74,700
27,100
7,000
8,700
11,700
0
320
1060
260
50
200
175
79.80
79.80
79.80
79.80
79.80
79.80
79.80
25,500
84,600
20,700
4,000
16,000
14,000
8.44
9.81
1.72
2.06
100
200
100
50
0
0
0
0
79.80
79.80
79.80
79.80
-
Surgical:
17110
20610
Evaluation & Management:
99211
70
99212
320
99213
1060
99214
260
99215
50
99307
200
99308
175
Injections & Supplies:
95115
15
95117
20
J3301
70
J3420
25
Totals
Average Per Visit
Percentage Change
$
145,750
70.07
Independent
RHC
Rate
RHC
Visits
Total
RHC
Reimburs.
2,080
$
166,000
79.80
14%
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I. Rural Health Clinic Overview
There may be limited Medicare RHC benefits for independent RHCs.
Below is the Medicare Physician Fee Schedule change in Part B payments
from 2009 to 2014 compared to the increase in the maximum payment limit
for independent RHCs.
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I. Rural Health Clinic Overview
Medicare Part B compared to Nat’l Provider-Based RHC average rate.
CPT
Code
Medicare
Volume
Medicare
Fee
Total
Medicare FFS
Reimburs.
10
5
104.57
57.95
1,000
300
10
5
156.74
156.74
1,600
800
19.35
42.02
70.46
104.12
139.61
43.47
66.97
1,400
13,400
74,700
27,100
7,000
8,700
11,700
0
320
1060
260
50
200
175
156.74
156.74
156.74
156.74
156.74
156.74
156.74
50,200
166,100
40,800
7,800
31,300
27,400
8.44
9.81
1.72
2.06
100
200
100
50
0
0
0
0
156.74
156.74
156.74
156.74
Surgical:
17110
20610
Evaluation & Management:
99211
70
99212
320
99213
1060
99214
260
99215
50
99307
200
99308
175
Injections & Supplies:
95115
15
95117
20
J3301
70
J3420
25
Totals
Average Per Visit
Percentage Change
$
145,750
70.07
PB Avg.
RHC
Rate
RHC
Visits
Total
RHC
Reimburs.
-
2,080
$
326,000
156.70
124%
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I. Rural Health Clinic Overview
 There
is a distinct reimbursement advantage for providerbased RHCs that are part of a small (< 50 bed) hospital.
 Independent
RHCs may still receive a slight benefit over
traditional Medicare Part B payments; however, independent
clinics often obtain/retain RHC status due to the Medicaid
reimbursement advantage.
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I. Rural Health Clinic Overview
Additional factors to consider:
A.
Current HPSA and PSA bonus payments.
B.
Cost to comply with RHC requirements:
• employment of non-physician practitioner
• certification and survey
• billing and cost reports
• staff training and education
C.
Patient co-insurance impact.
D.
Expected changes in RHC and FFS programs.
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RHC Information
Sources of Additional Information
Rural Assistance Center
www.raconline.org
CMS Rural Health Clinic Center
www.cms.hhs.gov/center/rural.asp
Shortage Area Designations
http://bhpr.hrsa.gov/shortage/
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RHC Information
Sources of Additional Information
 42 CFR §491
 Appendix G
Interpretive Guidelines – Rural Health Clinics
State Operations Manual (HCFA-Pub. 7)
 Starting a RHC – A How To Manual
 www.bphc.hrsa.dhhs.gov
 www.narhc.org
 www.nrharural.org
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RHC Legislative/Regulatory Update
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II. Legislative Update
Sequestration
 Beginning
in 2013, Sequester
mandated 2% cut in Medicare
payments was adopted. This applied to
all providers.
 As
of April 1, 2013, Medicare RHC
payments were reduced from 80% of
the approved amount to 78.4% of the
approved amount.
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II. Legislative Update
Sequestration – How It Works

On January 1, 2014, the RHC payment limit for independent and
large hospital RHCs was set at $79.80 per visit.

Medicare’s full payment is 80% of the approved amount, therefore,
the Medicare payment amount before the Sequester would have
been 80% x $79.80 = $63.84.

Medicare’s payment amount with the Sequester is 80% x $79.80 =
$63.84 x 98% = $62.56, a reduction of 1.6% from the maximum
payment rate.

RHC patient coinsurance remains at 20% of the charge.
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II. Legislative Update
RHC Regulations
To provide RHCs with greater flexibility in meeting their
staffing requirements, CMS proposed to “revise
§405.2468(b)(1) by removing the parenthetical "RHCs are
not paid for services furnished by contracted individuals
other than physicians," and revising § 491.8(a)(3) to allow
non-physician practitioners to furnish services under
contract in RHCs, when at least one NP or PA is
employed.”
This proposal was finalized and published in the Federal
Register on May 2, 2014.
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II. Legislative Update
RHC Regulations
CMS proposed to revise the CAH regulations at
§485.631(b)(2) and the RHC/FQHC regulations at
§491.8(b)(2) to eliminate the requirement that a physician
must be onsite at least once in every 2-week period (except
in extraordinary circumstances) to provide medical care
services, medical direction, consultation, and supervision.
This proposal was finalized and published in the Federal
Register on May 12, 2014.
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II. Legislative Update
“We expect each facility to evaluate its services and adjust its physician
schedule accordingly, as an appropriate physician schedule would reflect
the volume and nature of services offered. The amount of time spent at the
CAH or RHC by the physician to provide general oversight as well as
patient care will be evaluated at the time of a survey for compliance with the
CoPs (CAHs) or CfCs (RHCs).”
“We agree with the commenter’s assessment and would like to emphasize
that the role of the medical director of the CAH, RHC, or FQHC remains
unchanged by our proposal. We are amending the regulations with respect
to the prescribed frequency of a physician’s onsite presence at a CAH,
RHC, or FQHC.”
Federal Register on May 12, 2014.
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Medicare Benefit Policy Manual for RHCs (CMS
100-02, Chapter 13)
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III. RHC Policy Manual
20.1 - RHC Location Requirements
(Rev. 173, Issued: 11-22-13, Effective: 01-01-14, Implementation: 01-06-14)
A clinic applying to become a Medicare-certified RHC must meet
both the rural and underserved location requirements. Mobile
clinics must have a fixed schedule that specifies the date and
location for services, and each location must meet the location
requirements.
Existing RHCs are not currently required to continue to meet the
location requirements. RHCs that plan to relocate or expand
should contact their Regional Office to determine their location
requirements.
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III. RHC Policy Manual
70.4 - Productivity Standards
(Rev. 173, Issued: 11-22-13, Effective: 01-01-14, Implementation: 01-06-14)
Physician services that are provided on a short-term or irregular
basis under agreements are not subject to the productivity
standards. Instead of the productivity limitation, purchased
physician services are subject to a limitation on what Medicare
would otherwise pay for the services (under the Physician Fee
Schedule), in accordance with 42 CFR 405.2468(d)(2)(v).
Practitioners working in a RHC or FQHC on a regular, ongoing
basis are subject to the productivity standards, regardless of
whether they are paid as an employee or independent contractor.
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III. RHC Policy Manual
90 - Commingling
(Rev. 173, Issued: 11-22-13, Effective: 01-01-14, Implementation: 01-06-14)
If a RHC or FQHC practitioner furnishes a RHC or FQHC service
at the RHC or FQHC during RHC or FQHC hours, the service
must be billed as a RHC or FQHC service. The service cannot be
carved out of the cost report and billed to Part B.
If a RHC or FQHC is located in the same building with another
entity such as an unaffiliated medical practice, x-ray and lab
facility, dental clinic, emergency room, etc., the RHC or FQHC
space must be clearly defined. If the RHC or FQHC leases space
to another entity, all costs associated with the leased space must
be carved out of the cost report.
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III. RHC Policy Manual
170 – Physical and Occupational Therapy
PT and OT services furnished by a PT or OT therapist who is
employed by the RHC and furnished incident to a visit with a
RHC practitioner are not billable visits but the charges are
included in the charges for an otherwise billable visit if all of
the following occur:
•
The PT or OT is furnished by a qualified therapist incident to a
professional service as part of an otherwise billable visit,
•
The service furnished is within the scope of practice of the
therapist, and
•
The therapist is employed by or has an employment agreement
with the RHC.
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RHC Billing Information
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IV. RHC Billing
What Is Different About RHC Billing?
RHC services are billed and reimbursed by Medicare (and
Medicaid in some states) under an all-inclusive payment rate
regardless of the type of practitioner (physician vs. midlevel) or
the complexity of services performed (99212 vs. 99215, E/M
vs. surgical procedure).
RHC services are billed to Medicare on the UB-04 claim format
instead of the CMS 1500 form often used for billing physician
services.
CPT/HCPCS codes are typically not reported for Medicare
RHC billing purposes (except for preventive services).
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IV. RHC Billing
How Are RHCs Paid?
RHCs are paid a flat rate for each face-to-face encounter
based on the anticipated average cost for direct and
supporting services (including allocated costs), with a
reconciliation of costs (i.e., cost report) occurring at the end of
the fiscal year.
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IV. RHC Billing
A RHC visit is defined as a medically-necessary, face-to-face
(one-on-one) encounter between the patient and a –
• Physician
• Nurse Practitioner,
• Physician Assistant,
• Certified Nurse Midwife,
• Certified Psychologist, or
• Clinical Social Worker
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IV. RHC Billing
RHC visits may occur in the following locations:
 the RHC,
 the patient’s residence,
 an assisted living facility,
 a Medicare-covered Part A SNF, or
 the scene of an accident.
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IV. RHC Billing
A RHC visit can also be considered a medically-necessary,
face-to-face (one-on-one) encounter between the patient
through –
• An Initial Preventive Physical Examination (IPPE),
• An Annual Wellness Visit (AWV), or
• Transitional Care Management (TCM) services.
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Special RHC Billing Topics
Preventive Services
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Except for IPPE, all preventive services furnished on the same day as
another medical visit constitute a single billable visit. If an IPPE visit occurs
on the same day as another billable visit, two visits may be billed.
Service
HCPCS
Code
Long Description
Initial
Preventive
Physical
Exam
(IPPE)
G0402
Initial preventive physical
examination; face to face visits,
services limited to new
beneficiary during the first 12
months of Medicare enrollment.
Paid
at the
AIR
Yes
Eligible
for
Same
Day
Billing
Yes
Coinsur./
Deduct.
Waived
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Except for DSMT/MNT, all of the preventive services listed below may be
billed as a stand-alone visit if no other service is furnished on the same day.
Service
HCPCS
Code
Long Description
Paid
at the
AIR
Eligible
for
Same
Day
Billing
Coinsur./
Deduct.
Annual
Wellness
Visit
G0438
Annual wellness visit, including
PPPS, first visit
.
Yes
No
Waived
Annual
Wellness
Visit
G0439
Annual wellness visit, including
PPPS, subsequent visit
Yes
No
Waived
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Service
HCPCS
Code
Long Description
Paid
at the
AIR
Eligible
for
Same
Day
Billing
Coinsur./
Deduct.
Screening
G0101
Pelvic Exam
Cervical or vaginal cancer
screening; pelvic and clinical
breast examination
Yes
No
Waived
Prostate
Cancer
Screening
Prostate cancer screening; digital
rectal examination
Yes
No
Not
Waived
G0102
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Service
HCPCS Long Description
Code
Diabetes
SelfManagement
Training
(DSMT)
G0108
Diabetes outpatient selfmanagement training services,
individual, per 30 minutes
Paid
at the
AIR
No
Eligible
for
Same
Day
Billing
No
Coinsur./
Deduct.
Not
Waived
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Service
HCPCS
Code
Long Description
Paid
at the
AIR
Eligible
for
Same
Day
Billing
Coinsur./
Deduct.
Medical
Nutrition
Therapy
(MNT)
97802
Medical nutrition therapy; initial
assessment and intervention,
individual, face-to-face with the
patient, each 15 minutes
No
No
Waived
Medical
Nutrition
Therapy
(MNT)
97803
Medical nutrition therapy; reassessment and intervention,
individual, face-to-face with the
patient, each 15 minutes
No
No
Waived
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Service
HCPCS
Code
Long Description
Paid
at the
AIR
Eligible
for
Same
Day
Billing
Coinsur./
Deduct.
Glaucoma
Screening
G0117
Glaucoma screening for high risk
patients furnished by an
optometrist or ophthalmologist
Yes
No
Not
Waived
Glaucoma
Screening
G0118
Glaucoma screening for high risk
patient furnished under the direct
supervision of an optometrist or
ophthalmologist
Yes
No
Not
Waived
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Special RHC Billing Topics
Preventive Services (continued)
See http://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
In response to several recent inquiries, CMS has determined that the
screening pelvic and clinical breast examination, Healthcare Common
Procedure Coding System (HCPCS) code G0101, is a billable visit when
furnished by a Rural Health Clinic (RHC) or Federally Qualified Health
Center (FQHC) practitioner to a RHC or FQHC patient.
To avoid any delays in payment until the system is updated, providers
should follow the guidance in the Preventive Services Chart on the RHC or
FQHC center pages. Submit adjustments for any claims with G0101,
rejected on or after January 1, 2014 to your Medicare Administrative
Contractor, using this billing guidance.
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Special RHC Billing Topics
Preventive Services (continued)
•
•
•
•
•
The correct type of bill for an adjustment should end with “7”. Examples: 117, 217, 717,
etc. If using FISS to adjust the claim, the system automatically updates the adjustment
with the appropriate type of bill.
A Claim Change Reason Code (CCRC) is entered in the first available Condition Codes
field (FL 18-28). A listing of CCRCs used for claims adjustment is available in the Claims
Correction section of the FISS Reference Guide.
Enter the Document Control Number (DCN) of the claim you are adjusting in FL 64. This
information can be found in the “DCN” field on MAP171D or on the Remittance Advice (RA)
you received when the original claim processed. If using FISS to adjust the claim, the
system automatically populates the DCN field of the adjustment with the original claim’s
DCN.
Explain why you are submitting the adjustment in the Remarks field (FL 80). Note: if “D9”
(any other change or multiple changes) is the appropriate CCRC for your Medicare
adjustment, remarks are required when submitting the billing transaction.
If using FISS to adjust the claim, an “Adjustment Reason Code” is entered on FISS page
03. See the Claims Correction section of the FISS Reference Guide for a listing of
adjustment reason codes.
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This presentation was prepared by:
Jeff Bramschreiber, CPA
Partner, Health Care Practice
Wipfli LLP
469 Security Blvd.
Green Bay, WI 54313
920.662.2822
jbramschreiber@wipfli.com
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