Rural Health Clinic Billing & Coding
Janet Lytton, Director of Reimbursement
Rural Health Development
308-647-6455 janet.lytton@rhdconsult.com
Kearney, NE
September 2014
1
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Overview of RHC Regulations & changes
Elements of RHC Billing & “how to’s”
The following areas will be discussed:
 The RHC Encounters and Medical Necessity
 Rural Health Services
 Non-RHC Services
 Preventive Services
 Basic claim submission requirements
 Online RHC Resources
 From the NARHC website:
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http://narhc.org/resources/rhc-rules-and-guidelines/
 Interpretative Guidelines are also given
 Link of General rules redirects to:
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http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=
bd5ea765b228085fc1b9f5a7366f85a0&n=42y2.0.1.2.5.15
&r=SUBPART&ty=HTML
Current as of 8/1/14
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4
 Medicare Benefit Policy Manual Ch 13 – RHC
and FQHC Services Rev 173 issued 11/22/13,
effective 1/1/14
 MM8504 issued 11/22/13 updates effective 1/1/14
 Federal Register of 5/2/14 updated RHC regs
effective 7/11/14
 CMS clarification of stand-alone preventive
services 8/14/14
5
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RHC must be located in a healthcare shortage
area
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Health Professional Shortage Area (HPSA)
Medically Underserved Area (MUA)
• Medically Underserved Population does not meet the
shortage area designations (MUP)
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•
Governor’s list of Healthcare Shortage Areas
Check website:
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http://www.hrsa.gov/shortage/find.html
Search to find your area as either a HPSA or MUA
Check the State website for governor’s list of
shortage areas
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30.1 - RHC Staffing
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MUST employ 1 NP or PA (W-2 or owner)
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Others can be contract providers
NP, PA or CNM at least 50% of clinic hours
Contract services for “some” NPs/PAs
effective 7/11/14
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40.2 - RHC is required to post hours of operations
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All services during scheduled hours are RHC
services
Have clear schedules
Cannot rotate from clinic to hospital during RHC
hours
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40.3 – Multiple Visits Same Day, Payable if

Patient has second visit for additional DX
A medical visit and a mental health visit same
day (2 visits)
IPPE and Medical Visit and Mental Health Visit
(3 visits)
AWV and a Mental Health Visit (2 visits)
Clinic visit and Hospital admit is per your MAC
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WPS & Cahaba will allow if medically necessary
Patient must have face-to-face contact in hospital
10
40.4 – Global Billing
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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 prov performs hosp proc, bill w/54 mod, and
then bill each visit at clinic level as not in global
Services never included in global surgical package
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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
40.5 – 3-Day Payment Window
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RHC services are not subject
11
50.1 – RHC Services

Physician Services & services & supplies incident to
NP, PA, CNM Services & services & supplies incident
to
CP and CSW Services & services & supplies incident to
Visiting Nurse services in HHA shortage area
Medicare allowed Preventive Services
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Influenza, Pneumococcal & Hepatitis B Vaccinations
IPPE
AWV
All Medicare-covered preventive services
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50.3 – Emergency Services
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Neither IRHCs or PBRHCs are subject to EMTALA
Must have drugs & biologicals commonly used in life-saving
procedures
60.1 - Non RHC Services
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MCR excluded services, i.e. dental, hearing & eye tests
Technical component of an RHC service
Laboratory Services (does not include venipuncture)
DME, Prosthetic devices, Braces
Ambulance Services
Hospital Services, ASC, MCORF
Telehealth distant-site services
Hospice Services (if for DX of hospice)
Auxiliary Services, i.e. language interp, transp, security
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80.1 – Charges & Waivers
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Must charge all patients the same rates
May waive copays and deductibles after good faith
determination made that pt is in financial need but
cannot be on a routine basis (42 U.S.C. 1320a7a(6)(A))
80.2 – Sliding Fee Scale
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Not required, but may have
Must be applied to all patients
Policy must be posted
If based on income, must document that info from pt
Copies of wage statements or income tax return not
required
Self-attestations are acceptable
14
90 – Commingling
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Sharing space, staff, supplies, equipment and/or other
resources with an onsite Medicare Pt B or Medicaid FFS
practice operated by the same RHC providers.
Commingling is prohibited to prevent:
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Duplicate reimbursement or selectively choosing a higher
or lower reimbursement rate for services
May NOT furnish RHC services as a Pt B provider in the
RHC or in an area outside the RHC such as a treatment
room adjacent to the RHC during RHC hours of operation
If RHC is in the building with another entity the RHC
space MUST be clearly defined.
15
90 – Commingling (con’t)
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If RHC leases/rents space, all costs must be offset by
the fees paid
Does not prohibit provider going to hosp for
emergencies
Must follow schedules for hospital and RHC time
If a RHC practitioner furnishes a RHC service at the
RHC during RHC hours, the service must be billed as a
RHC service. The service cannot be carved out of the
cost report and billed to Part B.
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120.2 – Physician Supervision
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Effective 7/11/14, supervision of NP, PA, and
CNM is per your State Regulations
Nebraska: ARNP: The collaborating physician is
responsible for supervision through ready availability
for consultation and direction of the activities of the
ARNP within the ARNP’s defined scope of practice to
ensure the quality of health care provided to patients.
(NE Regulations 172 NAC 100)
17
Nebraska: PA: Supervision of a physician assistant by a
supervising physician shall be continuous but shall not require
the physical presence of the supervising physician at the time
and place that the services are rendered.
A supervising physician may supervise no more than four
physician assistants at any one time. The board may consider
an application for waiver of this limit and may waive the limit
upon a showing that the supervising physician meets the
minimum requirements for the waiver. (NE Statutes 38-2050)
18
200 – Hospice Services
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Can treat Patient for condition not related to hospice DX,
must use a condition code of 07 on claim to be paid
If treat hospice ailment, cannot bill for visit, even if
medically necessary and must look to the hospice
company for payment or write off. Cannot send to Pt B.
Providers should coordinate care with the Hospice Co.
19
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Medicare beneficiaries who elect the Medicare hospice
benefit may choose either an individual physician or NP to
serve as their attending practitioner (Section 1861(dd) of the
Act). RHCs are not authorized under the statute to be hospice
attending practitioners. However, a physician or NP who
works for a RHC may provide hospice attending services
during a time when he/she is not working for the RHC
(unless prohibited by their RHC contract or employment
agreement). These services would not be considered RHC
services, since they are not being provided by a RHC
practitioner during RHC hours.
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210 – Preventive Health Services

Only the professional services are billed as RHC
TCs are billed as nonRHC
Must use the appropriate G-codes
Flu and Pneumo Vaccines
Hepatitis Vaccines
Many preventive services have no copay or deductible
Diabetes Counseling and Medical Nutrition Services
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Not separately billable but “incident to” service
Costs allowed on the cost report
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 Patient Deductible = $147 per year
 IRHC Rate = $79.80/visit
 PBRHC PPS Hospital Rate = $79.80/visit
 PBRHC <50 bed hospitals = No limit
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Consent to be treated
Authorization to Bill
HIPAA Privacy notification
Medicare Secondary Payer Questions asked (keep 10 yrs)
• Pub 100-5 Chapter 3, section 20
• Required each time the patient presents to the clinic
• ABN issued if applicable
• Given when service does not meet medical necessity
• Routine services contractually non-covered do not
require an ABN, I.e. physical, can use the NEMB form
• Surgical Consent
• Coordination of Benefits Customer Service for CWF
• 1-800-999-1118 8 am–8 pm EST TDD 800-318-8782
• Beneficiaries, providers, attorneys, third party payers
23
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All billable services must be documented in the patient
record to support billing of procedures and E & Ms
 Each service must be specific
 CBC is only a CBC, not CBC with differential
 Injection given must be ordered in chart and also
noted as given by the nurse
 Lesions must be noted as to size, number, method of
removal, closure method
 Follow-up or plan with patient instructions must be
documented
 If more than one visit per day, document date and time
 If counseling is reason for visit, then time in and out can
be used to determine E & M Level
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25
 All pages of the Medical Record must have patient
identifier
 All Reports must be reviewed and signed off with
patient receiving results that is documented
 All documentation must be authenticated
 Signature
 Electronic signature – affirmation and password
protected—DO NOT leave screen on when leave room
 Stamped signature is not allowed (CR5971, SE0829)
 with the exception for a provider that is disabled and
cannot sign his/her name
26
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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, i.e. EKG, xray prof & tech comp
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 Physician
 FTE (Full Time Equivalent = 40 hrs/wk, 52
wks/yr or 2080 hrs year)
 4,200 visits per each FTE
 PA, NP, CNM
 2,100 visits per each FTE
VISITS OF ALL PAYER CLASSES ARE
COUNTED TO DETERMINE PRODUCTIVITY
STANDARD
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Face-to-Face with the Provider
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Medically necessary
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All payer classes are counted in the total visit
count
Place of Service
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Does it require the skills of a Provider?
Payer Class
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Physician, PA, NP, CNM
Clinical Social Worker or Clinical Psychologist
Clinic, Home, NH, SNF/SW B, Scene of Accident
Level of Service
•
All levels apply, to include procedures
• To include all services “incident to”
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Physician services
NP, PA & CNM services
Services & Supplies incident to provider service
Diabetes self-management training services and
medical nutrition therapy services for diabetic
patients provided by registered dietitians or
nutritional professionals
 not separately billable for RHCs but indirectly paid
 Visiting nurse services in non HHA area
 Clinical psychologist & clinical social worker
 CP & CSW supplies & services “incident to”
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CMS Manual 100-02 Chapter 13 Section 50
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Hospital patient services
Lab tests (except venipuncture is part of Visit)
Part D Drugs & Self administrable drugs
DME
Ambulance services
Technical components of diagnostic tests
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i.e. xrays & EKG, Holter Monitoring
Technical components of screening services
 i.e. screening paps/pelvic, PSA
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Prosthetic devices
Braces
CMS Pub. 100-02. Ch 13, Sec 60 & 60.1
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 Nurse service w/o face-to-face visit or
“incident to” visit
 I.e. allergy injection, hormone injection, dressing
change, venipuncture
 Provider MUST be in clinic to have “incident to”
 CMS Manual 100-02 Chapter 13 Section 110.2
 Telephone services
 CMS Manual 100-02 Chapter 13 Section 100 & 120
 Prescription services
 CMS Manual 100-02 Chapter 13 Section 100 & 120
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o
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Routine INR visit for lab
Simple suture removal
Dressing change
Results of normal tests
Blood pressure monitoring
B12 injection
Allergy Injection
Prescription service only
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DOES IT MATTER HOW WE CODE A VISIT?
Patient payment is affected
 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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Compliance Policy
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Required if practice receives Medicare dollars
Levels coded accurately = correct reimbursement
 All ancillary services must have an order
 Reimbursement difference from a level 3 and 4 of
an established patient is approximately 50%
more than the lower level charged
As an RHC this is important due to the 20% copay
based on the actual charge billed for Medicare
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35
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Better documentation does not mean MORE
documentation
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
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Providers tend to undercode their cognitive
services
Levels coded accurately = correct reimbursement
36
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
patient is considered established.
Established Patient
•
Patient who has received professional services from
the provider or any other provider in the same
group within the past 3 years.
37
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 physical CPT
codes with the exception of the Introduction to
Medicare Physical, paps, pelvic, annual wellness
visit, PSA, etc. (those listed in the Medicare
beneficiary booklet)
38
Definitions:
• Time
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Used to determine E & M Level when counseling
and/or coordination of care is >50%
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, planning for treatments, etc.
39
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 specialties.
40
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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 (in system only)
Use Modifier 25 when one of the following criteria
is met:
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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41
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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
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E/M documentation identifiably distinct from procedure
documentation
Must meet ALL requirements for E/M visit along with
documentation of procedure.
42
• UB 04 form or 837i electronic format
• Bill Type 711
• Revenue Codes (NO CPT CODES ON CLAIM)
• Exception when billing preventive services
• Sent to Fiscal Intermediary
• Claims for all RHC visits
• Office, Skilled Nursing Home, Swing Bed, Nursing
Home, Home, Scene of an accident
• Actual charges billed
43
 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
Only prof service as labs, drugs, x-ray TC, EKG
tracing gets billed to the SNF.
Patient not on a Part A SNF Stay
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527
528
780
900
Visiting Nurse Service in a HHA shortage
Visit at other site, I.e. scene of accident
Telehealth site fee
Mental Health Services
 All drugs & supplies, are bundled with the visit code charges in
the Revenue Codes shown above
44
MEDICARE:
Must file claims within one year from date of
services—effective 3/23/10.
I.e. August 1, 2013 must be filed by July 31, 2014
MEDICAID:
Must file claims within 6 months from date of
service—effective 9/1/13 PB 13-50
I.e. March 1, 2014 must be filed by Aug 31, 2014
45
• RHC office visit services
• Excludes all labs, x-ray TC & EKG Tracing, any TC
• Includes venipuncture effective 1/1/14
• Billed to the FI, 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
46
•
All labs, x-ray TC, EKG tracing, any
technical components (venipuncture is
part of the office visit bundled service)
•
All hospital services (IP, OP, ER, OBS)
•
Billed to WPS/MAC, HCFA 1500 Form
•
Paid on the Medicare Pt B fee schedule
47
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All hospital services (IP, OP, ER, OBS)*
•
Billed to WPS MAC, HCFA 1500 Form
•
Paid on the Medicare existing fee schedule
* The only exception is if the CAH is Method
II reimbursement; then the OP, ER & OBS
professional component is part of the
hospital’s claim.
48
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ALL Laboratory performed in the RHC,
including 6 basic tests (venipuncture is part
of the office visit bundled service)

Billed using 141 bill type for PPS Hospitals
 MLN SE1412, December 27, 2013

CAH 851 bill type
 For any facility owned by CAH or CAH employee
performing
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Technical Component
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X-ray
EKG
Holter Monitor
All TC’s Billed using 131 bill type for PPS Hosp
All TC’s Billed using 851 bill type for CAH
Paid on the Medicare Pt B Fee Schedule
49
50
CAH Method II
• Hospital bills for both the professional and
technical component when performed in the
hospital setting:
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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%
51
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Each State Medicaid is specific as to their
State requirements—50 states, 50 plans
May use either the 1500 or UB04
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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
52
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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
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
53
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Must have RHC and nonRHC number
Form for each is per the Managed Care Payer
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
54
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RHC services = bundled services—UB04 or 1500
Lab, X-ray TC and EKG tracings are billed on
the nonRHC provider #
X-ray PC and EKG interp is part of visit and
bundled on the RHC Provider #
All preventive, IP, OP, ER, OBS are nonRHC
services, billed with nonRHC Provider #
OB is global with exception of first visit
If only visits, then nonRHC# and list visit dates
All surgeries at the hospital have 2 wk global
55
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RHC services = bundled services—UB04
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 #
OB is global with exception of first visit
If only OB visits, bill nonRHC# and list visit dates
All surgeries at the hospital have 2 wk global
56
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“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, only the administration CPT is
billed on the nonRHC #
NO V-codes as primary
nonRHC services paid using the fee schedule and
not your RHC rates
57
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Billed as in fee-for-service clinic
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No changes in reimbursement
•
Must not discount charges
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no cash discounts at time of service payment
•
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
•
58
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.
59
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Injections with an Office Visit
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Charge All CPT codes in system
Bundle all charges and submit claim to RHC MCR
If it is a Pt D drug, it must be sent to Pt D plan or Patient
Injections only—nurse 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 30 days pre or post
nursing service and submitted with that f-t-f visit
 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
60
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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 and bill the
Pt D drug and get payment to include administration
of the drug and let you know the copay amount.
61
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Injections with an Office Visit
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Add charges to the E/M code and submit claim
Injections only—nurse service
Send on nonRHC Provider number
 Submit the CPT code for administration and the
second line the NDC of the drug
 If no NDC is listed, no payment for drug will be
made
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62

Part B Drugs cannot be obtained from a
Pharmacy and then a physician service be
charged in the clinic for the administration
effective with DOS 10/1/11. The clinic would
be required to obtain the drug from the
pharmacy and pay the pharmacy, and clinic
would submit claim for all Pt B services to the
patient or insurance for payment.
MM CR 7397 revised & Transmittal R2437CP
63
 Allowed Medicare Preventive Services are
billed through the Rural Health Clinic on
the UB04
 Technical Components, labs, EKG tracing are
billed on the nonRHC side, either through
the Hospital OP provider number (PBRHC)
or to MCR Pt B (IRHC) use correct G-codes
 Each preventive service MUST be on a separate
line on the UB with the G-code
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Preventive Services Quick Reference Guide:
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Dow
nloads/MPS_QuickReferenceChart_1.pdf
IPPE Quick Reference Guide:
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
Annual Wellness Visit Quick Reference Guide:
www.cms.gov/Outreach-and-Education/Medicare-Learning-Net
work-MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf
More Preventive Service info:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
/Downloads/clm104c09.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
/Downloads/clm104c18.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
69
/Downloads/bp102c13.pdf
Injections, i.e. Gardasil, Zostavax, Varivax, Tetanus (as
immunization update), DTAP
Medicare: Pt D drugs require billing to Pt D or the
Patient can pay for these services and send to their Pt D
plan and be reimbursed OR submit claim to a company
such as EDispense
Medicaid: If patient is eligible and has a visit, bill with
the visit on the RHC number.
Private/Commercial: Bill as did in FFS clinic
These drugs are not to be on your RHC claim as they are not a
Part B benefit for the patient
70

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 to the E/M code and submit claim
(Medicare)
71
• All coded with the accurate CPT code
• Don’t forget to charge the venepuncture in OV
• effective 1/1/14 is part of the office bundled services
• 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
72
• 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
• NE Medicaid follows Medicare guidelines
Medicare reg on “prof component” billing:
CMS Internet-Only Manual, Publication 100-02, Ch 13, Sec 30.3.
73
• Coded using the tracing only for the TC & the
interpretation only if provider interprets.
• 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
• NE Medicaid follows Medicare guidelines w/CPTs
74
 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”
 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
75
 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”
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, etc.
Can be bundled with a face-to-face encounter within a
30-day period
When added, the added reimb is the 20% copay
Otherwise, if not on a claim, all costs are part of your
cost report and are included in your rate
CMS 100-02, Ch 13, Sec 110; Sec 130; Sec 150
76
•
•
•
•
•
•
•
•
Can be combined on claim with a visit within 30days pre or post
“incident to” service for plan of treatment
NEVER considered a separate visit
List only the date of the visit as date of service
Charges should reflect all services bundled
When added, the added reimb is the 20% copay
Adjustments OK—717 Type of Bill; CC=D1;
remarks “changes in charges”
Otherwise, the costs are shown on your cost report
and claimed indirectly
CMS 100-02, Ch 13, Sec 110; Sec 130; Sec 150
77
Medicare: Bill OV and EKG interp (if provider does
the interp) to RHC Medicare on UB 04 (one
line item, no CPT codes); Bill EKG tracing to
MCR Pt B for IRHCs & PBRHCs bill with 131
or 851 TOB with Hosp OP # on UB04
Bill lab for IRHC to MCR Pt B & PBRHC bill
with 141 or 851 TOB with Hosp OP # on UB04
Medicaid: Follows Medicare guidelines w/CPT
Private/Commercial: Bill as in FFS clinic
78
I.e. Lesion removal, joint injection, wound closure,
AND E & M code
Medicare: Charge the OV level w/-25, the
procedure codes, any med used—bill as
collapsed into the 521 rev code (no CPTs on
claim)
Medicaid: Charge the OV level w/-25, the
procedure codes, any med used—on UB, bill
as collapsed into the 521 rev code (with E & M
CPT on claim)
Private/Commercial: Bill as in FFS clinic
79
80
Medicare: Cahaba & WPS (depends on medical
necessity)– but generally, if for same ailment,
are not allowing both services to be billed;
thus bill the Admit (services must take place
in the hospital)
Medicaid: Bill the hospital admit and not the
clinic visit.
Private/Commercial: Bill the hospital admit
For all payers make sure you are “accumulating”
all services to set the level of admit.
81
• No global charges for Medicare in the RHC
• Each visit in the clinic is a billable visit—if it
wasn’t your provider that did procedure,
verify they billed with the -54 modifier
• 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
• NE Medicaid has a 2 week global for
procedures in the hospital setting
82

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,
prophylaxis or diagnosis; initial up to 1 hr.
 96366 Intravenous infusion each addt’l hour
 96369 Subcutaneous infusion for therapy or
prophylaxis, initial up to 1 hr, incl pump set-up
 96370 Subcu. infusion each addt’l hour
 Add charges to the E/M code and submit claim
(Medicare & Medicaid)
83


Visits would be medically reasonable and
necessary and billed as an RHC visit with 711
TOB and 521 revenue code.
Delivery only would be billed as a hospital
nonRHC service; each post partum visit is a
billable visit
84
•
Only allowed if a different illness or injury
•
•
•
•
•
•
WPS wants 1st claim processed, then send 2nd claim
If same diagnosis, accumulate to set E & M level
If seen by physician and then the mental
health provider both are billable—2 visits
If have IPPE and an ailment visit, it is 2 visits
If IPPE, ailment and mental health visit, it is 3
visits billed
If seen in clinic, then admitted (MAC determines)
• If only one billed, bill hospital admission
85
•
Clinical Psychologist (PhD)
•
•
Clinical Social Worker (CSW)
•
•
•
•
Doctoral level of education
Masters level with at least 2 years experience
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
Reimbursement in 2014 is 80/20
86
 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 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
 NO Medicare Advantage on log
 LOGS MUST BE LEGIBLE
87
• Suggest inputting into system with the G0008-flu
administration, and G0009-pneumo administration
• Create a report that will list Medicare flu and
pneumo injections
• Patient Name
• Date of Service
• Patient Medicare number
• Log is sent with your RHC Cost Report for payment
through your cost report. NEVER send a claim
for a Medicare flu or pneumo injection to either
Medicare Rural Health or Pt B
88
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 on the
nonRHC Medicaid provider number
Private/Commercial: Bill as in FFS clinic
89
How does a RHC bill for a "Well Woman Exam"?
Medicare does not have a "Well Woman Exam" as a covered
preventive service. Each component of the "Well Woman Exam"
would have to be looked at and billed separately. For instance, the
Annual Wellness Visit is covered yearly and billed with either
G0438 for the initial exam (covered once in a lifetime) or G0439 if
it is a subsequent visit (covered annually). Both Screening Pap
Tests and Screening Pelvic Examinations are covered every 24
months for low risk women and billed with Q0091 and G0101
respectively. Each of these tests, if the beneficiary is eligible,
would be billed on a separate 052x revenue code line.
For more information on Medicare's Preventive Services, please
see the Medicare Preventive Services Quick Reference Chart
90
If a patient comes in for a preventive exam which is
not a covered exam, who do we bill?
Since it is not a covered service, you will bill the
beneficiary. (This includes DOT physical)
For any preventive service that has a frequency
limitation, it is encouraged to get an ABN just in case
the service is done at the incorrect timing, if no ABN,
the clinic cannot charge if Medicare does not pay. As
of 9/1/12 the UB claim is allowed to have the GA
modifier along with the HCPCS code with the
Occurrence Code of 32 with the date the ABN was
signed.
91
•
For NF/SNF/SW Bed visits
•
•
Code/Bill 99304 - 99318
If Prolonged Services apply
•
•
•
Code also 99356 or 99357
Effective with DOS 7/1/08
Can use Prolonged Service codes for NF/SNF
services 99304-99306, 99307–99310 & 99318 but if
codes are set for counseling, must be at highest
level to code the prolonged service code
MM5968, CR5968, Effective 7/1/08
92
•
When seen for the hospice condition
•
•
•
Is not payable to the clinic and must be coordinated
with the Hospice Entity
Any TC is billed to the Hospice Co, if required
When seen for a condition other than the reason for
being on hospice
• Bill the MAC/FI as an RHC visit, RC 52X
•
•
Use Condition Code 07
Use diagnosis for ailment not the hospice DX
Medicare Benefits Policy Manual 13, Sec. 200
93
•
•
•
•
•
•
•
Bill to RHC FI
Revenue Code 780
Does not require a Face-to-Face visit same day
Q3014 code is paid separately from allinclusive rate at the Medicare Phys Fee
Schedule
Bill for transmission fee
REQUIRED to put the Q code on the claim
RHCs are not allowed to be the provider
94
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, per
CMS Internet-Only Manual, Publication 100-04, Chapter
1,Adobe Portable Document Format Section 60.1.1.1. This
section of the manual states, "... all of a bundled service must
be billed as noncovered, or none of it. Therefore, as long as
part of a bundled service is certain to be covered or medically
necessary, billing the entire bundled service as covered is
appropriate."
95
Medicare is secondary and we've billed an office visit, a
joint injection and a drug, and the primary pays on all
three lines. We then need to bill to Medicare for secondary
payment. Do we add charges into one line? If Medicare
was primary, we would roll everything into one line. How
do we bill if the primary pays each line separately?
When billing the claim to Medicare, you will roll everything
into one line. Even though the primary may pay each line
item separately, you still need to send the claim to Medicare
according to Medicare billing regulations.
96
Do we only indicate what was paid, or do we send the
allowed amount?
You would bill the charges as you normally would if
Medicare was primary. If you have a contractual obligation
with the other insurance and if they paid less than the
contractual amount and less than the total charges of the
claim, you would use the 44 value code to indicate the
contractual amount. Your other value code indicates what
type of policy the primary is and what they actually paid.
97
If I bill a liability policy as primary, and it is denied
for benefits exhaust, how do we bill Medicare?
If you have a denial from a primary insurance, you
would bill the claim as a conditional payment. If it is a
liability policy, the 47 value code will have $0.00. You
need to enter the 24 occurrence code with the date of
the denial from the primary insurance, and in remarks
enter why the claim was denied. In this case the
primary benefits were exhausted.
98
Because RHCs are not paid based on the Medicare
Physician Fee Schedule, they are not included in the
eRx program.
Thus, there are no penalties for any RHC services
when the clinic does not participate in eRx. If the
clinic does a significant amount of nonRHC
services, the clinic may be required to participate in
eRx in order to not be penalized.
99
•
•
•
•
TOB 717
Claim must be in finalized status
Adjustment will appear as a debit or credit
on future remittance advice
Encourage submitting electronically
•
•
•
exceptions—denied charges & claims rejected as
MSP
Do not send another 711 claim as will error
as a duplicate
Examples of Adjustments:
•
Revenue code changes, Service unit decrease or
increase, Total charges changed, Primary payer
incorrect
100









Documentation !!!

Must use either 1995 or 1997 documentation guidelines

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 determine 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?
101



Number of RHC encounters by each
Physician, NP or PA by payer class
Number of nonRHC (hospital services)
encounters by Physician, NP or PA
Log of all Flu and Pneumonia injections to
include: date, patient name, HIC#, charge

Staffing schedules

TIME STUDIES!
102




Must keep patient name, date of service, HIC#, if
a Medicaid patient or not, is it co-insurance or
deductible and dates billed
Exhibit 5 of the CMS 339 Form
If send to collections, this is not considered
written off as bad debt, cannot put on log until
it is totally written off and no chance of
payment.
RHC Medicare Bad Debt to be reduced
103
Q.RE: CHOW - If a RHC is in a county that is no longer designated
as a HPSA and then sells its practice to another entity (CHOW),
would the clinic lose its RHC status since the clinic is no longer in
a HPSA?
A. As long as the new owner accepts assignment of the Medicare
agreement and does not relocate the clinic, it would remain an RHC
(unless and until CMS adopts new regulations implementing the 1997
Balance Budget Act “essential provider” provision). Conversion from
independent to provider-based would not affect its status, either.
CAUTION: If the clinic submits the CMS 29 form as part of the application,
the clinic will may lose its status because it will come back as denied due to
lack of a HPSA designation. The key is not to submit the CMS 29 form but
many of the state licensing offices require it as part of the CHOW
application. You will need to explain to the local licensing office that the
CMS 29 form is not part of the CHOW.
104
Table of Contents
A.
Overview of the Rural Health Clinic
B.
Disclosure of Ownership
C.
Listing of Physicians and Midlevel Providers
D.
Definitions used in the report
E.
Review of Clinic Records
F.
Review of Encounters by Type
G.
CPT Code Analysis by Provider
H.
Cost Analysis
I.
Statement of Scope of Practice
J.
Review of Policy and Procedure Manual
K.
Listing of Individuals on the Annual Evaluation Review Committee
L.
Signatures of Annual Evaluation Review Committee accepting the
Annual Report
M.
Mock Inspection
N.
Timeline for Recommended Changes/Improvements
O.
Confirmation of Changes/Improvements Made
P.
Minutes From Annual Evaluation Review Committee Meeting
105
•
•
•
•
•
•
•
All practices that accept Medicare & Medicaid
dollars are required to have a Clinic Corporate
Compliance Policy
Hosp/Clinic Corporate Compliance Policy
HIPAA Policies in place
Do we have consents signed?
Are we getting ABNs (Advanced Beneficiary
Notices) when appropriate (must be CMS-R131 03/11)
Keep copy of ABN
Are we asking the MSP (Medicare Secondary
Payer) questions?
106
Information Needed
to Complete
the RHC Cost Report
CMS 222-92 (05/2013)
Provider based – owned, operated by
Hospital, SNF, HHA (Schedule M)
Independent – (Freestanding) – may be
MD/DO owned, privately owned or
owned by other health professionals
(CMS 222)


Method to reconcile and verify payments to
allowable costs
Allowable RHC Costs/RHC Visits = RHC Cost Per
Visit = RHC rate; not to exceed the maximum allowable
reimbursement rate for current period. ($79.80 2014)

Determines future reimbursement rates

Cost reports are due five months after FYE

Must obtain (PS&R) Provider Summary Report 90
days after FYE through the IACS internet system


Cost reports must be submitted in electronic
format (ECR File) on CMS approved
software
Vendor list on the CMS website

Many use HFS software


Financial Statements
Visits by payer class—Medicare, Medicaid, Medicare
Advantage, All other

Clinic Hours of Operation

FTE Calculations—Time studies are strongly encouraged

Total number of nursing staff hours worked during the
cost report period.


Staff of RHC (Worksheet 5)
Vaccine Information (Worksheet 6 and Sample
Vaccine Logs)

Payments received

Depreciation Schedule



Medicare Bad Debt (Exhibit 5 of CMS 339)
Laboratory Costs (From time study &
financials)
Non-RHC X-ray Costs (From time study &
financials)





Broken down by provider and by insurance
type for all health care providers
Count only face-to-face encounters
Do not include visits for hospital, non covered
services, non qualified providers or injections
If computer print out, assure accuracy
If manual, total for each provider



RHC Hours
Non-RHC Hours (if applicable) – must have
reasonable methodology for carve out (i.e.
average time spent, visits, space, clinical hours)
Do Time Studies for provider services, lab
services, x-ray, flu and pneumo administration
Time studies are required for providers to be 1 week
a month, different weeks each month
 Service time studies are a study of the time it takes to
perform each type of service (usually =>10 services)



BASED ON TIME STUDIES PERFORMED
Average hours worked per week for each health care
provider at the RHC:
 Average administrative hours worked per week
(used to reclassify wages of provider)
 Average patient care hours worked per week (used
to calculate the FTE input on the cost report for the
provider)
 Average inpatient care hours worked per week
(used to adjust wages of provider to hospital
services)

Total number of nursing staff hours worked
per year (for use in calculating the staff time
ratio of time available for giving vaccines).

RN

LPN

MA
118

Job Titles

Gross Wages

Fringe benefits and payroll taxes of all
providers and clinical staff



Staff performing lab duties
Allocate % of time for non-RHC carve out for
staff performing non-RHC lab/x-ray duties vs.
RHC duties
Time studies of staff to support the allocated
carve out

Balance Sheet

Profit and Loss Statement

Trial Balance

All accounting in the accrual method of
accounting





Date Asset Purchased
Description of Asset
Cost of Asset
Life of Asset
All depreciation is based on straight-line
method with CMS healthcare lives
124
125

Influenza and Pneumovax

Total vaccines given of each to all payer types

Total Medicare vaccines given of each (log must
accompany cost report – sample log attached)

Cost per dose of each from invoices
 Must submit copies of invoices with cost report
128
129




Medicare bad debt form must accompany cost
report of total bad debt being claimed.
Medicare bad debt is claimed on the cost report
based on which fiscal year the bad debt was
written off in, not date of service.
All Bad Debts must have been written off “after”
at least 120 days of statements sent (4)
Accounts cannot be sent to collection and claimed
as bad debt


RHC must request the PS&R at approx. 90 days
after FYE using the IACS internet system
Compare PS&R total to your Medicare visit
count. Is this accurate? If not, determine why
and if this is a common issue that occurred
when pulling all insurance visit type
information
133
http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/
Health_and_Human_Services_System/Title-471/Chapter34.pdf
NE Medicaid RHC Provider Information Chapter 34
http://dhhs.ne.gov/medicaid/Documents/471-000-77.pdf
NE Medicaid Billing Instructions for RHCs
135
www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloa
ds/MPS_QuickReferenceChart_1.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning Network-MLN/MLNProducts/downloads//MPS_QRI_
IPPE001a.pdf
www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/
/AWV_Chart_ICN905706.pdf
www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
Make sure you are a part of your MAC listserve for updated info!
136
www.ruralhealthweb.org (NRHA)
www.nebraskaruralhealth.org (NeRHA)
www.cms.gov
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/bp102c13.pdf
(new RHC/FQHC Regulations 11/13)
www.cms.gov/Regulations-and-Guidance/Guidance /Manuals/
Downloads/clm104c09.pdf
(RHC CMS Claims Manual)
www.wpsmedicare.com
www.cahabagba.com
www.narhc.org
Rural Health Development Website & my e-mail:
www.rhdconsult.com janet.lytton@rhdconsult.com
137
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