RHC Billing for Independent RHCs...RHC Billing for Independent RHCs “Dedicated to providing access...

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RHC Billing for Independent RHCs


RHC Services• An RHC Encounter is defined as a medically-

necessary, face-to face (one-on-one) medical or mental health visit, or a qualified preventative health visit, with a RHC practitioner during which time one or more RHC services are rendered.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf


RHC Providers• Physicians• Nurse Practitioners• Physician Assistants• Certified Nurse Midwifes (CNM)• Clinical Psychologists• Clinical Social Workers (CSW or LCSW)


What about Specialists?• 491.9 Condition of Coverage: Provision of Services-

Providing Rural Health Clinic Services:o A facility may provide services in addition to RHC services, usually,

related health care services such as the “other ambulatory services”

• Must be 51% Primary Care Services

• http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf


RHC Billing Requirements• Beginning October 1, 2016, RHCs shall add modifier

CG to the line with all the charges subject to coinsurance and deductible. (SE1611) **Exception is the Initial Preventative physical Exam (IPPE)**

• RHCs are required to bill the appropriate HCPCS code for each line along with the correct revenue code on each line.


Claim ExamplesWhen a claim is for an office visit only then you would have the 0521 revenue code, with a CG modifier placed at the end of the procedure code


Medicare Part A Only• If the patient only has Part A then they aren’t

covered under RHC services


Medicare Advantage Plans• Billed the same as regular Medicare.


Claim Submission Information• Claims are submitted on a UB-04• RHC Claims billed to Part A.


Revenue Codes• 0521- Clinic Visit• 0522- Home Visit • 0524- Part A SNF Visit• 0525- SNF, NF or Residential facility (Non Part A) Visit• 0528- Scene of an Accident• 0780- Telehealth • 0900- Mental Health Service


Bill Types• RHC claims typically have 4 types of bills:o710- Non payment/ Zero Claimo711- Original Claim o717- Adjustment Claim (Replacement of prior

claim)o718- Cancelled Claim (Void/Cancel Prior claim)


Non RHC Services• Hospital Visits- Billed to Part B• DME- Must have a DME Provider number• Part D Drugs- www.mytransactrx.com

•

http://www.mytransactrx.com/


ABNs


Lab Charges• Must be able to furnish these 6 tests onsite

o Blood Sugaro Pregnancy Testso Primary Culturing for transmittal to a certified labo Hemoglobin or hematocrito Exam of stool specimen for occult bloodoChemical exam of urine by stick or tablet or both


How to Bill Labs• All lab charges should be billed on a HCFA 1500 and

Billed to Part B with your Group Information.


Procedures• EKGs: 93000 vs 93005, 93010 (93005 should be

billed to Part B and 93010 should be billed to Part A)

• X-rays (Technical goes to Part B, Professional Part A)


Claim Example

0521 Office Visit 99213CG $225.00 ($175.00)

0521 EKG 93010 $50.00


Preventive Services• Preventive services can be stand alone visits or billed

with another visit. • https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf


Deductible/Coins Waived


Initial Preventive Exam

Procedure Code Description Paid at the AIR Eligible for Same Day Billing

Coins/Deductible Applied

G0402 Initial Preventive Exam

Yes Yes Waived


Annual Wellness VisitProcedure Code Description Paid at the AIR Eligible for Same

Day BillingCoins/Deductible Applied

G0438 Initial Visit Yes No Waived

G0439 Subsequent Yes No Waived


ScreeningsProcedure Code Description Paid at the AIR Eligible for Same

Day Coins/Deduct Applied

G0101 CA Screening. Pelvic/Breast

Yes No Waived

Q0091 Obtaining Pap

Yes No Waived


Claim Examples• Preventative services with an Office visit.


Two Visits on the Same Day

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1611.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1611.pdf


Claim Example

0521 Office Visit

99213CG25 or 59 175.00

0521 Office visit 99215CG 250.00


Claim Example

0521 Office Visit 99213CG25 275.00 (175.00)

0521 Procedure 12001 100.00


Claim Example

0521 Office Visit 99213CG25 $175.01 ($175.00)

0521 Procedure 12001 $0.01


Influenza and Pneumonia Vaccines• Should be put on your Shot Log and submitted as

part of your cost report. Do not submit on a claim.

Patient NameHealth Insurance Number

Date of Service

Donald Duck 123456789A 10/15/2017

Daisy Duck 987654321A 10/15/2017


Chronic Care Management• Patient must have 2 or more chronic conditions• Patient has to agree to service and can cancel

anytime. • Care plan developed as either a part of the Annual

Wellness Exam or other face to face visit. • Requires: EHR, Documented Care plan• 20 minutes of documented clinical time


Chronic Care Management• Coinsurance and Deductible Apply• Procedure Code is billed as 99490• Billing Date can be the day the 20 minutes is met or

anytime after that but must be before the end of the month

• Diagnosis code(s) billed should reflect the chronic condition that the patient has.


Advanced Care Planning• Stand alone service or billed with Annual Wellness

Visit. • Explanation and discussion of Advanced Directives

such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional.


Advanced Care Planning• 99497 for the first 30 minutes• 99498 for additional 30 minutes

Deductible/Coins Applied

Deductible/Coins Not Applied

AWV and ACP XXACP XXSick Visit and ACP

XX


Telehealth Services• RHCs may only serve as the “originating” site• Billable as the only service or as an additional service

with another visit• RHCs cannot be the “consulting/distant” site• Billed with 0780 Revenue Code with Q3014


Hospice Services• Can treat a patient for Non-Hospice Diagnosis• If treating for Non-Hospice Diagnosis then 07

condition code must be applied to the claim• If provider is treating for Hospice related diagnosis

then claim should be billed to hospice company or adjusted. Claim cannot be billed to Part B.


Questions??


Contact Information107 Saluda Pointe DrLexington, SC 29072Phone: 803-454-3850Fax: [email protected]

http://www.scorh.nethttp://twitter.com/scruralhealthhttp://www.facebook.com/SCORHhttp://www.youtube.com/user/scruralhealth

mailto:[email protected]

RHC Billing for Independent RHCs...RHC Billing for Independent RHCs “Dedicated to providing access...

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