Archived SECTION 13 -BENEFITS AND LIMITATIONS. Section 13 - Benefits and Limitations

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1 SECTION 13 -BENEFITS AND LIMITATIONS 13.1 DEFINITION OF RURAL HEALTH CLINIC (RHC) VISIT MULTIPLE VISITS LABORATORY SERVICES VACCINES FOR CHILDREN (VFC) PROGRAM VACCINES FOR CHILDREN (VFC) BILLING SAFE/CARE EXAMINATIONS OUTPATIENT CLAIM FORM HEALTHY CHILDREN AND YOUTH (HCY) SERVICES FAMILY PLANNING SERVICES SURGERIES/ PROCEDURES PERFORMED IN THE HOSPITAL SETTING GLOBAL OB/GYN SERVICES POSTOPERATIVE CARE

2 SECTION 13 BENEFITS AND LIMITATIONS This section contains program-specific information regarding the benefits and limitations of the Rural Health Clinic (RHC) Program. RHC core service providers are subject to the same benefit limitations and coverage restrictions that apply to services provided by non-rhc providers enrolled with Missouri Medicaid. Refer to the program provider manuals for program limitations for specific services. Missouri Medicaid does not allow physician assistants (PA) to enroll individually. PAs providing services in a rural health clinic setting can bill services under the rural health clinic Medicaid provider number. Refer to Section 1 for information regarding recipient eligibility and Section 2 for information regarding provider participation issues such as nondiscrimination and retention of records. Third party liability is addressed in Section 5. Refer to other general sections for general program requirements DEFINITION OF RURAL HEALTH CLINIC (RHC) VISIT Rural Health Clinic (RHC) visits between RHC patients and RHC core practitioners (physician, nurse practitioner, nurse midwife, physician assistant, licensed clinical social worker, or clinical psychologist) must include a medically necessary evaluation and management service in order to be reimbursed at the RHC rate. When a face-to-face encounter with a core service practitioner does not occur or when patients present to the clinic for a routine non-covered service, such as a blood pressure check, follow-up reading of a TB skin test, venipuncture, etc., an RHC visit may not be billed. An RHC visit is billable only for services provided in the clinic, in the patient's home or in a nursing home. RHCs are entitled to their costs associated with Medicaid services. These costs include expenses incurred for services, such as injections, when a visit cannot be billed. The costs for such services are to be included in the RHC cost report. Medical records must clearly document a medically necessary evaluation and management service when an RHC visit is billed. Billed visits that are not medically necessary are subject to recoupment by the Program Integrity Unit, Division of Medical Services (DMS) MULTIPLE VISITS Visits with more than one health professional and multiple visits with the same health professional which take place on the same day and at a single location constitute a single visit, except when one of the following conditions exist: 2

3 After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment. The patient has a medical visit and a psychiatrist, clinical psychologist or clinical social worker visit. If it becomes necessary to provide additional services on the same date which constitute a separate visit, a Certificate of Medical Necessity form must be completed and attached to the claim form. When filing through the DMS Internet web service, the clinic may complete the on-line version of the medical necessity form using the "Add Header Medical Necessity" link. NOTE: Both visits must be billed on the same claim form LABORATORY SERVICES Rural health clinics are required to provide the following basic laboratory services on-site: Chemical examinations of urine by stick or tablet method or both (including urine ketones); Hemoglobin or hematocrit tests; Blood glucose tests; Examination of stool specimens for occult blood; Pregnancy tests; and Primary culturing for transmittal to a certified laboratory. (This service is required for RHC certification but is not separately billable through any Missouri Medicaid Program; reimbursement is included in the fee for the visit.) These six laboratory services are waived from the Clinical Laboratory Improvement Amendments (CLIA). If a patient or laboratory service is referred to an independent laboratory for laboratory services beyond the six required services, the independent laboratory must bill for the service(s). Laboratory services must be billed by the entity that performs the service VACCINES FOR CHILDREN (VFC) PROGRAM Medicaid requires providers who administer immunizations to qualified Medicaid eligible children to enroll in the Vaccines for Children (VFC) Program. The VFC Program is administered by the Department of Health and Senior Services (DHSS). Providers must contact DHSS at the following address or telephone number to enroll: Department of Health and Senior Services Section of Vaccine-Preventable & Tuberculosis Disease Elimination PO Box 570 3

4 Jefferson City, MO (800) or (573) The vaccine is available at no cost to providers for Medicaid eligible children ages 0 through 18 years. Provider-based rural health clinics (RHCs) may not bill an administration fee for any vaccine. Refer to Section A of the Physician Manual for additional information regarding the VFC Program VACCINES FOR CHILDREN (VFC) BILLING Provider-based Rural Health Clinics (RHCs) may bill an appropriate level Evaluation and Management (E & M) code when a Vaccines for Children (VFC) immunization is provided if a medically necessary evaluation and management service is provided in addition to the VFC immunization. An administration fee may not be billed in addition to the RHC visit. If a VFC immunization is identified as being medically necessary during an RHC visit but cannot be administered at that time, an office visit may not be billed when the patient returns for the immunization if the immunization is the only service provided. Include the costs associated with the immunization on the provider-based cost report. If it is medically necessary to re-examine the patient when the patient returns for the immunization, an office visit may be billed. Medical records must document medical necessity and the service(s) provided SAFE/CARE EXAMINATIONS Sexual Assault Findings Examinations (SAFE) and Child Abuse Resource Education (CARE) examinations and related laboratory studies that ascertain the likelihood of sexual or physical abuse are covered by Medicaid when performed by SAFE trained providers certified by the Department of Health and Senior Services (DHSS). SAFE/CARE examinations may not be billed with the rural health clinic (RHC) provider number. SAFE trained providers must bill for the examinations under their individual provider numbers through the feefor-service fee schedule. Claims submitted by RHCs for SAFE/CARE examinations are subject to denial or recoupment by the Program Integrity Unit, Division of Medical Services (DMS). Refer to Sections and A of the Physician Manual for complete information regarding SAFE/CARE examinations. 4

5 13.7 OUTPATIENT CLAIM FORM Provider-based rural health clinics (RHCs) bill Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) procedure codes on the outpatient claim form. Refer to Section 15, Billing Instructions, for claim filing instructions HEALTHY CHILDREN AND YOUTH (HCY) SERVICES The federal government requires detailed reporting of screening and referral in the Early Periodic Screening, Diagnosis and Treatment (EPSDT) also known as the Healthy Children and Youth (HCY) Program. Section 15, Billing Instructions, includes specific information for the reporting of EPSDT/HCY services. Refer to Section 9, Healthy Children and Youth Program, for complete information regarding the EPSDT/HCY Program FAMILY PLANNING SERVICES It is important to correctly identify family planning procedures on the outpatient claim form to capture the federal portion of the Medicaid reimbursement for these services. Section 15, Billing Instructions, includes specific claim filing instructions for billing family planning services. Family planning and nonfamily planning services should not be reported on the same claim form. Refer to the Section 10, Family Planning, for complete information regarding family planning services SURGERIES/ PROCEDURES PERFORMED IN THE HOSPITAL SETTING Providers were notified in February 2001 that the Centers for Medicare and Medicaid Services (CMS) had issued a Medicaid Bulletin to clarify that services provided by Rural Health Clinic (RHC) practitioners in the hospital setting are outside of the RHC benefit. This includes services provided in all types of hospital settings, such as inpatient, outpatient, and the emergency room. Surgeries/procedures performed in the hospital setting must be billed with the practitioner's private practice provider number or as performing provider of a non-rhc clinic/group. Payment is made through the fee-for-service fee schedule. Information on the Medicaid provider enrollment process and criteria is available on the Division of Medical Services website at under the "Provider" link. For further questions 5

6 regarding the enrollment process, contact the Provider Enrollment Unit via at GLOBAL OB/GYN SERVICES Prenatal care must be billed as individual visits. If the patient delivers in the hospital, the delivery must be billed with the appropriate Current Procedural Terminology (CPT) code with the practitioner's private practice provider number or as performing provider of a non-rhc clinic/group. Payment is made through the fee-for-service fee schedule. When a delivery and postpartum procedure code is billed, a visit may not be billed. Routine postpartum care for the mother within six weeks after delivery is included in the Medicaid reimbursement for the delivery. When a different practitioner has performed and billed for the delivery without postpartum care, the postpartum care only procedure code may be billed POSTOPERATIVE CARE Surgeries/procedures performed in the hospital setting must be billed with the practitioner's private practice provider number or as performing provider of a non-rhc clinic/group. Payment is made through the fee-for-service fee schedule. Postoperative care includes 30 days of routine follow-up care for those surgeries/procedures having a Medicaid reimbursement amount of $75.00 or more. Refer to Section of the Physician Manual for additional information regarding postoperative care. END OF SECTION TOP OF PAGE 6