Rural Health Clinic (RHC) Coverage Requirements. Part A Provider Outreach and Education April 2016
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1 Rural Health Clinic (RHC) Coverage Requirements Part A Provider Outreach and Education April 2016
2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. February
3 Objective This presentation is designed to educate providers on the Rural Health Clinic (RHC coverage requirements. February
4 Agenda RHC Coverage Requirements RHC Visits RHC Services Non-RHC Services Resources February
5 ACP AIR CCM DSMT Helpful Acronyms Advanced Care Planning All-Inclusive Rate Chronic Care Management Diabetes Self management Training HCPCS Healthcare Common Procedure Coding System IOM Internet Only Manual MNT MLN TCM Medical Nutrition Therapy Medicare Learning Network Transitional Care Management February
6 What is an RHC?
7 What is a Rural Health Clinic (RHC)? Located in areas designated by the Bureau of Census A non-urbanized area Established to address shortage of physicians in rural areas Increase utilization of nurse practitioners (NP) and physician assistants (PA) February
8 What is a RHC? 2 Independent RHCs are stand-alone or freestanding clinics generally hospital clinics Provider-based is an integral and subordinate part of hospital Critical Access Hospital (CAH) Skilled Nursing Facility (SNF) Home Health Agency (HHA) February
9 What is a RHC? 3 Provider-based CMS Certification Number (CCN) is not an indication that the provider based determination for purposes of an exception to the payment limit CCN provider-based range , , CCN independent range Posted days and hours of operation February
10 What is a RHC? 4 Directly furnish routine diagnostic and laboratory services Arrangements with hospital(s) to furnish medically necessary services Available drugs and biologicals for emergencies Participate in an annual program evaluation February
11 What is a RHC? 5 Not be concurrently approved as a Federally Qualified Health Center (FQHC) Not a rehabilitation agency or facility primarily for mental health treatment Meet other applicable State and Federal requirements Meet all health and safety requirements February
12 What is a RHC? 6 Furnish on-site certain lab tests Chemical examination of urine by stick or tablet method or both Hemoglobin or hematocrit Blood sugar Examination of specimens for occult blood; Pregnancy tests Primary culturing for transmittal to a certified laboratory February
13 What is a RHC? 7 Non-Physician Directed Clinics Must have arrangement with a physician who provides supervision and guidance of NP, PA and Certified Nurse Midwife (CNM) Must be consistent with state laws Must have on-site supervisory visits as needed February
14 RHC Staffing Requirements Must employ a Nurse Practitioner (NP) or Physician Assistant (PA) NP, PA or Certified Nurse-Midwife (CNM) must be working at clinic at least 50 percent of time clinic operates RHCs may contract with NPs, PAs, certified nurse midwives, clinical psychologists, or clinical social workers February
15 RHC Staffing Requirement 2 Conditions that do not satisfy staffing obligation NP or PA who is employed by a hospital that has an ownership interest in the RHC but is not physically present and working in the RHC CNM who is employed by the RHC Advanced Practice Registered Nurse who is not an NP or PA NP or PA who is working as a substitute in an arrangement similar to a locum tenens physician February
16 RHC Temporary Staffing Waivers Staffing requirements must be met before requesting the waiver for the following NP or PA is not currently employed NP, PA or CNM is not furnishing patient care at least 50 percent of the time the clinic operates Replacement of staff begins when the RHC is aware of non-compliance February
17 RHC Temporary Staffing Waivers 2 Staffing waivers are valid up to one year Six months must pass after the initial waiver was granted in order to request an additional waiver Failure to meet staffing requirements or temporary staffing waiver elements can result in the RHCs termination February
18 RHC Practitioners1 Physicians Nurse Practitioner (NP) Physician Assistant (PA) Certified Nurse Midwife (CNM) Clinical Psychologist (CP) Clinical Social Worker (CSW) February
19 RHC Practitioners2 Physician includes: Doctor of medicine or osteopathy Dental surgery or Dental Medicine Podiatry Optometry Chiropractic Licensed and practicing within scope of practice RHCs are required to provide primary health care February
20 RHC Practitioners3 Physician includes: Dental surgery or Dental Medicine Podiatry Optometry Chiropractic These practitioners do not meet the requirements of Medical Director, physician, NP, PA or CNM February
21 Non-Physician Practitioners Professional services of Nurse Practitioner, Physician Assistant and Certified Nurse Midwife Diagnosis, therapy, surgery and consultation Furnished under general supervision of physician (direct if required by State law) Furnished within scope of license, State law and clinic policy February
22 Clinical Psychologist (CP) Doctoral Degree in clinical psychology, and Licensed or certified for independent practice by State to furnish diagnostic, assessment, preventive and therapeutic services February
23 Clinical Social Worker (CSW) Master s or doctors degree in social work 2 years supervised post-graduate clinical social work Licensed or certified as clinical social worker by State If State doesn t license/certify, must have completed post-masters degree supervised clinical social work February
24 CP and CSW Services Diagnosis, treatment and consultation Within scope of license/certification Furnished in accordance with clinic policies and any physician orders February
25 What is a RHC Visit? A visit must be a face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW Medically-necessary medical or mental health visit Qualified preventive health visit Transitional Care Management (TCM) Advanced Care Planning (ACP) February
26 What is a RHC Visit? 2 Visiting nursing services qualify as a visit must be between a home-bound patient and RN, LPN, under certain conditions Nurse services are skilled, reasonable and necessary Physician referral based on patient medical condition when services were ordered February
27 What is a RHC Visit? 3 Visiting nurse requirements Patient is homebound RHC is located in a home health agency shortage area Geographic area determined by the Secretary Written plan of treatment for services Part-time or intermittent only Drugs and biological are not provided February
28 What is a RHC Visit? 4 RHC visit can occur in: RHC Patient s home Assisted living center Skilled Nursing Facility (SNF) Scene of an accident RHC patient receives services in another location by a paid employee of the RHC and services included on the cost report February
29 What is a RHC Visit? 5 RHC visits cannot occur in: Inpatient hospital setting Outpatient department of a hospital, including Critical Access Hospitals (CAHs) Settings that precludes RHC visits Comprehensive Outpatient Rehabilitation Facility (CORF) Ambulatory Surgical Center Hospice February
30 Multiple Visits on Same Day Encounters with more than one RHC practitioner on same day Including a specialist for further evaluation Related or unrelated to subsequent visit Scheduled or unscheduled Multiple evaluations with another practitioner on same day for the same or different condition payable as one AIR February
31 Multiple Visits on Same Day 2 Two visits can be billed when Patient suffers illness or injury that requires additional diagnosis or treatment on same day Patient has medical visit in the a.m. and returns later after a fall in the p.m. Patient has a medical visit and a mental health visit on the same day February
32 Multiple Visits on Same Day 3 Exceptions for the following Patient has an initial preventive physical examination (IPPE) Plus a separate medical visit and/or mental health visit clinical psychologist or clinical social worker on same day 2 or 3 visits can be billed February
33 RHC Services February
34 RHC Services Physicians' services; Services of nurse practitioners (NP), physician assistants (PA), certified nurse midwives (CNM), clinical psychologist (CP), clinical social worker (CSW) services Services and supplies incident to a physician, NP, PA, CNM, CP and CSW services Visiting nurse services to the homebound February
35 RHC Preventive Services Influenza, Pneumococcal Hepatitis B vaccinations Hepatitis C Screenings Initial Preventive Physician Exam (IPPE) Annual Wellness Visit (AWV) Medicare-covered preventive services recommended by USPSTF With grade A or B February
36 RHC Preventive Services 2 AIR includes professional component for preventive services except IPPE When performed on the same day Influenza and pneumococcal vaccines and administration Included on the cost report only Preventive services may be billed as stand-alone if no other service is given on the same day February
37 RHC DSMT and MNT Diabetes Counseling and Medical Nutritional Services consider as incident to services Not separately billable as visit DSMT and MNT cost may be allowed on the cost report RHCs can become certified DSMT providers Costs reported on cost report for inclusion in allinclusive payment rate February
38 RHC Covered Drugs and Administrations Otherwise covered drugs that are furnished by, and incident to, services of physicians and non-physician practitioners drugs and its administration are allowable costs and are part of the clinic s all-inclusive rate calculation Cannot bill separately for Part B drugs IOM , Chapter 13, Section 120 for costs of formulating antigens February
39 RHC Services and Supplies Services and Supplies incident to Physicians Furnished as an incidental, although integral, part of a physician s professional services Services provided by clinic employees other than non-physician practitioners listed (PA/NP/CNM and CP/CSW), furnished under the direct, personal supervision of a physician February
40 RHC Services and Supplies 2 Incident to Physicians Direct supervision physician must be in RHC and immediately available Does not have to be in same room Staff Nurse making a house call RHC physician must be present to be considered incident to Must represent expense incurred by RHC Cost of item/drug purchased elsewhere is not incident to Must result from the patient encounter February
41 RHC Services and Supplies 3 Incident to Non-Physician Practitioners Type commonly provided in physician office setting Incidental, integral part of professional services of the NPP Furnished under direct supervision of NPP as permitted by policy and physician orders Furnished by employee of RHC February
42 RHC Physical and Occupational Therapy Physical and Occupational Therapy may be provided By physician, nurse practitioner or physician assistant if within scope of license or By physical and occupational therapist employee of RHC incident to physician, nurse practitioner or physician assistant February
43 RHC Physical and Occupational Therapy 2 Incident to not a separately payable standalone visit Skilled therapy services performed Must be provided on date of billable visit to be included in billable visit charge Cannot be incident to service if provided by therapist in private practice or contracted to RHC by another provider February
44 RHC Transitional Care Management (TCM) Stand-alone visit/encounter If occurs on the same date as another visit, only one can be billed Only one TCM visit paid for 30-day post discharge period Subject to deductible and coinsurance February
45 RHC TCM 2 Must be furnished within 30 days of date of discharge from hospital (including outpatient observation), SNF or Community Mental Health Center Direct contact, telephone or electronic communication with patient/caregiver must begin within 2 business days of discharge February
46 RHC TCM 3 Face-to-face visits must occur Within 7 days of discharge for high complexity decision making (CPT code 99496) Within 14 days of discharge for moderate complexity decision making (CPT code 99495) IOM , Chapter 13, Section February
47 RHC Chronic Care Management (CCM) Affect RHC billing under the All-Inclusive Rate (AIR) for service rendered January 1, 2016 CMS began making separate payment for HCPCS January 1, 2015 Paid for: Physician services Services and supplies incident to Added payment for: Multiple chronic conditions Expected to last at least 12 months Significant risk of death, acute exacerbation/decompensation or functional decline February
48 RHC CCM 2 CCM must be initiated during a comprehensive evaluation and management (E&M), Annual Wellness Visit (AWV) or Initial Preventive Physical Examination (IPPE) CCM HCPCS minute minimum Face-to-Face requirements are waived during CCM Co-insurance and deductible is waived February
49 CCM Beneficiary Permission Inform beneficiary of CCM services available Obtain consent before providing services and billing Electronic Health Record (EHR) shared with other providers Document in medical records acceptance or denial of CCM Discontinuing CCM is an option Only one practitioner provide services and bill during a calendar month One consent required or when practitioner is changed February
50 CCM Beneficiary Discussion Conversation with beneficiary and caregiver when applicable Items covered in the agreement process What is CCM service How to get the elements of the service How will the patient information be shared How cos-sharing apply (co-insurance and deductibles) How to revoke the service February
51 CCM Scope of Service Elements EHR Requirements CMS requests the use of certified EHR technology for some services EHR using CCM Certified Technology Demographic, problems, medications, medication allergies Clinical summary Document beneficiary written consent Communication to and from home base providers about psychosocial needs and functional deficits February
52 CCM Scope of Service Elements 2 EHR Requirements - continued Record in EHR using CCM Certified technology Clinical summary transmitted electronically other than by fax Document provision of care plan Capture care plan information Make information available 24/7 electronically other than by fax February
53 CCM Scope of Services Consist of systematic assessment of beneficiary medical, functional and psychosocial needs Ensure timely delivery of recommended preventive care services Review and oversight of beneficiary taking prescribed medications and interactions February
54 CCM Scope of Services 2 Managing care transitions between health care providers Referrals to other clinicians Follow-up after Emergency department visit Skilled nursing facility stay Discharged from hospital Other health care facilities February
55 CCM Scope of Services 3 Better chances for communication between RHC and beneficiary Including caregiver Communication situations to provide consultation Telephone Secure messaging ( ) Internet Non face-to-face February
56 RHC Surgical Procedures Surgical procedures are bundled into qualified visit not separately payable Performed in RHC Surgery performed in another setting (not RHC) and still in the global billing period Maybe subject to global billing Duplicate billing RHC can bill a visit if it is for a service not included in global billing package February
57 Services Not Included in the Global Surgical Package Initial consultation by the surgeon Visits unrelated to diagnosis of surgical procedure Unless the visit is for complication of surgery Added course of treatment that is not part of normal recovery from surgery More information found at IOM Chapter 12, Section 40.1.B February
58 Physical and Occupational Therapy Physical Therapy (PT) and Occupational Therapy (OT) may be provided directly by a physician, NP, or PA, Within the practitioner s scope of practice Furnished by a RHC practitioner Therapist can provide services incident to PT and OT is furnished as part of the professional RHC visit Furnished by a qualified therapist February
59 Telehealth Services Beneficiary or patient must be present in the originating site located in a rural Health Professional Shortage Area (HPSA) Must use an interactive audio and video telecommunications system Real-time between you and distant site Asynchronous store and forward technology permitted AK and HI only February
60 Non-RHC Services
61 Non-RHC Services Laboratory services Includes basic RHC required tests furnished onsite Exception: the venipuncture Bundled into the encounter rate Provider-based bill using the hospital PTAN/NPI (837I/UB04) TOB 14X or 85X Independent bill using practitioner PTAN/NPI (837P/1500) February
62 Non-RHC Services 2 Technical services/components of diagnostic tests X-rays Electrocardiograms (EKG) Other diagnostic tests May be billed separately by the providerbased facility Provider-based bill using the hospital PTAN/NPI (837I/UB04) Professional component is a RHC service Performed by practitioner or incident to February
63 Non-RHC Services 3 Technical services/components of diagnostic tests X-rays Electrocardiograms (EKG) Other diagnostic tests May be billed separately by the independent RHC Independent bill using PTAN/NPI (837P/1500) February
64 Hospice Services Non-RHC Services 4 Physician or NP can provide services when not working for RHC Services must comply with Medicare prohibitions on commingling Bill using his/her own provider number Services not related to terminal condition treated as RHC services February
65 Non-RHC Services 5 Ambulance services DME Prosthetic devices Body braces Telehealth distant-site services Hospice Medicare excludes services February
66 Non-RHC Services 6 If the clinic does not compensate a physician for services furnished to clinic patients in a location other than at the RHC location, the physician may bill the carrier for Medicare payment under the Part B payment system. Services provided to hospital inpatients or outpatients are never RHC services February
67 Non-RHC Services 7 If covered under another separate Medicare benefit category, the services must be separately billed to the Medicare carrier by the appropriate Medicare provider/supplier furnishing the services, using that provider/supplier number (not RHC number). February
68 Non-RHC Services 8 Since these services are NOT RHC services, any related costs for space, equipment, supplies, facility overhead, and personnel associated with these services must be identified and removed from allowable costs on the center s Medicare RHC cost report or the RHC subschedules February
69 RESOURCES
70 Resources CR Manual revisions s/r2186cp.pdf MM 7208 Summarizes RHCs billing instructions for certain preventive services under the Affordable Care Act ownloads/mm7208.pdf February
71 Resources 2 MM 8504 Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) Update Chapter 13 Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM8 504.pdf February
72 Resources 3 CMS MLN Publications ds/ruralhlthclinfctsht.pdf CMS Rural Health Clinic Center Type/Rural-Health-Clinics-Center.html February
73 Telehealth Services Resources 4 Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/telehealthsrvcsfc tsht.pdf February
74 Questions? Thank you!
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