Rural Health Clinics Billing Requirements. Part A Provider Outreach and Education September 2016

Transcription

1 Rural Health Clinics Billing Requirements Part A Provider Outreach and Education September 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. September

3 Objective To provide RHC billing guidelines and information about Healthcare Common Procedure Coding System (HCPCS) on claims. September

4 Agenda RHC Encounter/Visit RHC Coding and Billing April 1 to September 30, 2016 Effective October 1, 2016 Non-RHC Services Resources September

5 AIR AWV CNM DSMT Helpful Acronyms All-Inclusive Rate Annual Wellness Visit Certified Nurse Midwife Diabetes Self -Management Training HCPCS Healthcare Common Procedure Coding System IOM Internet Only Manual IPPE Initial Preventive Physical Exam LPN Licensed Practical Nurse September

6 Helpful Acronyms2 MLN MNT NP PA RHC RN TCM USPSTF Medicare Learning Network Medical Nutrition Therapy Nurse Practitioner Physician Assistant Rural Health Clinic Registered Nurse Transitional Care Management U.S. Preventive Services Task Force September

7 RHC Visit, Encounter or Services

8 Billable Encounter Billable visit = face-to-face encounter between the patient and a physician or NP, PA, CNM, clinical psychologist (CP), or clinical social worker (CSW) One or more RHC service is rendered Services furnished within the practitioner s state scope of practice Transitional Care Management (TCM) is a RHC visit RN or LPN visit to a home-bound patient September

9 Billable Encounter2 Stand-alone visit when the only service give on that day Qualified preventive health services Initial Preventive Physical Examination (IPPE) Annual Wellness Visit (AWV) USPSTF grade A and B preventive services List of preventive services and USPSTF categories in CR7012 Deductible and coinsurance waived RHC Preventive Services Chart on CMS website September

10 RHC Policy Guidelines Billing Requirements

11 Historical RHC Reporting HCPCS were required since 2011 only for preventive services Separate line item Coinsurance and deductible waived Charges were not included in the encounter/visit Venipuncture charges included in AIR and not separately billable September

12 Required Billing Updates Effective April 1, 2016, RHCs, including RHCs exempt from electronic reporting under Section (d)(3), are required to report the appropriate HCPCS code for each service line along with the revenue code, and other required billing codes. No change to the AIR system and payment MLN Matters Article 9269 September

13 Service Line Item Billing One or more encounters after April 1 Select one RHC qualifying HCPCS per encounter Coinsurance and/or deductible is based on the qualifying visit HCPCS Include the total charge on the line item Additional charges require a HCPCS and the payment included in the AIR September

14 Service Level Information Professional component of qualifying medical service and approved preventive health services Bill under revenue code 0521 Mental health service Use revenue code 0900 Telehealth originating site facility fees Use revenue code 0780 with Q3014 September

15 Revenue Codes Codes not accepted on RHC claims Revenue Codes 002x-024x 045x 056x 065x 080x-088x 096x-310x Revenue Codes 029x 054x 060x 067x-072x 093x September

16 Revenue Codes2 Codes that may be accepted on RHC claims Billable not separately payable Revenue Codes 025x 042x 063x 090x Revenue Codes 030x 043x 077x September

17 Remittance Advice Codes Remittance Group code CO Contractual obligation Claim Adjustment Reason Code (CARC) 97 benefit included in another service Remittance Advice Reason Code (RARC) M15 separately billed service have been bundled September

18 Qualifying Visit List (QVL) Updates CMS updated the visit list on March 24, 2016 Added medically necessary billable codes Effective April 1, 2016 Payable October 1, 2016 Billable visits are shown in red RHCs were instructed to hold claims for these billable visit September

19 Qualifying Visit List (QVL) Updates2 CMS updated the visit list on August 1, 2016 Added medically necessary billable codes Payable October 1, 2016 Billable visits are shown in red Effective October 1, RHCs should add CG modifier to stand-alone billable visits that meet policy requirements for coverage Applies to HCPCS on QVL held April 1 September

20 Qualifying Visit List (QVL) Tips HCPCS on qualifying visit list is not an allinclusive stand-alone billable list RHC billable visits must meet Medicare coverage requirements Services documented and retained in the patient s medical record QVL HCPCS code does not guarantee payment September

21 HCPCS Reporting Requirement April 1, 2016

22 Claim Requirements Qualifying Visit Service Line Report revenue code 052x or 0900 Charges represent the amount that will be used to assess coinsurance and deductible Additional Service Line(s) Report each additional service furnished with the most appropriate revenue code with charges $0.01 or greater Some charges were displayed twice On the line with the qualifying visit and on the service line for the specific service September

23 HCPCS for Qualifying Visit Patient s account for medical visit and preventive service Revenue Code HCPCS Service Date Service Units Charges $ G $ $ 3.00 Charge Total $88.40 September

24 HCPCS for Qualifying Visit2 Preventive service and medical visit FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied $49.73 AIR Yes 0521 G $38.67 CARC 97 No $ 3.00 CARC 97 No 0001 $91.40 September

25 HCPCS for Qualifying Visits3 Stand-alone preventive service FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment 052x G $38.67 AIR Yes Coinsurance and deductible applied September

26 HCPCS for Qualifying Visits4 Mental Health Services Revenue Code HCPCS Service Date Service Units Charges $ $25.42 Charge Total $96.05 September

27 HCPCS for Qualifying Visits5 Mental Health Services FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied $96.05 AIR Yes $25.42 CARC 97 No 0001 $ September

28 HCPCS for Qualifying Visits6 Medical E/M visit FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied 052x $ AIR Yes September

29 Services and Supplies Incident to Physician, NP, PA, CNM, CP and CSW Incident to services provided separate from face-to-face encounter should be included with charges for billable encounter Nurse administers injection on second visit would be covered when incident to physician face-to-face Bundle/add to qualifying visit September

30 Services and Supplies Incident to Physician, NP, PA, CNM, CP and CSW2 No specified time limit for bundling incident to services to billable encounter; frequency should support physician/np active involvement in patient care Documentation for incident to services provided separate from face-to-face encounter should be included with charges for billable encounter September

31 Medical Services and Incident to Hepatitis B Vaccine incident to FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied $ AIR Yes $3.00 CARC 97 No $59.71 CARC G $5.00 CARC $ September

32 Advance Care Planning (ACP) as Part of AWV Date of Service on or after January 1, 2016 through March 31, 2016 FL 42 Revenue Code 052x FL 44 HCPCS G0438 or G0439 FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment $ AIR No 052x $ Included in AIR 0001 $ Coinsurance Deductible Applied No September

33 Multiple Visits on Same Day Select one RHC qualifying HCPCS Coinsurance and/or deductible is based on the qualifying visit HCPCS Encounters with more than one RHC practitioner on same day Including a specialist Related or unrelated to subsequent visit Multiple evaluations with a different practitioner on same day for the same or different condition September

34 Multiple Visits on Same Day2 RHC receives one AIR Other services performed on the same day Use appropriate revenue code No coinsurance and deductible is applied Bundled into the AIR September

35 Multiple Visits on Same Day3 Two visits billed on same day when Patient suffers illness or injury that requires additional diagnosis or treatment on same day Subsequent medical service Bill using modifier 59 Distinct Procedural Service Identifies a separate encounter during the same day Only situation which modifier 59 is used September

36 Multiple Visits on Same Day4 Two visits billed on same day when Patient has medical visit and clinical psychologist or clinical social worker visit Qualifying mental health visit on same day Each line item must have a HCPCS and total charge Both lines are paid the AIR September

37 HCPCS for Qualifying Visit7 Patient account for an office visit and minor wound repair Revenue Code HCPCS Service Date Service Units Charges $ $ Charge Total $ September

38 HCPCS for Qualifying Visit8 FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied $ AIR Yes $ CARC $ September

39 HCPCS for Qualifying Visits9 Unrelated encounters; different diagnosis FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied 052x $ AIR Yes 052x $ AIR Yes 0001 $ September

40 HCPCS for Qualifying Visits10 Qualifying mental health visit FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied 052x $ AIR Yes $ AIR Yes 0001 $ September

41 Transitional Care Management (TCM) TCM can be billed when furnished by a RHC practitioner Stand-alone encounter/visit If occurs on the same date as another medical visit Bundled into the AIR Only one TCM visit paid for 30-day post discharge period Subject to coinsurance and deductible September

42 Transitional Care Management (TCM) 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) September

43 Chronic Care Management (CCM) Effective January 1, 2016 CCM CPT code Reimbursement is based on the Physician Fee Schedule (PFS) non-facility payment rate Stand-alone encounter/visit Billable with other RHC medical visits Coinsurance and deductible is applied September

44 Billing CCM Services Medical visit and CCM, subsequent visit FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied 052x $89.40 AIR Yes 052x $45.60 Based on the PFS national average non-facility payment rate Yes September

45 HCPCS Reporting Requirement October 1, 2016

46 HCPCS on Claims Held Until October 2016 Append CG modifier on billable visits in red on the RHC QVL Revenue codes 052x and/or 0900 Charges are subject to coinsurance and deductible Additional service lines are for informational purposes only Charges are greater than $0.01 September

47 HCPCS for Qualifying Visits Claim was held as requested by CMS FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied CG $ AIR Yes $ CARC N/A $0.01 CARC $3.00 CARC $ September

48 HCPCS for Qualifying Visits2 Previously processed claim must be adjusted; type of bill 717 FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied CG $98.40 AIR Yes 0521 G $25.00 CARC $ September

49 Home Health Visit Effective October 1, billable as a standalone visit FL 42 Revenue Code FL 44 HCPCS FL 45 Service Date FL 46 Service Units FL 47 Total Charges Payment Coinsurance Deductible Applied 0521 G0490 CG $98.40 AIR Yes 0001 $98.40 September

50 Invalid Revenue Codes and HCPCS Service lines will reject on RHC claims Durable Medical Equipment (DME) Revenue code 029x Ambulance services Revenue code 054x Hospital-based care , , and Group services 97804, G0271 Non-face-to-face services September

51 Returned Claims Claim(s) will return for correction Invalid HCPCS codes Qualifying visit HCPCS code does not meet policy requirements Improper use of modifier 59 or 25 Modifier CG used more than once per day Line rejected for invalid revenue codes for bill type 0711 September

52 Incident to Tips Report a valid revenue code for incident to services or supplies Not acceptable on RHC line item billing 002x-024x, 029x 045x 054x, 056x, 060x, 065x, 067x- 072x, 080x-088x, 093x, or 096x-310x Incident to services are included in the AIR and not separately payable September

53 RHC Billing Tips Report one service line per encounter/visit Review RHC qualifying visit list (RHC QVL) for the appropriate E/M, mental health or screening service HCPCS Continue to bill approved preventive health services Remember frequency edits apply Use modifier 59 appropriately September

54 Preventive and Screening Services RHC Preventive Services Chart

55 IPPE Preventive Service IPPE one-time exam within first 12 months following enrollment Report on a separate line HCPCS G0402 Coinsurance and deductible do not apply May be paid when billed with another qualified encounter Reimbursed at AIR September

56 Preventive Services Preventive services that can be billed as a stand-alone visit if it is the only medical visit Screening Papanicolaou Smear Q0091 Prostrate Cancer Screening G0102* Glaucoma Screening G0117* and G0118* Does not qualify for separate payment on the same day as another medical visit *Deductible and coinsurance are not waived September

57 Preventive Services Report HCPCS code on line items separate from encounter Payment included in encounter rate Deductible and coinsurance do not apply Subtract charges for preventive services from the total visit charge reported under the encounter revenue line September

58 Influenza and Pneumonia Vaccines Billing Reimbursed separately through cost report Provider-based report charges on cost report Worksheet M-4 Freestanding RHCs on B-1 Do not report on UB-04 form Influenza HCPCS G0008 Pneumococcal HCPCS G0009 Deductible and coinsurance waived September

59 Non-RHC Services

60 Non-RHC Services Ambulance services DME Prosthetic devices Body braces Telehealth distant-site services Hospice Medicare excludes services September

61 Group Services Non-RHC Services2 Health education classes or group education activities Group or mass information programs including medical productions and publications September

62 Non-RHC Services3 Technical components of a RHC service Includes diagnostic tests such as x-rays, electrocardiograms (EKGs) Test(s) authorized by Medicare statue or the National Coverage Determination (NCD) Laboratory services RHCs are required to furnish but these types of services are not within the scope of the RHC benefit September

63 Non-RHC Services4 Technical component billed by parent hospital (provider-based) Use PTAN on 837I or the UB-04 claim form or HCPCS and line item coding required Subject to frequency limit edits Independent facilities submit 837P or CMS-1500 form September

64 Non-RHC Services5 RHC may provide services beyond the scope when authorized and covered under a separate Medicare benefit Other payment rules apply to the non-rhc services September

65 Non-RHC Services Tips Identify and remove from allowable costs on the cost report associated with the non- RHC service Such as space, equipment, supplies, facility overhead and personnel Description of non-rhc services Medicare excluded routine physical checkups, dental care, hearing tests, eye examinations September

66 Non-RHC Services Tips2 Physician services at other Medicare facilities, including Critical Access Hospitals (CAH) Inpatient or outpatient services Ambulatory surgical center (ASC) Comprehensive outpatient rehabilitation facility (CORF) Any facility whose Medicare requirements preclude RHC services September

67 RESOURCES

68 Resources CMS IOM, Publication , Medicare Claims Processing Manual, Chapter 9 m104c09.pdf CMS IOM, Publication , Benefit Policy Manual, Chapter 13 p102c13.pdf September

69 Resources2 CMS IOM, Publication , Medicare Benefit Policy Manual, Chapter 16 General Exclusions From Coverage Guidance/Guidance/Manuals/Downloads/bp102 c16.pdf September

70 Resources3 Rural Health Clinic (RHC) Qualifying Visit List Updated October 1, Service-Payment/FQHCPPS/Downloads/RHC- Qualifying-Visit-List.pdf Required Billing Updates MLN Matters Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM9269.pdf September

71 Resources4 CMS MLN SE1611 Reporting Requirement and Billing Updates Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1611.pdf Advanced Care Planning ICN Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/AdvanceCarePlanni ng.pdf September

72 Resources5 Chronic Care Management FAQ Fee-for-Service- Payment/PhysicianFeeSched/Downloads/Pa yment_for_ccm_services_faq.pdf Chronic Care Management Fact Sheet Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCare Management.pdf September

73 Resources6 CMS Preventive Services Center Education/Medicare-Learning-Network- MLN/MLNProducts/PreventiveServices.html Screening for Hepatitis C Virus in Adults Guidance/Guidance/Transmittals/Downloads/R3 285CP.pdf September

74 Questions? Thank you!