2/12/13 1. Iowa Primary Care Association Coding Training Webinar #5. The Medicare Program. General Health Center/FQHC Billing attention Guidelines

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1 acumen Iowa Primary Care Association Coding Training Webinar #5 insight ideas General Health Center/FQHC Billing attention Guidelines reach expertise February 12, 2013 (11:30 1:30 CST) depth Presented by: Marla Dumm, CPC, CCS-P agility Supervising Consultant talent The Medicare Program Established by Title XVIII of the Social Security Act (the Act) on July 1, 1966 Provides medical coverage to individuals age 65 years or older, certain disabled individuals & individuals with End-Stage Renal Disease (ESRD) 2/12/13 1

2 The Medicare Program Medicare consists of the following four parts: Part A, hospital insurance Part B, medical insurance Part C, Medicare Advantage (MA) Part D, prescription drug plan (PDP) The Medicare Program In general, Medicare covered services are considered medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary s condition. Services or supplies are considered medically necessary if they are: Needed for the diagnosis or treatment of the beneficiary s medical condition For the diagnosis, direct care & treatment of the beneficiary s medical condition Meeting the standards of good medical practice Not mainly for the convenience of the beneficiary, provider or supplier The Medicare Program For every service billed, the provider or supplier must indicate the specific sign, symptom or beneficiary complaint necessitating the service. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment for services without beneficiary symptoms or complaints (with a few defined exceptions). 2/12/13 2

3 Medicare Benefit Entitlement An individual is qualified to receive FQHC services under Part B Provides reimbursement for 80% of encounter rate Patient copay is equal to 20% of the total charge(s) (for most services) Part B deductible is not applied to FQHC services Medicare Benefit Entitlement CMS suggests obtaining a photocopy of patient s Medicare card & photo identification Information on UB-04 should match the patient s Medicare card exactly UB forms must reflect the entire Medicare number including prefixes & suffixes Billing for FQHC services Use CMS-1450 (UB-04) form or electronic equivalent HIPAA compliant Bill to Fiscal Intermediary/Medicare Administrative Contractor (MAC) Claims cannot overlap calendar years Claims should not be for multiple dates 2/12/13 3

4 Type of Bill (TOB) As of April 1, 2010 = Use bill type 77x Third digit provides additional information on individual claims: 770 = non-payment/zero claim (non-covered charges) 771 = Admit through discharge (original claim) 777 = Replacement of prior claim (adjustment) 778 = Void/cancel prior claim (cancellation) Payable Revenue Codes Clinic visit by member to FQHC Home visit by FQHC practitioner Visit by FQHC practitioner to member in covered Part A stay at the SNF Visit by FQHC practitioner to a member in a SNF not in a covered Part A stay Payable Revenue Codes, cont FQHC Visiting Nurse Service to a member s home when in a home health shortage area 528 Visit by FQHC practitioner to other non- FQHC site (e.g., scene of accident) FQHC request for supplemental payment for Medicare Advantage enrollee 2/12/13 4

5 Payable Revenue Codes, cont Visits subject to outpatient mental health treatment limitation (therapeutic psychiatric) 780 Tele-health originating site facility fee Medicare FQHCs must report HCPCS codes & corresponding revenue codes Beginning with dates of service on or after January 1, 2011 Informational & data gathering purposes NOT to determine current Medicare payment to FQHCs FQHC Prospective Payment System (PPS) implementation = 2014 Medicare payments prior to 2014: current FQHC interim per-visit payment rate methodology Does not impact claims for supplemental payments to FQHCs under contract with Medicare Advantage Plans. Reference: MLN Matters MM7038 Key Points of Mandate (effective 1/1/11) If all the service lines do not contain valid HCPCS code(s) the claim will be returned to the provider, except for those revenue codes that do not permit HCPCS code reporting All claims with any service lines with any of the following revenue codes will be returned to the provider: 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096x-310x. Medicare will not make payment for both DSMT and MNT sessions on the same DOS. 2/12/13 5

6 Key Points of Mandate (effective 1/1/11) Service lines containing revenue code 0520 will not receive the all-inclusive rate. The specific site of service revenue code 0521, 0522, 0524, 0525, 0527 or 0528 should be used to report an encounter/visit. For complete details of Change Request # 7038: /R2034CP.pdf Excluded Revenue Codes 002x-024x 065x 029x 067x-072x 045x 080x-088x 054x 093x 056x 096x-310x 060x Additional Claim Instructions Per MLN Matters SE1039 When reporting multiple services, the 052X revenue line should include the total charges for all services Charges for preventive services with grade A or B must be deducted from the total charge line 2/12/13 6

7 Claim Example Total Charge is $ LINE REVENUE CODE HCPCS CODE Office Visit ($50) Penicillin Injection Lesion Removal Preventive Service DATE OF SERVICE CHARGES 01/01 $ /01 $ /01 $ /01 $50.00 Two Visits on Same Day If two unrelated visits occur on the same day, both visits should be reported on the same claim The visits must be independent and distinct from each other Example: medical visit followed by behavioral health visit Append modifier -59 on claims with two clinic visits Condition being treated is totally unrelated and provided at separate times of the day Timely Filing Limits Under the Patient Protection and Affordable Care Act (PPACA), services furnished on or after January 1, 2010 must be filed within one calendar year after the date of service 2/12/13 7

8 Advance Beneficiary Notice of Noncoverage (ABN) Effective November 1, 2011, the NEMB will be replaced by Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131 Mandatory - When Medicare will deny items or services as not medically necessary, experimental, not safe and effective, etc. Voluntary Statutorily excluded care or services that Medicare never covers Medicare does not require an ABN for services that are never paid by Medicare. Advance Beneficiary Notice Should be issued when: You believe Medicare may not pay for an item or service, Medicare usually covers the item or service, and Medicare may not consider it medically reasonable and necessary The service exceeds frequency limitations 2/12/13 8

9 Supplemental Payments Billing for supplemental payments under contract with Medicare Advantage (MA) plans: FQHCs are entitled to payments to cover difference between payment received for MA enrollee and allinclusive payment rate Must establish a rate with fiscal intermediary (FI) or MAC Contact Provider Audit & Reimbursement department Submit claims with revenue code 0519 HCPCs codes are not required Payment Rate Increases Effective January 3, 2013 through December 31, 2013 FQHC upper payment limit per visit: Urban FQHCs = $ Rural FQHCs = $ Voluntary Self-Disclosure Protocol Section 6402 of ACA Establishes a deadline for reporting & returning overpayments by the later of: The date which is 60 days after the date on which the overpayment was identified; or The date any corresponding cost report is due, if applicable 2/12/13 9

10 Enrollment Revalidation Section 6401 (a) of the ACA All enrolled providers and suppliers to revalidate their enrollment information Applies to those providers and suppliers that were enrolled prior to March 25, 2011 Only after the FQHC has received notification from the MAC Then the FQHC has 60 days from the date of the letter to submit complete enrollment forms Fee of $505 Coverage Criteria for FQHCs Medical Documentation Requirements Patient medical record must support & verify services billed Record must include: Identification & social data Physical examinations Test results & consultative findings Provider orders & other pertinent information Signature of provider Services and Supplies Are covered if they are: Furnished as incidental, but integral part of physician s professional services A type commonly rendered either without charge or included in FQHC bill FQHC services include drugs furnished by, and incident to, services of physicians and nonphysician practitioners. Reference: Medicare Benefit Policy Manual, Chapter 13, /12/13 10

11 Encounter Definition Face-to-face encounter between a patient and a FQHC physician (that is: MD, DO, podiatrist, optometrist or chiropractor, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, qualified clinical psychologist or clinical social worker) during which a coverable service is performed Encounter Definition, cont. As a result of the Deficit Reduction Act of 2005 (DRA) the definition was expanded to include encounters with qualified practitioners of outpatient Diabetes Self Management Raining (DSMT) services and Medical Nutrition Therapy (MNT) services when the FQHC meets all relevant program requirements for the provision of services. 2/12/13 11

12 Non-Billable Encounters Reading an EKG or X-ray is not an encounter Dressing changes by nursing staff Receiving a lab result Writing a prescription or refill Drawing blood Non-Billable Encounter Interpretation of results of tests or procedures which do not require face-toface contact between a physician/provider & the patient are not considered a reimbursable encounter Billing Non-Encounter Visits 30 Day Rule Services such as B-12 injections, when ordered by the provider, subsequent to the encounter, can be billed with the date of service of the original encounter For services that do not qualify as a billable encounter, the usual charges for the services are added to those of the appropriate encounter (i.e., 30 day rule) Reference: Medicare, Change request /12/13 12

13 Services Incident-To a Physician or Non- Physician Practitioner Performed by a NPP or nursing personnel/staff who are employees Will be a type of service commonly performed in a physician office setting Would be rendered without charge or included on the bill Furnished as incidental, but integral part of the professional service Provided under DIRECT supervision Nurse-only services Reference: Medicare Benefit Policy Manual, Chapter 13, 60.4 Covered Physician Services Are covered in an FQHC if the following apply: Medically reasonable & necessary Provided by a physician who is employed by or receives compensation from the clinic Service(s) are incidental but integral part of physician s professional service Covered NP, CNM or PA Services Are covered in an FQHC if the following apply: NP, CNM or PA is an employee of the clinic or receives compensation by the clinic Has general (or direct, if state law requires) medical supervision by physician Any physician order(s) for treatment are followed NP, CNM or PA are legally permitted by state law to perform services Service(s) would be covered if performed by a physician 2/12/13 13

14 FQHC Services - Providers Physician Services professional services performed by a physician for a patient, including diagnosis, therapy, surgery & consultation Nurse Practitioner, Physician Assistant and Midwife Services services are of a type that practitioners can legally perform in their state & would be covered if furnished by a physician Clinical Psychologist & Clinical Social Worker Services Physician Services professional services performed by a physician for a patient, including diagnosis, therapy, surgery & consultation FQHC Services - Providers Visiting Nurse Services: services are rendered to patients who are homebound under a written plan of treatment established by a supervising physician, nurse midwife or nurse practitioner CMS must determine there is a shortage of home health agencies. The FQHC must make a request for this status through the state. FQHC Services-Telemedicine May be used as a substitute for faceto-face encounters Consultations, office visits, individual psychotherapy, pharmacological management, psychiatric diagnostic interview, MNT, DSMT, etc. FQHC may serve as an originating site (where patient is located) Non-MSA and FQHC HPSA areas 2/12/13 14

15 FQHC Services-Telemedicine Patient must be present real time interactive audio & visual Originating site facility fee will be subject to Part B deductible Utilize HCPCs code Q3014 & 780 revenue code Only non-fqhc service that is reported on the clinic professional UB and paid at the facility rate Reference: Medicare Claims Processing Manual, Chapter 9, FQHC Services Nursing Facility Services of billable practitioners employed by an FQHC That provide medical care to patients in a NF/SNF setting are coverable FQHC services Includes swing bed FQHC Services DSMT & MNT Diabetes Self-Management Training/Medical Nutrition Therapy FQHCs may bill for DSMT services if they have obtained certification through an approved agency American Diabetes Association, Indian Health Service, American Association of Diabetes Educators) Reimbursed on a per visit basis (i.e., encounter rate) By Registered Dieticians or nutritional professionals 2/12/13 15

16 FQHC Services-DSMT & MNT Nursing staff may provide IF they are certified Additional program requirements must be met Instructions in self-monitoring blood glucose Education about diet & exercise Insulin plan treatment developed Motivation to use skill Cannot be provided in a group setting and billed as encounter Cost allocation FQHC Services-DSMT & MNT May not bill DSMT and MNT on same date of service Must be face-to-face Payment in addition to a qualifying medical visit if performed on same day FQHC Services-DSMT & MNT Order must be part of a plan of care Signed statement from provider documenting need for service Number of hours ordered FQHCs should follow normal billing procedures to include HCPCS G0108 2/12/13 16

17 FQHC Services-DSMT & MNT Revenue code 521 DSMT G0108 (Individual therapy, per 30 minutes) MNT (Initial assessment, Individual, each 15 minutes (Reassessment, individual, each 15 minutes) G0270 (Reassessment and subsequent intervention following second referral in same year, change in diagnosis, individual, each 15 minutes) Non-FQHC Services Paid by Medicare Part B X-rays & EKGs Technical component Hospital services If appropriate compensation agreement exists between FQHC and physician Lab: as of January 1, 2001, TR A Ambulance services Leg, arm, back & neck braces Prosthetic devices Hospice patient Durable medical equipment Technical Component Billing The provider who performs the technical service for a radiological exam should bill this to the Medicare Part B carrier. The technician who performs the EKG can bill this service to the Medicare Part B carrier. NOTE: If the FQHC physician or NPP performs and documents a separate interpretation of the technical service (EKG, radiology), this professional service is billed to Part A on the center UB-04 2/12/13 17

18 Laboratory Services HCFA (CMS) Program Memorandum A provides instruction to bill lab services to the Medicare Part B carrier to be paid from laboratory fee schedule. Must carve out all associated expenses in filing the cost report No professional service associated with laboratory services FQHC - Hospice If FQHC physician or non-physician practitioner is designated as the patient s attending physician/provider Care Related to terminal illness billed to the carrier Care unrelated to terminal illness billed to the FI/MAC FQHC Services Flu, Pneumonia & Hepatitis B Vaccinations Flu, Pneumonia or Hepatitis B vaccine HCPCS or CPT code(s) Medicare administration HCPCS code(s) (G0008-Flu, G0009- pneumonia, and G0010-Hepatitis B) Listed on clinic UB-04 with appropriate revenue code Condition code A6 with vaccines identified in reason code narrative Subtract cost/charge from total charges Flu and Pneumonia reported on log sheet for cost report Hepatitis B only is paid under the encounter rate DO NOT report an encounter if vaccine administration was only service provided 2/12/13 18

19 FQHC Services Drug Administration Add to center UB-04 when performed during a medically necessary encounter with provider List drug/solution/medication HCPCS code on separate line item on UB-04 List administration/injection CPT code on separate line item on UB- 04 Service and supplies are paid under the encounter rate If given as a nurse only service No claim is generated Services are tracked for the annual cost report May meet 30-day rule and can be added to next encounter charges Initial Preventive Physical Examination(IPPE) Revenue Code 521 Coinsurance is waived May be billed on the same day as a medical or other preventive service May involve an ordered EKG List service with appropriate HCPCS code on a separate line item Paid at encounter rate IPPE Codes G0402 = physical examination performed face-toface with the patient G0404 = screening EKG tracing only (without interpretation & report G0405 = screening EKG interpretation & report only, (without the EKG tracing) 2/12/13 19

20 Annual Wellness Visits (AWV) Revenue Code 521 Coinsurance is waived May be billed on the same day as a medical or other preventive service List service with appropriate HCPCS code on a separate line item Paid at encounter rate G0438 Initial annual wellness visit G0439 Subsequent annual wellness visit Additional Covered FQHC Screening & Preventive Services Screening mammography as defined in 1861(jj); Screening pap smear and screening pelvic exam as defined in 1861 (nn); Prostate cancer screening tests as defined in 1861(oo); (E) Colorectal cancer screening tests as defined in 1861 (pp) Bone mass measurement as defined in 1861 (rr) Screening for glaucoma as defined in 1861 (uu) Additional Covered FQHC Screening & Preventive Services, cont. Cardiovascular screening blood tests as defined in 1861 (xx)(1) Diabetes screening tests as defined in 1861 (yy) Ultrasound screening for abdominal aortic aneurysm as defined in 1861 (bbb) Additional preventive services (as defined in 1861 (ddd)(1)) Network-MLN/MLNProducts/Downloads/MLNPrevArticles.pdf 2/12/13 20

21 Billing Covered Behavioral Health Services to Medicare Eligible providers: Licensed Clinical Psychologists Licensed Clinical Social Workers Physicians Physician Assistants Nurse Practitioners Billing Covered Behavioral Health Services to Medicare Service categories: Psychiatric Diagnostic Interview Therapy Pharmacological Management Effective January 1, 2013, all new CPT codes Need to update any paper or electronic charge tickets Provide education on appropriate use 2/12/13 21

22 Clinical Psychologist Services The services of clinical psychologists are not covered if they are otherwise excluded from Medicare coverage, even though a clinical psychologist is authorized by state law to perform them. Services at the FQHC or away from the FQHC are covered. 2/12/13 22

23 Clinical Psychologist Services The clinical psychologist must provide written notification to the patient s designated attending or primary care physician that services are being provided to the patient, or must consult directly with the physician to consider medical conditions that may be contributing to the patient s symptoms, unless the patient specifically requests that such notification or consultation not be made. 2/12/13 23

24 Covered Mental Health Services: Incident To Clinical psychologist & services/supplies furnished incident to such services are covered in an FQHC. CP must be legally authorized to perform the services under applicable licensure laws of the state in which they are furnished. 2/12/13 24

25 Covered Mental Health Services: Incident To To be covered incident to a CP s service, the services & supplies must be: Mental health services that are commonly furnished in a clinical psychologist s office An integral, although incidental, part of professional services performed by the clinical psychologist Performed under the direct and personal supervision of a clinical psychologist (i.e., the clinical psychologist must be physically present and immediately available) Behavioral Health Services Mental Health Treatment Limitation (MHTL) applies to therapeutic services: Limitation has been 62.5% since the inception of the Medicare Part B program. However, MHTL is being phased out as follows: LIMITATION DATES PERCENTAGES January 1, 2010 December 31, % January 1, 2012 December 31, % January 1, 2013 December 31, % January 1, 2014 onward 100% Behavioral Health Services, cont. Excluded from the MHTL are diagnostic procedures & medical management: Medication management: brief office visits for the sole purpose of monitoring or changing drug RXs used in treatment of mental, psychoneurotic or personality disorders Diagnostic services: such as psychological testing or an office visit to establish a diagnosis Medical care: as opposed to psychotherapy, furnished to a patient diagnosed with Alzheimer s disease or related disorder, outpatient treatment SNF management of mental, psychoneurotic or personality disorders 2/12/13 25

26 Behavioral Health Services, cont. Provider is responsible for determining application of MHTL prior to claim submission MHTL is based on revenue code 900 Claims submitted with ICD-9-CM codes without revenue code 900 are reviewed for additional information & returned if information is not included in FL 80 of the UB-04 Unfortunately, there is no EASY button! Common Scenarios How Do We Bill? Injection given with an encounter with the provider Injection given with an encounter with the nurse only Center visit with procedure(s) Center visit with diagnostic testing Visit for diagnostic testing only Preventive encounter Center visit resulting in direct admission to hospital or observation ER visit resulting in direct admission to hospital or observation Two clinic visits on the same date of service (i.e., medical visit, OBGyn-well woman visit) 2/12/13 26

27 Final Thoughts Review current charge capture process Review and update paper or electronic charge tickets Run utilization reports to identify charge errors or patterns Perform internal and external audits on concurrent or retrospective basis Research guidelines for any new service(s) Provide annual education to new and established staff on coding and FQHC billing criteria 79 Questions? Thank You! Marla Dumm, CPC, CCS-P Supervising Consultant BKD, LLP 910 E. St. Louis St. Springfield, MO acumen insight ideas attention reach expertise depth agility talent 2/12/13 27

28 Resources CMS Publication Chapter 13 Chapter 15 Publication Chapter 9 Chapter 16 Chapter 18 Chapter 30 National Government Services National Association of Community Health Centers Copyright "CPT codes copyright 2013 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. " Disclosure Information contained in this presentation is informational only & is not intended to instruct hospitals & physicians on how to use, or bill for health care procedures. Providers should consult with their respective insurers, including Medicare fiscal intermediaries & carriers, for specific information on proper coding & billing for health care procedures. Additional information may be available from physician specialty societies & hospital associations. Information contained in this presentation is not intended to cover all situations or all payers' rules & policies. Reimbursement laws, regulations, rules & policies are subject to change. 2/12/13 28