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NARHC Spring Institute
Tuesday, March 31, 2015
San Antonio Conference
Breakout Sessions
Your choice…
Regency Ballroom East:
RHC Billing
for Independents:
Charles James
Rio Grande Center & West:
Being Emotional Solid
In a High Pressure
Environment
Don Alan Lucas
You are HERE!
RHC Billing for Independents
Charles James
MBA, President & CEO
North American Healthcare
Management Services
Rural Health Clinic Billing - Independent
Charles A. James, Jr.
President and CEO
North American Healthcare Management Services
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What is a RHC?
Rural Health Clinics were established by the Rural Health
Clinic Service Act of 1977 to address an inadequate supply of
physicians serving Medicare beneficiaries in underserved
rural areas, and to increase the utilization of nurse
practitioners (NP) and physician assistants (PA) in these
areas. RHCs have been eligible to participate in the Medicare
program since March 1, 1978, and are paid an all-inclusive
rate (AIR) per visit for primary health services and qualified
preventive health services. (Medicare Benefit Policy Manual.
Chapter 13. Section 10.1.)
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The RHC Encounter Rate
“In general, the all-inclusive rate (AIR) for an
RHC or FQHC is calculated by the MAC/FI by
dividing total allowable costs by the total
number of visits for all patients. Productivity,
payment limits, and other factors are also
considered in the calculation.”
(Medicare Benefit Policy Manual. Chapter 13. Section 70.)
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Medicare Fees (Patient Charges)
“RHCs and FQHCs must charge Medicare
beneficiaries the same rate that nonMedicare beneficiaries are charged.”
(Medicare Benefit Policy Manual. Chapter 13. Section 80.)
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Medicare Payments
“In general, Medicare pays 80 percent of the
RHC or FQHC’s all-inclusive rate, subject to a
per-visit payment limit. The beneficiary in an
RHC must pay the deductible and
coinsurance amount.”
(Medicare Benefit Policy Manual. Chapter 13. Section 80.)
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RHC Encounter Rate FY 2015
The Current RHC maximum encounter rate is
$80.44.
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Independent RHCs
• Independent RHCs are generally private physician offices
or hospital clinics whose parent is > 50 beds.
• RHC encounters are paid using the current RHC cap.
• Independent RHCs must file an annual cost report, which
is due 5 months after the end of each fiscal year.
• Failure to file timely cost reports can result in full refunds
of RHC payments.
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Provider-Based RHCs
• Provider-based RHCs (PBRHC) are those owned by a
parent entity such as a hospital, nursing facility, or home
health agency.
• Claims are billed to the MAC which services the parent
entity.
• PBRHCs owned by a hospital with 50 beds or less qualify
for an un-capped RHC rate.
• PBRHCs whose parent entity is greater than 50 beds have
the same cap as independents.
• PBRHCs rate is set under the parent entity’s cost report.
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RHC Locations
“An RHC or FQHC visit may take place in the
RHC or FQHC, the patient’s residence, an
assisted living facility, a Medicare-covered
Part A SNF, the scene of an accident…”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)
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Never a RHC Location
“…an inpatient or outpatient hospital, including
CAHs.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)
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Qualified RHC Providers
An RHC encounter can be billed for the
following providers:
• Physicians (MD, or DO)
• Nurse Practitioners, Physician Assistants, and
Certified Nurse Midwives
• Clinical Psychologists (PhD)
• Clinical Social Workers (CSW or LCSW)
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Rural Health Services
• Physicians' services, as described in section 100;
• Services and supplies incident to a physician’s
services, as described in section 110;
• Services of NPs, PAs, and CNMs, as described in
section 120;
• Services and supplies incident to the services of
NPs, PAs, and CNMs, as described in section 130;
(Medicare Benefit Policy Manual Chapter 13)
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Rural Health Services (Continued)
• CP and CSW services, as described in section 140;
• Services and supplies incident to the services of
CPs and CSWs, as described in section 150; and
• Visiting nurse services to the homebound as
described in section 180.
(Medicare Benefit Policy Manual Chapter 13)
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RHC Services
RHC services also include certain preventive
services... These services include:
• Influenza, Pneumococcal, Hepatitis B
vaccinations;
• Hepatitis C screenings;
• IPPE/Annual Wellness Visit;
• Medicare-covered preventive services
(Medicare Benefit Policy Manual Chapter 13)
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The RHC Encounter is:
“A RHC or FQHC visit is defined as a medically-necessary
medical or mental health visit, or a qualified preventive
health visit. The visit must be a face-to-face (one-on-one)
encounter between the patient and a physician, NP, PA,
CNM, CP, or a CSW during which time one or more RHC or
FQHC services are rendered. A Transitional Care
Management (TCM) service can also be a RHC or FQHC visit.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.)
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RHC Encounters are not:
• Visits for the sole purpose of obtaining or
renewing a prescription, in which the need was
previously determined are not covered services.
• Reviewing lab results.
• Administration of an injection.
• Time used in completion of claim forms.
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Physician Services
The term “physician” includes a doctor of medicine,
osteopathy, dental surgery, dental medicine,
podiatry, optometry, or chiropractic who is licensed
and practicing within the licensee’s scope of
practice, and meets other requirements as
specified.
(Medicare Benefit Policy Manual. Chapter 13. Section 100.)
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Physician Services
“Physician services are professional services furnished by a
physician to an RHC or FQHC patient and include diagnosis,
therapy, surgery, and consultation. The physician must either
examine the patient in person or be able to visualize directly
some aspect of the patient’s condition without the
interposition of a third person’s judgment. Direct
visualization includes review of the patient’s X-rays, EKGs,
tissue samples, etc.
(Medicare Benefit Policy Manual. Chapter 13. Section 100.)
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Incident-to Services Defined
• Commonly rendered without charge or included in the RHC or FQHC
bill;
• Commonly furnished in a physician office or clinic;
• Furnished under the physician’s direct supervision; and
• Furnished by a member of the RHC or FQHC staff.
• Drugs and biologicals that are not usually self-administered, and
Medicare-covered preventive injectable drugs (e.g., influenza,
pneumococcal);
• Bandages, gauze, oxygen, and other supplies; or
• Assistance by auxiliary personnel such as a nurse, medical assistant,
or anyone acting under the supervision of the physician.
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Incident-to Services Defined
• Incident-to services are considered covered and paid
under the RHC.
• They must be bundled with the RHC encounter. They are
not separately billable or payable.
• Services that do not occur on the same date as the
encounter can be bundled if they occur 30 days before or
after.
• The effect on payment is an increase in the charge, and
therefore in the co-insurance.
• The cost for these services are included in the cost report,
but are not separately payable on claims.
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Provision of Incident-to Services
• Incident to services and supplies can be furnished
by auxiliary personnel.
• More than one incident to service or supply can
be provided as a result of a single physician visit.
• Incident to services and supplies must be
provided by someone who has an employment
agreement or a direct contract with the RHC or
FQHC to provide services
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Provision of Incident-to Services
• Services and supplies furnished incident to
physician’s services are limited to situations in
which there is direct physician supervision of the
person performing the service.
• Direct supervision does not mean that the
physician must be present in the same room…the
physician must be in the RHC or FQHC and
immediately available.
(Medicare Benefit Policy Manual. Chapter 13. Section 110.1)
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Examples of incident-to services
•
•
•
•
•
Injections
Suture Removal
Dressing Changes
Prescription Services
Blood Pressure Monitoring
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How to Bundle Services
Example: An office visit for $105.00 and an
injection for $75.00 is provided by the
physician, NP, PA, or CNM.
One line item for $180.00 will be submitted
to Medicare. The patient (or secondary)
will be responsible for $36.00 (20% coinsurance).
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Bundled Injection
Amount
Description
Office Visit – 99213
$105.00
Clinic’s Customary Fee
Rocephin Injection
$75.00
Injection Fee
521 Rev Code Line Item
$180.00
Office Visit and Injection Bundled
Patient Co-insurance
$36.00
Billed to Patient or Secondary
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Multiple Encounters
“Encounters with more than one RHC or FQHC
practitioner on the same day, or multiple
encounters with the same RHC or FQHC practitioner
on the same day, constitute a single RHC or FQHC
visit, regardless of the length or complexity of the
visit or whether the second visit is a scheduled or
unscheduled appointment.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Multiple Encounters are allowed when:
• The patient, subsequent to the first visit, suffers an illness
or injury that requires additional diagnosis or treatment
on the same day (2 visits), or
• The patient has a medical visit and a mental health visit on
the same day (2 visits), or
• The patient has his/her IPPE and a separate medical
and/or mental health visit on the same day (2 or 3 visits).
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Global Billing
• Surgical procedures furnished in an RHC or FQHC by an
RHC or FQHC practitioner are considered RHC or FQHC
services.
• The RHC is paid based on its all-inclusive rate and is not
subject to the Medicare global billing requirements.
• Surgical procedures furnished at locations other than
RHCs or FQHCs may be subject to Medicare global billing
requirements.
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Minor Surgical Procedures
• Minor surgical procedures performed in the
RHC, during RHC hours, must be billed as
encounters.
• Follow-up visits for dressing changes, or
suture removal can only be billed as
encounters if there is a medicallynecessary, documented reason and it is
performed by an RHC provider.
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Office Visit and Surgical Procedure
• If an office visit is performed during the
same visit as a minor surgical procedure,
the clinic will only have one encounter to
bill.
• These should be bundled and submitted as
one line item.
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Injections and Surgical Procedures
• When performed during RHC hours,
injections are incident to an encounter.
• Surgical procedures are definitely an
encounter.
• RHC services can only be billed FFS with
significant administrative adjustment and
extreme caution. (Commingling)
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90 - Commingling
Commingling refers to the sharing of RHC or
FQHC space, staff (employed or contracted),
supplies, equipment, and/or other resources
with an onsite Medicare Part B or Medicaid
fee-for-service practice operated by the same
RHC or FQHC physician(s) and/or nonphysician(s) practitioners.
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90 - Commingling
• Duplicate Medicare or Medicaid reimbursement
(including situations where the RHC or FQHC is
unable to distinguish its actual costs from those
that are reimbursed on a fee-for-service basis),
• Selectively choosing a higher or lower reimbursement rate for the services.
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100.2 - Treatment Plans or Home Care
Plans
Treatment plans and home care oversight
provided by RHC or FQHC physicians to RHC
or FQHC patients are considered part of the
RHC or FQHC visit and are not a separately
billable service.
(Medicare Benefit Policy Manual. Chapter 13)
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100.4 - Transitional Care Mgmt
TCM services can be billed as a stand-alone visit if it
is the only medical service provided on that day
with a RHC or FQHC practitioner and it meets the
TCM billing requirements. If it is furnished on the
same day as another visit, only one visit can be
billed.
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170 - Physical and Occupational
Therapy
PT and OT services furnished incident to a visit with
a RHC or FQHC practitioner are not billable visits but
the charges are included in the charges…for a
billable visit if:
• The PT or OT is furnished by a qualified therapist
incident to a professional service as part of an
otherwise billable visit,
• The service furnished is within the scope of
practice of the therapist.
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170 - Physical and Occupational
Therapy
If the services are furnished on a day when
no otherwise billable visit has occurred, the
PT or OT service provided incident to the visit
would become part of the cost of operating
the RHC or FQHC. The cost would be included
in the costs claimed on the cost report and
there would be no billable visit.
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Non-Rural Health Services
Non-Rural Health Services can be billed to the
fee-for-service carrier (or hospital FI). These
services include:
• Diagnostic testing - X-Ray, EKG, etc.
• Laboratory services - Venipuncture
• Professional services rendered in the
hospital
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Venipuncture
“Although RHCs and FQHCs are required to furnish certain
laboratory services…laboratory services are not within the
scope of the RHC or FQHC benefit. When clinics and centers
separately bill laboratory services, the cost of associated
space, equipment, supplies, facility overhead and personnel
for these services must be adjusted out of the RHC or FQHC
cost report. This does not include venipuncture, which is
included in the all-inclusive rate when furnished in the RHC
or FQHC by an RHC or FQHC practitioner and as part of an
RHC or FQHC visit.” (MLN Matters® MM8504)
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Diagnostic Testing and Lab:
Independent
• The professional component for X-Ray,
EKG, and other diagnostic testing is
bundled with the RHC encounter.
• The technical component of these tests are
billed to the Medicare Part B carrier using
the fee-for-service provider number.
• All lab services are also billed to the Part B
carrier.
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How RHC Medicare Services are Billed:
Type of RHC
Encounter
CLIA Lab
Other
Lab/Ancillary
Outside RHC
Hours
Independent or
Freestanding
Part A
UB-04
Part B*
Form 1500
Part B*
Form 1500
Part B*
Form 1500
Provider Based
Part A
UB-04
Billed by Parent
hospital or
absorbed into
costs
Billed by
Parent
hospital/entity
Billed either Part
B to MAC or as
hospital charge if
appropriate.
* Costs related to services reimbursed under Part B are carved out on the RHC cost report so
that the encounter rate is not overstated (double-dipping).
CMS Quick Reference Guide
• See the following chart for a quick
reference on RHC billing.
• This is also posted on
www.northamericanhms.com.
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads//RuralChart.pdf
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Hospital Services
• Physician services at the hospital are billed
to the Medicare Carrier for fee-for-service
reimbursement.
• If the parent-entity is a Critical Access
Hospital (CAH) using option II billing – outpatient hospital services are billed to the
parent’s FI.
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Hospice
• RHCs and FQHCs can treat hospice beneficiaries
for any medical conditions not related to their
terminal illness.
• If a Medicare beneficiary who has elected the
hospice benefit receives care from an RHC or
FQHC related to his/her terminal illness, the RHC
or FQHC cannot be reimbursed for the visit.
(Medicare Benefit Policy Manual. Chapter 13. Section 200)
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Non-Hospice Related
• When the RHC provider DOES see a hospice
patient for non-hospice related condition:
• Hospice Code ‘07’
• Enter ‘Non-Hospice Related Service’ in
remarks
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99211 Office Visits
• E/M code 99211 is commonly used for
nursing visits, (injection administration,
etc.), even though physicians sometimes
bill them.
• For RHC purposes, these are NOT
considered encounters.
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Non-Covered Services
If a rejection for a Medicare non-covered service is
needed so that we can submit a claim to the
patient’s secondary insurer.
A claim with a type of bill 710 (non-covered service)
should be submitted to Medicare. This will prompt
a rejection that can be submitted to the secondary
payer.
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Influenza, Pneumococcal Injections
• Flu and pneumonia shots are covered
under the RHC program. These are the
only injections that are separately payable.
• These are not billed on a claim, but are
submitted on the cost report.
• They are paid with the clinic’s annual cost
report reconciliation.
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Visiting Specialists in an RHC
Any qualified provider (MD, DO, NP, PA) can
see patients in an RHC.
The only stipulation is that the RHC must
provide primary care services fifty-one
percent of operating hours. (FP, IM, Peds, OB)
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Two Scenarios for Visiting Specialists
Scenario #1: A specialist rents space from the
RHC one morning per week, brings his own
staff, and does his own billing.
Configuration: The RHC carves out the cost
of the space and removes all associated
costs from the cost report.
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Visiting Specialists
Scenario #2: A general surgeon comes to the
RHC once per week. She sees RHC patients
and they are billed as RHC encounters.
Configuration: In-patient surgeries should be
billed with modifier 54 (surgery only).
Follow-up visits can then be billed as
encounters.
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Mental Health Providers
• Medicare RHC providers are:
 Clinical Psychologist (PhD)
 LCSW
 LCPC or CPC is not payable by Medicare
(Check with your own state to see if LCPC
or CPC are eligible – in most states they
are not)
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Mental Health Services
• Mental Health Services performed by a
qualified provider are billed using revenue
code 900.
• Diagnostic services are paid as an
encounter.
• Therapeutic services are subject to a
limitation which is being phased out.
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Telehealth
• Report on UB04 with Q3014. (app. $23.17)
• Can accompany an E/M service or be
reported alone.
• ‘Remote’ physician bills an E/M code with
modifier.
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Telehealth
RHCs and FQHCs are not authorized to serve as a
distant site for telehealth consultations, which is the
location of the practitioner at the time the
telehealth service is furnished, and may not bill or
include the cost of a visit on the cost report. This
includes telehealth services that are furnished by a
RHC or FQHC practitioner who is employed by or
under contract with the RHC or FQHC, or a non-RHC
or FQHC practitioner furnishing services through a
direct or indirect contract.
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210.1 - Preventive Health Services in RHCs
Preventive Service billing changed
dramatically effective 1.5.2015.
Many services previously un-billable by RHCs
are now payable as encounters.
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Preventive Services – Cost Reporting
• Medicare pays 80% of the RHC Encounter
rate, but no co-insurance or deductible.
• Track Medicare Preventive Services (MPS)
charge amounts.
• These are to be entered on the cost report.
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Influenza (G0008) and
Pneumococcal and Vaccines (G0009)
Influenza and pneumococcal vaccines and
their administration are paid at 100 percent
of reasonable cost through the cost report.
No visit is billed, and these costs should not
be included on the claim. The beneficiary
coinsurance and deductible are waived.
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Hepatitis B Vaccine (G0010)
Hepatitis B vaccine and its administration is
included in the RHC visit and is not separately
billable. The cost of the vaccine and its
administration can be included in the line item for
the otherwise qualifying visit. A visit cannot be
billed if vaccine administration is the only service
the RHC provides. The beneficiary coinsurance and
deductible applies.
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Hepatitis C Screening (GO472)
Hepatitis C screening is included in a RHC visit and is
not separately billable. The cost of the professional
component of the screening can be included in the
line item for the otherwise qualifying visit. A visit
cannot be billed if this is the only service the RHC
provides. Effective for claims with dates of service
on or after June 2, 2014, the beneficiary
coinsurance and deductible are waived.
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Initial Preventive Physical Exam
(G0402)
The IPPE is a one-time exam that must occur within
the first 12 months following the beneficiary’s
enrollment. The IPPE can be billed as a stand-alone
visit if it is the only medical service provided on that
day with a RHC practitioner. If an IPPE visit is
furnished on the same day as another billable visit,
two visits may be billed. The beneficiary
coinsurance and deductible are waived.
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Annual Wellness Visit (G0438 and
G0439)
The AWV is a personalized prevention plan for beneficiaries
who are not within the first 12 months of their first Part B
coverage period and have not received an IPPE or AWV
within the past12 months. The AWV can be billed as a standalone visit if it is the only medical service provided on that
day with a RHC practitioner. If the AWV is furnished on the
same day as another medical visit, it is not a separately
billable visit. The beneficiary coinsurance and deductible are
waived.
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Diabetes Counseling and Medical
Nutrition Services
Diabetes counseling or medical nutrition services
provided by a registered dietician or nutritional
professional at a RHC may be considered incident to
a visit with a RHC practitioner provided all
applicable conditions are met.
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Diabetes Counseling and Medical
Nutrition Services
RHCs are permitted to become certified
providers of DSMT services and report the
cost of such services on their cost report for
inclusion in the computation of their AIR.
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Screening Pelvic and Clinical Breast
Examination (G0101)
Screening pelvic and clinical breast examination can
be billed as a stand-alone visit if it is the only
medical service provided on that day with a RHC
practitioner. If it is furnished on the same day as
another medical visit, it is not a separately billable
visit. The beneficiary coinsurance and deductible are
waived.
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Screening Papanicolaou Smear
(Q0091)
Screening Papanicolaou smear can be billed as a
stand-alone visit if it is the only medical service
provided on that day with a RHC practitioner. If it is
furnished on the same day as another medical visit,
it is not a separately billable visit. The beneficiary
coinsurance and deductible are waived.
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Prostate Cancer Screening (G0102)
Prostate cancer screening can be billed as a standalone visit if it is the only medical service provided
on that day with a RHC practitioner. If it is furnished
on the same day as another medical visit, it is not a
separately billable visit. The beneficiary coinsurance
and deductible apply.
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Glaucoma Screening (G0117 and
G0118)
Glaucoma screening for high risk patients can be
billed as a stand-alone visit if it is the only medical
service provided on that day with a RHC
practitioner. If it is furnished on the same day as
another medical visit, it is not a separately billable
visit. The beneficiary coinsurance and deductible
apply.
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210.2 - Copayment and Deductible
for RHC Preventive Health Services
When one or more qualified preventive
service is provided as part of a RHC visit,
charges for these services must be deducted
from the total charge for purposes of
calculating beneficiary copayment and
deductible.
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AWV with ‘Sick Visit’ Billing
The MPS is $175.00 and the ‘sick visit’ charge is $150, the
line items would be reported as follows:
Rev Code
HCPCS
DOS
Charges
0521
0521
G0438
3.22.2015 $175.00
3.22.2015 $150.00
One encounter rate will be paid. Patient co-ins and
deductible are waived on the $175.00.
Co-insurance will be based on $150.00 ($30.00).
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Medicare Preventive Reference
MPS Chart:
http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_
QuickReferenceChart_1.pdf
CMS Preventive Services Center:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/PreventiveServices.html
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Types of Bill
The following rules apply specifically to all RHC claims:
The third digit of TOBs 71x provides additional information regarding
the individual claim. When the third digits, called frequency codes,
are used on RHC claims the TOBs are:
710 = non-payment/zero claim (a claim with only noncovered
charges)
711 = Admit through discharge (original claim)
717 = Replacement of prior claim (adjustment)
718 =Void/cancel prior claim (cancellation)
CMS Medicare Claims Processing Manual
www.northamericanhms.com
888.968.0076
NPI - Taxonomy
FL 56 = RHC NPI
FL 81CC = B3 (Taxonomy=261QR1300X)
Name of the Facility with the correct 9 digit
zip code, the Tax ID, the NPI and the
Taxonomy code MUST match exactly or
claims will reject.
Pay to Address cannot be P.O. Box.
www.northamericanhms.com
888.968.0076
Revenue Codes
The following revenue codes are used on UB04 claims:
0521 Clinic Visit at RHC by qualified provider;
0522 Home visit by RHC provider;
0524 Visit by RHC provider to a Part A SNF bed;
0525 Visit by RHC provider to a SNF, NF or other
residential facility (non-Part A);
0527 Visiting Nurse service in home health shortage
area
0528 Visit by RHC provider to other non-RHC site
(scene of an accident)
www.northamericanhms.com
888.968.0076
Claim Submission
• All claims are billed on a UB-04.
• Type of Bill 711 for initial claims.
• Actual charges should be submitted, not the RHC
encounter rate.
• Co-insurance and deductible amounts are applied
based on the charge.
• A medically-necessary diagnosis is required.
• Only one encounter per day is billable.
www.northamericanhms.com
888.968.0076
MSP Audits
• What is your MSP policy?
• Does it comply with Medicare
requirements?
• What is required?
www.northamericanhms.com
888.968.0076
MSP Information Requirement
“As a Medicare provider, you must determine whether
Medicare is the primary or secondary payer for each
inpatient admission or outpatient encounter prior to
submitting a claim to Medicare. You can do this by asking
Medicare beneficiaries about other coverage. The CWF also
contains MSP information. The questions you ask can help
you verify the CWF information is correct and up to date.”
MSP Fact Sheet
www.northamericanhms.com
888.968.0076
MSP Information
You should retain a copy of completed MSP
questionnaires in your files or online for 10
years. You may keep hard copy files, optical
images, microfilms, or microfiches. If you
store these files online, you must keep both
negative and positive responses to questions.
MSP Fact Sheet
www.northamericanhms.com
888.968.0076
RHC Updates – My Blog!
http://northamericanhms.com/blog/
www.northamericanhms.com
888.968.0076
Submission of MSP Claims
The best way to get these claims paid
(assuming all the fields are correct!) is:
- ANSI 837 claims
- PC-Ace
Your software vendor must be able to
produce a valid 837 claim for submission.
www.northamericanhms.com
888.968.0076
More CMS Resources
Medicare Claims Processing Manual – UB04 Completion
www.cms.gov/manuals/downloads/clm104c25.pdf
Medicare Claims Processing Manual – Chapter 9 RHC/FQHC
Coverage Issues
www.cms.gov/manuals/downloads/clm104c09.pdf
!! NEW !! Medicare Benefit Policy Manual – Chapter 13
RHC/FQHC
www.cms.gov/Regulations-and
Guidance/Guidance/Manuals/Downloads/bp102c13.pdf
www.northamericanhms.com
888.968.0076
Contact Information
Charles A. James, Jr.
North American Healthcare Management Services
President and CEO
888.968.0076
[email protected]
www.northamericanhms.com
www.northamericanhms.com
888.968.0076
Breakout Sessions
Your choice…
Regency Ballroom East:
RHC Billing for
Provider Based
Janet Lytton
You are HERE!
Rio Grande Center & West:
Practice Management
Issues
Marty Bennett
RHC Billing for Provider Based
Janet Lytton
RHIT, Director of Reimbursement
Rural Health Development
Provider Based Rural Health Clinic
Billing
Janet Lytton, Director of Reimbursement
Rural Health Development
308-647-6455 [email protected]
San Antonio, TX
March 2015
1
 Understand the billing of the various revenue codes
 Understand how to bill preventive services and
how the RHC is paid
 Understand how the changes in billing affect the
RHC
 Discuss Billing “issues”
2
 Medicare Benefit Policy Manual Ch 13 – RHC
and FQHC Services Rev 201 issued 12/12/14,
effective 1/1/15
 CR8981 issued 12/12/14 updates effective 1/1/15
3
•
Face-to-Face with the Provider
•
•
•
Medically necessary
•
•
All payer classes are counted in the total visit count
Place of Service
•
•
Does it require the skills of a Provider?
Payer Class
•
•
Physician, PA, NP, CNM
Clinical Social Worker or Clinical Psychologist
Clinic, Home, NH, SNF/SW Bed, Scene of Accident
Level of Service
•
All levels apply, to include procedures
• To include all services “incident to”
4
 521
 522
 524
Office visit in clinic
Home visit
Visit to a Part A SNF or SW patient
Only prof service as labs, drugs, x-ray TC, EKG
tracing gets billed to the SNF.
 525
Visit to a Pt in a SNF, NF, ICF MR, AL
Patient not on a Part A SNF Stay




527
528
780
900
Visiting Nurse Service in a HHA shortage
Visit at other site, I.e. scene of accident
Telehealth site fee
Mental Health Services
 All drugs & supplies, are bundled with the visit code charges in
the Revenue Codes shown above
5





All Procedure Codes that are normally performed
in a physician’s clinic are applicable in the RHC
Coding in the RHC is no different than any clinic
If your coder is also your biller, the knowledge of
what service to bill to which payer is imperative
Some CPT codes will have to be “split” billed, i.e.
EKG, x-ray prof & tech comp
The difference is how the RHC gets paid
6




Physician services
NP, PA & CNM services
Services & Supplies incident to provider service
Diabetes self-management training services and medical
nutrition therapy services for diabetic patients provided
by registered dietitians or nutritional professionals
 not separately billable for RHCs but indirectly paid
 Visiting nurse services in non HHA area
 Clinical psychologist & clinical social worker
 CP & CSW supplies & services “incident to”
7






Hospital patient services
Lab tests (except venipuncture which is part of visit)
Part D Drugs & Self administrable drugs
DME
Ambulance services
Technical components of diagnostic tests


i.e. x-rays & EKG, Holter Monitoring
Technical components of screening services
 i.e. screening paps/pelvic, PSA



Prosthetic devices
Braces
Hospice Services (see also Sec 200)
CMS Pub. 100-02. Ch 13, Sec 60 & 60.1
8
 Nurse service w/o face-to-face visit or “incident to”
visit
 I.e. allergy injection, hormone injection, dressing
change
 Provider MUST be present to have “incident to”
 CMS Manual 100-02 Chapter 13 Section 110.2
 Telephone services
 CMS Manual 100-02 Chapter 13 Section 100 & 120
 Prescription services
 CMS Manual 100-02 Chapter 13 Section 100 & 120
9
o
o
o
o
o
o
o
o
Routine INR visit for lab
Simple suture removal
Dressing change
Results of normal tests
Blood pressure monitoring
B12 injection
Allergy Injection
Prescription service only
10
Definitions:
• Preventive CPT codes
•
•
•
CPT codes for physical exams based on age
Use when patient has no significant complaints or follow up
of ailments
Medicare does not pay for Preventive physical CPT codes
with the exception of the Introduction to Medicare
Physical, paps, pelvic, annual wellness visit, PSA, etc.
(those listed in the Medicare beneficiary booklet)
11

Significant, separately identifiable E/M service by
same provider on the same day of a procedure
or other service.
 Append

to E/M code , I.e. 99214-25 (in system only)
Use Modifier 25 when one of the following criteria
is met:



Visit for a problem unrelated to the procedure
Visit for a new problem or a problem that has changed
significantly and requires re-evaluation before
performing the procedure.
Visit for the same problem in different sites; one treated
surgically and one treated medically.
12
• UB 04 form or 837i electronic format
• Bill Type 711
• Revenue Codes (NO CPT CODES ON CLAIM)
• Exception when billing preventive services
• Sent to Medicare Administrative Contractor
• Claims for all RHC visits
• Office, Skilled Nursing Home, Swing Bed, Nursing
Home, Home, Scene of an accident
• Actual charges billed
• Billed under the provider that saw the patient
13
• RHC office visit services
• Excludes all labs, x-ray TC & EKG Tracing, any TC
• Includes venipuncture effective 1/1/14
• Billed to the FI, UB04 Form or electronic
• Paid on the clinic’s “all inclusive rate”
• All Medicare coverage rules apply
• Reasonable & necessary
• Allowed preventive is covered, I.e. pap, PSA
14
•
All hospital services (IP, OP, ER, OBS)*
•
Billed to MAC, HCFA 1500 Form
•
Paid on the Medicare existing fee schedule
* The only exception is if the CAH is Method II
reimbursement, then the OP, ER & OBS professional
component is part of the hospital’s claim.
15

ALL Laboratory performed in the RHC, including 6 basic tests
Billed using 141 bill type for PPS Hospitals
 CAH 851 bill type

 For any facility owned by CAH or CAH employee performing

Technical Component







X-ray
EKG Tracing
Holter Monitor
All TC’s Billed using 131 bill type for PPS Hosp
All TC’s Billed using 851 bill type for CAH
Paid at the Medicare Pt B Fee Schedule Rates
Can be “input” by either Clinic or Hospital on hospital OP#
16


Each State Medicaid is specific as to their
State requirements—50 states, 50 plans
May use either the 1500 or UB04





Managed Care Plans have choice as well
Coverage is specific to each state
Most States require both RHC and nonRHC
Medicaid provider numbers
Paid on the RHC rate or a PPS rate
Know YOUR State billing requirements
17
•
Billed as in fee-for-service clinic
Billed on the 1500 claim form
•
No changes in reimbursement
•
All discounts given should be based on finances of
patients
•
•
i.e. sliding fee scales can be developed to as high as
400% of poverty guidelines per Federal Regulations
18
Two types of plans
PFFS – Private Fee for Service
Send Claims on UB04 with Medicare Rate letter
Regional/PPO Plans
Must provide service to the entire region per CMS
Send Claims on UB04; you negotiate payment
When patients switch to MA, they are on your “Private”
section of your visit counts
You may want to keep them separate as they will count as
Medicare patients if you need to figure the % of Medicare
utilization.
19
 Direct supervision by provider required
 Must be in clinic, not in same room
 being in the hosp when attached to clinic is NOT
“incident to”
 Part of provider’s services previously ordered
 integral, though incidental
 covered as part of an otherwise billable encounter
 I.e. dressing change, injection, suture removal, etc.
 When added, the additional reimb is the 20% copay
 Otherwise, if not on a claim, all costs are part of your
cost report and are included in your rate
CMS 100-02, Ch 13, Sec 110.1 110.2
20
•
•
•
•
•
•
•
•
Can be combined on claim with a f-t-f visit
“incident to” service for plan of treatment
NEVER considered a separate visit
Visit should be within 30-days pre or post
List only the date of the f-t-f visit as DOS
Charges should reflect all services bundled
Adjustments OK—717 Type of Bill; CC=D1;
remarks “changes in charges”, ICN# on claim
Otherwise, the costs are shown on your cost
report and claimed indirectly
21

Injections with an Office Visit




Charge All CPT codes in system
Bundle all charges and submit claim to RHC MCR
If it is a Pt D drug, it must be sent to Pt D plan or Patient
Injections only—nurse service




Charge in system
Either DO NOT bill (write off) as there is no f-t-f visit
OR can be bundled with a visit within 30 days pre or post
nursing service and submitted with that f-t-f visit
If injectable is a Part D drug it MUST not be a part of the
RHC claim as it is only billable to the patient or to Part D
22

Injectable/Vaccine as a Part D drug – 1/1/08

The injectable/vaccine is payable only through Pt D
 i.e. TDAP; Zostavax; Gardisil; Varivax; update vaccinations

If injectable/vaccine is obtained at the clinic level,
then the patient is to pay for the injectable/vaccine and
the administration privately and then they have to
submit that claim to their Part D company to be
reimbursed for the services.
Clinics can link to: www.mytransactrx.com and bill the Pt
D drug and receive payment to include administration of the
drug and site will show the copay amount due from patient.
(MLN Vaccine Payments under Medicare Pt D ICN 908764)
23
 Lab Services are nonRHC services
 Exception: Venipuncture is part of the bundled OV services
 All lab tests, to include the 6 basic required tests, are billed by
the parent facility (hosp or CAH) for PBRHCs
 If a waived test—the claim will show a QW modifier
 Venipuncture
 When part of visit, bundle the veni charge with OV
 When “incident to” on a day without an OV, can add to a
previous f-t-f OV or do an adjustment of the claim
 Is never to be sent to Pt B for payment
 Remember, you must charge all payers the same, thus if not
charging Medicare, you don’t charge anyone.
24
• Coded using the tracing only for the TC & the
interpretation only if provider interprets.
• EKG Tracing only = 93005
• EKG Interpretation and report = 93010
• Interp is billed with the office visit and included in the total
charges that are submitted to Medicare Rural Health
• Tracing only: PBRHC bills using the hospital OP provider
number on 131, or 851 Type of Bill
• IF “preventive service” use the appropriate G-code
25
Medicare: In calls to MACs (depends on medical
necessity)– but generally, if for same ailment, are not
allowing both services to be billed; thus bill the Admit
(services must take place in the hospital), if not, bill the
OV
Medicaid: State Specific
Private/Commercial: Bill the hospital admit
For all payers make sure you are “accumulating” all
services to set the level of admit.
26
• No global charges for Medicare in the RHC
• Each visit in the clinic is a billable visit
• Code the hosp surgical procedure with -54
(surgical procedure only) and bill to Part B or if
CAH method II, hospital bills
• Bill the pre and post visits as RHC visits as it is the
RHC facility billing the services, not a specific
provider
• If not your provider doing procedure, verify with the
provider that the -54 was billed
CMS Manual 100-02 Chapter 13 Section 40.4
27


Visits would be a medically reasonable and
necessary and billed as an RHC visit with 711
TOB and 521 revenue code.
Delivery only would be billed as a hospital
nonRHC service; each post partum visit is a
billable visit
28
•
Only allowed if a different illness or injury
•
•
•
•
•
•
If same diagnosis, accumulate to set E & M level
If seen by physician and then the mental health
provider both are billable—2 visits
If have IPPE and an ailment visit, it is 2 visits
If IPPE, ailment and mental health visit, is 3 visits
If seen in clinic, then admitted (MAC determines)
If seen by two different specialties, only 1 visit billable
CMS Manual 100-02 Chapter 13 Section 40.3
29
•
•
•
•
•
•
Clinical Psychologist (PhD)
Clinical Social Worker (CSW masters level)
Use 900 revenue code to bill therapeutic
behavioral health
The first visit to determine services by a
physician/PA/NP is an RHC visit, then
behavioral health services apply
Reimbursement in 2014 changed to 80/20
Make sure the CP and CSW have credentials
30
 Keep a log of injections, or have your computer track








Medicare paid on your Medicare Cost Report
Flu payable once per season
Pneumo 1st paid; second paid >11 months after 1st
Medicaid is paid if in your State benefits plan
Keep track of vaccine and supply costs
Determine average nursing hours per week
Determine average provider hours per week
Generally allow 10 minutes per injection on Cost
Report, but do a time study
 NO Medicare Advantage on log
 LOGS MUST BE LEGIBLE
31
 Allowed Medicare Preventive Services are billed
through the Rural Health Clinic on the UB04
 Technical Components, labs, EKG tracing are billed
on the nonRHC side using the Hospital OP
provider number; MUST use correct G-codes
 Know which codes are “stand alone” that can be
submitted without another OV service
 This list was published in January and is on the next several
slides
32
33
34
35
36
37
38
39
Preventive Services Quick Reference Guide:
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS
_QuickReferenceChart_1.pdf
IPPE Quick Reference Guide:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
Annual Wellness Visit Quick Reference Guide:
www.cms.gov/Outreach-and-Education/Medicare-Learning-Net workMLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf
More Preventive Service info:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
/Downloads/clm104c09.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
/Downloads/clm104c18.pdf
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals
40
/Downloads/bp102c13.pdf
41
42
43
For any preventive service that has a frequency
limitation, it is encouraged to have an ABN signed in
case the service is performed at the incorrect timing,
if no ABN, the clinic cannot charge the patient if
Medicare does not pay. As of 9/1/12 the UB claim is
allowed to have the GA modifier along with the
HCPCS code with the Occurrence Code of 32 with the
date the ABN was signed.
44
•
When seen for the hospice condition
•
•
•
Is not payable to the clinic and must be coordinated with
the Hospice Entity
Any TC is billed to the Hospice Co, if required
When seen for a condition other than the reason for
being on hospice
• Bill the MAC/FI as an RHC visit, RC 521
•
•
Use Condition Code 07
Use diagnosis for ailment not the hospice DX
Medicare Benefits Policy Manual 13, Sec. 200
Update: MM8504
45
•
•
•
•
•
•
•
Bill to RHC FI
Revenue Code 780
Does not require a Face-to-Face visit the same day
Q3014 code is paid separately from all-inclusive
rate at the Medicare Phys Fee Schedule
Bill for transmission fee
REQUIRED to put the Q code on the claim
RHCs are not allowed to be the provider
46


If all charges are noncovered, send 710 TOB with all
charges as noncovered and condition code 21.
If only some of the charges are noncovered, per CMS
Internet-Only Manual, Publication 100-4, Ch 1, Sec
60.4.3. This section of the manual states, "... all of a
bundled service must be billed as noncovered, or
none of it. Therefore, as long as part of a bundled
service is certain to be covered or medically
necessary, billing the entire bundled service as
covered is appropriate."
47
•
•
•
•
•
•
TOB 717
Claim must be in finalized status
Adjustment will appear as a debit or credit on future
remittance advice
Encourage submitting electronically
• exceptions—denied charges & claims rejected as MSP
Do not send another 711 claim as will error as a duplicate
Examples of Adjustments:
• Revenue code changes, Service unit decrease or
increase, Total charges changed, Primary payer
incorrect
48



When claim billed on 1500 on separate line items--roll
everything into one line. Even though the primary may
pay each line item separately, you still need to send the
claim to Medicare according to Medicare billing
regulations.
If clinic has a contractual obligation with the other
insurance and if they paid less than the contractual amount
and less than the total charges of the claim, you would use
the 44 value code to indicate the contractual amount.
Another value code to indicate what type of policy the
primary is and what they actually paid is required.
49
•
•
•
•
•
•
•
•
All practices that accept Medicare & Medicaid dollars are
required to have Corporate Compliance Policies
Hosp/Clinic Corporate Compliance Policy
HIPAA Policies in place
Do we have consents signed?
Are we getting ABNs (Advanced Beneficiary Notices)
when appropriate (must be CMS-R-131 03/11)
Keep copy of ABN
Are we asking the MSP (Medicare Secondary Payer)
questions? (must keep 10 years)
Is the Clinic billing appropriately
50
www.cms.gov/Medicare/Prevention/PrevntionGenInfo/downloads/MPS_
QuickReferenceChart_1.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning -NetworkMLN/MLNProducts/downloads//MPS_QRI_ IPPE001a.pdf
www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/ /AWV_Chart_ICN905706.pdf
www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
Make sure you are a part of your MAC listserve for updated info!
51
www.narhc.org (NARHC)
www.cms.gov
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/bp102c13.pdf
(RHC Benefit Manual)
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c09.pdf (RHC CMS Claims Manual)
www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
Make sure you are a part of your MAC listserve for updated info!
Rural Health Development Website & my e-mail:
www.rhdconsult.com [email protected]
52
?
?
?
?
?
?
53
Network Break
Food in Rio Grande East  Beverages in Regency Foyer
Compliments of our sponsor…
Breakout Sessions
Your choice…
Regency Ballroom East:
RHC Cost Reporting
Jeff Bramschreiber
Rio Grande Center & West:
Understanding &
Solving People
Problems
Deborah Marshall
You are HERE!
RHC Cost Reporting
Jeff Bramschreiber, CPA
Partner, Wipfli LLP
Rural Health
Clinic Cost
Reporting
11:00 a.m. – 12:00 p.m.
Jeff Bramschreiber, CPA
Health Care Partner
© Wipfli LLP
Presentation Overview
I. Rural Health Clinic Medicare Cost Report Overview
II. Allowable Costs/Non-RHC Costs
III. RHC Visits
IV. Cost Report Settlement
© Wipfli LLP
2
Medicare Cost Report
Completing the Medicare cost report is the method of reconciling
payments made by Medicare with the allowable costs for
providing those services.
• If total Medicare payments exceed the allowable costs, the
provider must pay back the difference.
• If total Medicare payments are less than the allowable costs,
Medicare will make an additional payment to the provider.
Note: Medicaid cost report filing requirements vary by state.
© Wipfli LLP
3
Medicare Cost Report
There are two types of RHCs;
cost reporting is slightly different for each:
• Independent RHCs submit an RHC cost report to a
regional to MAC.
• Provider-based RHCs submit an RHC cost report as a
subset of the host provider (usually a hospital).
© Wipfli LLP
4
Medicare Cost Report
• Cost report is due five months after the close of the period
covered. Must be filed electronically.
• Terminating cost reports are due 150 days after the termination
of provider agreement.
• Extension to file the cost report may be granted by intermediary
only for extraordinary circumstances such as a natural disaster,
fire, or flood.
© Wipfli LLP
5
Medicare Cost Report
Cost Report Components
•
•
Trial Balance of Expenses
Reclassification and Adjustment of Trial Balance of Expenses
− Reclassifications
− Adjustments
− Related-party adjustments
•
•
RHC Provider Statistics
•
Visits (part I), Overhead (part II)
•
Determination of Medicare Reimbursement (part I) &
Payment (part II)
Flu/PPV Vaccine Costs
© Wipfli LLP
6
Medicare Cost Report
Misrepresentation or falsification of any information contained in
this cost report may be punishable by criminal, civil, and
administrative action, fine, and/or imprisonment under federal
law. Furthermore, if services identified in this report were
provided or procured through the payment directly or indirectly of
a kickback or where otherwise illegal criminal, civil, and
administrative action, fines and/or imprisonment may result.
Signed: Your Name?
© Wipfli LLP
7
What Is Needed to Prepare the Cost Report
1. Financial statements
2. Cost report software
3. Provider/practitioner data
4. Visits by practitioner
5. Wage and benefit summary, by position
6. Equipment (fixed asset) records
7. PS&R Report (Medicare payments)
8. Influenza/pneumococcal vaccines
9. Laboratory costs
© Wipfli LLP
8
What Is Needed to Prepare the Cost Report
10. Radiology costs
11. Advertising costs
12. Other items:
•
Medicare bad debt log
•
Additional costs not included in financial statements
•
Costs included in financial statements not related to
RHC services
© Wipfli LLP
9
Allowable Costs for
Rural Health Clinics
© Wipfli LLP
Allowable Costs
Allowable RHC Costs:
• Defined at 42 CFR 413.
• Explained in Provider Reimbursement Manual, Pub. 15.
“Allowable costs are the costs actually incurred by you
which are reasonable in amount and necessary and proper
to the efficient delivery of your services.” RHC Manual,
Ch.501
© Wipfli LLP
11
Allowable Costs
What is the source document for the “allowable RHC
costs”?
• For provider-based RHCs
− Departmental summary reports
− Internally prepared financial statements
− Hospital cost report data
• For independent RHCs
− Financial statements prepared by outside accountants
− Internally prepared financial statements
− Tax returns?
© Wipfli LLP
12
Allowable Costs
Not the same as tax deductions:
• Accrual vs. cash basis
• Depreciation
• Related parties
• Provider/Owner compensation
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Allowable Costs
Costs recorded on an accrual basis:
• Recorded when cost incurred, not when paid.
• Payment must be made within 12 months after year-end
(unless a more restrictive requirement applies).
Examples:
• Employee profit sharing contributions recorded in 2014 but
contributions made in 2015.
• Expenses incurred in December 2014 but paid in January
2015.
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Allowable Costs
Related parties:
• Related through ownership or control (board of directors, key
employees)
“The intent is to treat the costs incurred by the supplier
as if they were incurred by the provider itself.”
CMS Pub. 15-1 (PRM)
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Allowable Costs
Related parties:
• Building and equipment leases
• Contracted employees
• Purchased services (e.g., cleaning, billing, etc.)
Examples:
• Clinic shareholders own clinic building through separate real
estate partnership. Lease to RHC.
• Clinic management forms separate billing service and contracts
with RHC.
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Allowable Costs
Related-Party Example – Building Lease:
• RHC pays $4,000 per month ($48,000 per year) to owners’
partnership for building rent.
• Actual annual cost of building incurred by partnership:
− Interest on mortgage = $20,000
− Depreciation on building = $8,000
− Property taxes = $6,000
− Insurance on building = $1,000
− Total annual costs = $35,000
• RHC costs must be reduced by $13,000.
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Allowable Costs
Cost Report Requires Separation of Staff Costs
•
Health Care Staff Costs:
− Physician
•
Facility Overhead Costs:
− Office Staff
•
Cost Other Than RHC Services:
− Laboratory
− Physician Assistant
− Nurse Practitioner
− Visiting Nurse
− Other Nurse
− Clinical Psychologist
− Clinical Social Worker
− Radiology
− Hospital Services
− Other
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Allowable Costs
Cost Report Requires Separation of Staff Costs
COMPENSATION
1
FACILITY HEALTH CARE STAFF COSTS
Physician
Physician Assistant
Nurse Practitioner
Visiting Nurse
Other Nurse
Clinical Psychologist
Clinical Social Worker
1
2
3
4
5
6
7
8
9 Other Facility Health Care Staff Costs
10 Subtotal (sum of lines 1-9)
850,000
120,000
OTHER
COSTS
2
150,000
40,000
175,000
1,145,000
TOTAL
3
RECLASSIFICATIONS
4
1,000,000
160,000
175,000
190,000
1,335,000
-
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
NET
EXPENSES
FOR
ALLOCATION
7
1,000,000
160,000
175,000
1,335,000
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Non-RHC Costs
Identify Costs of Non-RHC Services
• Laboratory services
• Diagnostic radiology
• Hospital patients (inpatient/ER/ASC)
• Medical directorships
• Mammography
• DME
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Non-RHC Costs
Laboratory Services
Most common direct costs associated with lab:
• Lab tech salaries/benefits
• Reagent costs
• Other lab supplies
• Lab equipment depreciation
• CLIA licensure/reference lab fees
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Non-Allowable RHC Costs
Non-allowable costs may be removed through an
adjustment:
Example:
• Shared (non-RHC) facility costs
• Advertising used to promote clinic utilization
• Purchased lab services
• Interest income (limited to interest expense)
• Miscellaneous income
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Rural Health Clinic Visits
© Wipfli LLP
Payment Rate Calculation
This is a review (and there may be a test) . . .
Allowable RHC Costs
Rural Health Clinic Visits
=
RHC Cost Per Visit (Rate)
(Not to exceed the maximum reimbursement limits.)
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RHC Visits
“The term ‘visit’ is defined as a face-to-face encounter
between the patient and a physician, physician assistant, nurse
practitioner, nurse midwife, specialized nurse practitioner, visiting
nurse, clinical psychologist, or clinical social worker
during which an RHC service is rendered.”
RHC Manual, Ch.504
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RHC Visits
• Total visits, the denominator in the cost per visit calculation,
should include all “visits” that take place in the RHC during
hours of operation, home visits, and SNF visits for all payers.
• Total visits should not include hospital visits (either inpatient or
outpatient visits) or “nurse-only” visits in the RHC setting.
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Rural Health Clinic Productivity
Productivity Standards:
• Physician 4,200 visits annually for 1.0 FTE
• Midlevel 2,100 visits annually for 1.0 FTE
Total visits used in calculation of cost per visit is the greater of
the actual visits or minimum allowed (FTEs x Productivity
Standard)
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Rural Health Clinic Productivity
Cost Report Simulation
Number
1
2
3
4
5
6
7
8
9
Positions
Physicians
Physician Assistants
Nurse Practitioners
Subtotal (sum of lines 1-3)
Visiting Nurse
Clinical Psychologist
Clinical Social Worker
Total FTEs and Visits (sum of lines 4-7)
Physician Services Under Agreements
Minimum
of FTE
Total
Productivity Visits (col. 1
Personnel
Visits
Standard (1)
1
3.80
0.90
2
13,000
5,200
4.70
18,200
4.70
18,200
3
4,200
2,100
2,100
Greater of
col. 2 or
x col. 3)
col. 4
4
15,960
1,890
17,850
5
18,200
18,200
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RHC Visits
• Counting of “visits” is easier said than done.
• Computer-generated reports may be misleading
− Counting units of service instead of visits
− Including non-visits (e.g., nurse-only 99211)
− Including non-RHC visits (e.g., hospital visits)
− Excluding non-billable visits (e.g., cash-only)
• Remember:
higher visits = lower cost per visit = lower rate!
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Reimbursement Settlement
© Wipfli LLP
Reimbursement Settlement
The final step:
• Reconcile payments made by Medicare with the allowable
costs for providing services
− If total Medicare payments exceed the allowable costs, the
provider must pay back the difference.
− If total Medicare payments are less than the allowable costs,
Medicare will make an additional payment to the provider.
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Reimbursement Settlement
Allowable RHC Costs
Rural Health Clinic Visits
=
RHC Cost Per Visit (Rate)
(Not to exceed the maximum reimbursement limits.)
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Reimbursement Settlement
Adjusted Cost per Visit
Reflects total allowable cost divided by total RHC clinic visits equals cost per
encounter. Allowable costs adjusted for PPV/Flu costs.
AMOUNT
DETERMINATION OF RATE FOR RHC SERVICES
1 Total Allowable Costs (Worksheet M-2, line 20)
2 Cost of Pneumococcal and Influenza Vaccine (W/S M-4, line 15)
3
4
5
6
7
Total Allowable Costs Excluding Pneumococcal and Influenza
Vaccine
Greater of Minimum Visits or Actual Visits by Health Care Staff
(W/S M-2, column 5, line 8)
Physician Visits Under Agreement (W/S M-2, column 5, line 9)
Total Adjusted Visits (line 4 + line 5)
Adjusted Cost Per Visit (line 3 divided by line 6)*
* May be subject to maximum limit.
1,663,930
8,000
1,655,930
$
18,200
18,200
90.99
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Payment Rate
RHC Reimbursement Limits*
2009
Maximum
Increase
2010
2011
2012
2013
2014
2015
$ 76.84 $ 77.76 $ 78.07 $ 78.54 $ 79.17 $ 79.80 $ 80.44
1.6%
1.2%
0.4%
0.6%
0.8%
0.8%
0.8%
*Limits do not apply to RHCs in hospitals with < 50 beds.
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Reimbursement Settlement
The Provider Statistical and Reimbursement System (PS&R)
is an essential component of cost report reconciliation
• Report summarizes all paid Medicare claims
− Visits
− Charges
− Deductible
− Medicare payments
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Reimbursement Settlement
Reimbursable Cost
• Program visits (per PS&R) times rate per encounter equals
program costs.
• Medicare pays 80% of cost less deductibles to allow for
coinsurance.
• Preventive services and vaccines are excluded from
coinsurance calculation.
• Settlement equals Medicare’s share of cost less interim
payments received, plus Medicare bad debts claimed.
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Reimbursement Settlement
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Helpful Hints
© Wipfli LLP
Helpful Hints
• Collect as much data as possible on an ongoing basis.
• Set up accounting procedures to collect as much financial data
in the form and level of detail required for year-end reporting.
Use the cost report forms for reference.
• Determine early if the clinic will need to collect special data for
the cost report (i.e., related-party expense).
• Be consistent from year to year.
• Use the PS&R report provided by the intermediary to report
Medicare visits, deductibles, and payments.
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Helpful Hints
• Send adequate documentation to support information on the
cost report.
− Injection logs
− Bad debt logs
− Working trial balance
− CMS 339 questionnaire
− Workpapers to explain reclasses on W/S A-1 and
adjustments on W/S A-2
• Review the cost report for reasonableness (i.e., $300 cost per
pneumococcal injection is not reasonable).
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Contact Information
Jeff Bramschreiber, CPA
Partner, Health Care Practice
469 Security Boulevard, Green Bay, WI 54313
920.662.2822
[email protected]
www.wipfli.com/healthcare
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www.wipfli.com/healthcare
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LUNCH
On Your Own
Check out restaurant in the Hyatt
or on the Riverwalk
Sessions resume at 1:15 p.m.