Norris - NGS Presentation by wuyunyi


									  Indiana Rural Health
Association Fall Workshop
   Rural Health Clinics
                October 1, 2008

National Government Services, Inc. has produced this material as
an informational reference for providers furnishing services in our
contract jurisdiction. National Government Services employees,
agents, and staff make no representation, warranty, or guarantee that
this compilation of Medicare information is error-free and will bear
no responsibility or liability for the results or consequences of the
use of this material. Although every reasonable effort has been made
to assure the accuracy of the information within these pages at the
time of publication, the Medicare program is constantly changing,
and it is the responsibility of each provider to remain abreast of the
Medicare program requirements. Any regulations, policies and/or
guidelines cited in this publication are subject to change without
further notice. Current Medicare regulations can be found on the
Centers for Medicare & Medicaid Services (CMS) Web site at

CFR    Code of Federal Regulations
CMS    Centers for Medicare & Medicaid Services
CNM    Certified Nurse Midwives1
CP     Clinical Psychologist
CSW    Clinical Social Worker
CWF    Common Working File
DSMT   Diabetic Self Management Training
FI     Fiscal Intermediary
FQHC   Federally Qualified Health Clinic or
HCPCS HCFA Common Procedure Coding System
ICF   Intermediate Care Facility
IOM   On line manual
IPPE    Initial Physical Preventative Exam
MHTL    Mental Health Limitation
NGS     National Government Services
NP      Nurse Practitioner
NF      Nursing Facility
PA      Physician Assistant
R&N     Reasonable & Necessary
RHC     Rural Health Clinic
SNF     Skilled Nursing Facility
SSA     Social Security Administration
UB-04   Universal Billing Form

• Cover RHC criteria and covered services
• Documentation Requirements
• To provide the basic requirements for billing
  RHC Clinic services to Medicare and
  payment calculations
         RHC Background

• Rural health clinics are located in areas
  designated both by the Bureau of the Census
  as rural and by the Secretary of the
  Department of Health and Human Services as
  medically underserved population
• There is an insufficient number or shortage
  of needed health care practitioners in the
  RHC setting
      Face to Face Encounter
• A face to face encounter in an outpatient
  setting between a patient and a RHC Core
• An encounter between a clinical psychologist
  or clinical social worker and a family member
  only is not billable
• Encounters with more than one health
  professional and multiple encounters with the
  same health professional which take place on
  the same day and location is billed as one
      Face to Face Encounter

Exceptions to 1 encounter per day rule
• If the patient leaves and later returns the
  same day with a different illness or
  impairment requiring additional diagnosis or
  treatment (medical records must support
  this), or
• The patient has a medical visit and a mental
  health visit on the same day (CP or CSW)
       Covered RHC Services

• Physician services
   – Professional services that include diagnosis,
     therapy,surgery, and consultation
   – Physician services performed at the clinic
     are payable only to clinic or center
   – Physician services away from the clinic are
     covered services e.g., (patient’s home)
 Covered RHC Services/Drugs

• Covered drugs are furnished by, and incident
  to, services of physicians and nonphysician
  practitioners of the RHC

  IOM Publication 100-2, Chapter 15, Section 50
 Covered RHC Services/Drugs

• Services and supplies incident to a
  physician’s professional services are covered
  if they are:
   – Furnished as an incidental, but integral
      part of a physician’s professional services
   – A type commonly rendered either without
      charge or included in the RHC bill
    NP, CNM and PA Services
• Services are covered if:
   – Furnished by an employee of the clinic or
     an individual who receives compensation
     from the clinic
   – General (or direct, if State Law requires)
     medical supervision of a physician
   – Furnished in accordance with clinic
     policies and any physician medical orders
     for the care and treatment of a patient
   NP, CNM, and PA Services

• Practitioners who furnish the service must be
  legally permitted by state law to perform
  them in the state in which the service is
• Must be of a type that would be covered
  under Medicare if performed by a physician
     Services and Supplies
  Incident to NP, CNM, or PA
• To be covered as RHC service/supply must
  – Type commonly found in a physician office
  – Type commonly rendered without charge or
    included in the RHC bill
  – Furnished as a incidental, but integral part of the
    professional services offered
  – Furnished under direct supervision of a NP, PA,
    or CNM, and
  – In cases of services, furnished by a member of the
    clinic’s staff who is an employee of the clinic
   Diabetes Self-Management
        Training (DSMT)

• RHCs can become certified providers of DSMT
• Report cost of such services on their cost report
   – Inclusion in computation of all-inclusive rate
• Considered incident to services and do not constitute
  an RHC visit

   IOM Publication 100-4, Chapter 9, Section 181
   IOM Publication 100-2, Chapter 15, section 300.2
      Visiting Nurse Services

• Visiting nurse services are covered as RHC service if:
   – RHC is located in a home health shortage area as
     determined by CMS
   – Patient is homebound
   – Patient is furnished part time or intermittent
     nursing care by a registered nurse, licensed
     practical nurse or licensed vocational nurse who is
     employed by the RHC
   – Services are furnished under a written plan of
       Clinical Psychologist (CP)
           Covered Services
• CPs may provide the following services:
  – Diagnostic & therapeutic services that the CPs is
    legally authorized to perform in accordance with
    state law and regulation
  – Services/supplies furnished incident to CPs
    services (requirements that apply to services
    incident to a physician’s service) are met and
    furnished by an employee of the RHC
     Clinical Psychologist (CP)
         Covered Services
• To be covered the services/supplies must be:
  – Mental health services that are commonly
    furnished in CPs’ offices
  – An integral, although incidental, part of
    professional services performed by CP, and
  – Performed under the direct supervision of the
     • Must be physically present and immediately available
              CSW Services
• Covered CSW services are:
  – The type of services that are otherwise
    covered if furnished by a physician, or
    incident to a physician’s service;
  – Performed by a person who meets the
    definition of a CSW; and
  – Not otherwise excluded from coverage
  Non covered RHC Services

• If services are excluded from Medicare they
  are not covered:
  – State laws do not supercede this rule
  – Services perform at the clinic or away from
    the clinic are payable to the clinic. Services
    must be billed to the fiscal intermediary
        Telehealth Services
• Originating Site is the location of the
  beneficiary and is payable in a RHC
• Must be located in in a rural HPSA or non-
  metropolitan statistical area county
• Covered services are outlined in Publication
  100-2, Benefit Policy Manual, Chapter 15,
  Section 270.2
 Documentation requirements
• Must be legible
•Practitioner’s credentials must be clear to
 identify as a core practitioner
•Beneficiary name present on documentation
•A core practitioner co-signing a note of a non
 billable service is not considered proof that a
 face to face encounter occurred.
          Preventive Services

• Professional components of preventive
  services are part of the overall encounter
• Associated technical component billed on
  other type of claims
• Vaccines are not reported separately
  – Influenza virus or PPV
  – Included on cost report
• Hepatitis vaccine reimbursed thru cost report
  – Not paid at 100%
    Initial Physical Preventive
• Payment for professional services will be
  made under the all-inclusive rate
• Beneficiary CWF records will not be updated
  to reflect the IPPE exam when it is provided
  in an RHC
• Provider-based RHC bill the technical
  component of the EKG through your main
• Bill G0344 with revenue code 52x
RHC Services for Hospital

• Inpatients and outpatients of a
  hospital are not payable to the
• When an agreement exist that
  specifically doesn’t compensate
  the practitioner for hospital
  services, payment may be sought
  under Part B of Medicare
RHC Services for Skilled
 Nursing Facility (SNF )

• SNF’s Part A resident receives services
  of a physician from an RHC are
  excluded from consolidated billing
   – Effective 01-01-05
 Services Provided by Clinics
 Which are Non RHC Services
• Leg, arm, back and neck braces
• Artificial legs, arms and eyes, including
  replacements if required due to change in
  physical condition
• Services provided in a hospital setting

 Note: These charges should never be on the RHC
 claim because they are covered under a different
 benefit category/ payment method
  Services Provided by Clinics
  Which are Non RHC Services
• Technical component of the following
  preventative services:
  –   Prostate cancer screening
  –   Colorectal cancer screening tests
  –   Screening mammography
  –   Bone mass measurements
  –   Glaucoma screening
  –   screening pap smears and pelvic examinations
       Laboratory Services

• Provider Based RHC providers should bill
  laboratory services through their main
• The technical component of RHC labs are not
  considered RHC services
RHC Billing
 Deductible and Coinsurance

• The Part B deductible is applied to RHC
• The beneficiary is responsible for 20 percent
  of billed charges
  Bill Type and Revenue Codes

• Bill type for RHC is 711
• Revenue codes are:
  – 0900- Psychological services
     • Use this code for services provided by a
       psychologist and clinical social worker for
       treatment of mental illness of a patient
RHC Site of Service Revenue
  Codes Effective 7-01-06

• 0521- Clinic visit by member to RHC
• 0522- Home visit by RHC practitioner
• 0524- Visit by RHC practitioner to a
 member in a covered Part A stay at the
RHC Site of Service Revenue
• 0525- Visit by RHC practitioner to a
  member in a SNF (no Part A stay) or NF
  or ICF or other residential facility
• 0527- RHC Visiting Nurse Service(s) to a
  member’s home when in a home health
  shortage area
• 0528- Visit by RHC practitioner to other
  non RHC site (e.g., scene of accident)

  Reference CR 4210 dated February 1, 2006
        Telehealth Services

• 0780 - Telehealth services effective April 1,
• Q3014 – Facility fee
• Only one encounter (and Telehealth service)
  will be accepted on a claim per day effective
  April 4, 2005
      Billing Manual References

• Publication 100-4, Medicare Claims
  Processing Manual
  –   Chapter 1 General Billing Requirements
  –   Chapter 2 Admission/Registration Requirements
  –   Chapter 9 RHC & FQHC Manual
  –   Chapter 18 Preventive and Screening Services
  –   Chapter 25 UB04 Claim Completion
• RHCs do not bill for influenza and
  Pneumococcal vaccines on the UB-04
• Vaccines and administration is included at
  cost report time
• Hepatitis B vaccine is included at cost
  report time
• No line item specifying the vaccine s/b
  listed on the claim

  IOM Publication 100-4, Chapter 9, Section 120
      Coverable Not Billable Details
• There are RHC services that on their own do not
  generate a RHC encounter
• However, these charges can be added to those
  of the appropriate (previous or subsequent)
• The date of the face to face encounter would be
  used as the single date on the line item billed as
  one unit
• These allowable costs would affect the
  provider’s future all inclusive payment rate
      Payment Calculations

• Medical Encounter Provider Payment
  –(Medicare Primary Payer)
  To Calculate
  Provider payment is equal to the number of visits
  times the provider’s all-inclusive payment rate times
  80 percent. Each provider has its own specific
  encounter rate
  For example:
  1 visit x 91.03 (encounter rate) x 80% =$72.82
  provider reimbursement
      Payment Calculations

• Mental Health Calculation- coinsurance
  – Multiply charges for revenue code 900 by 62.5% to
    calculate recognized charges
  – Multiply the recognized charges by 20%
     Revenue code 900 charges($50.00)X 62.5% =
     Then take $31.25 X 20% = $6.25
• IOM Publication 100-2, Chapter 13
• IOM Publication 100-4, Chapter 9
• Code of Federal Regulations 42CFR Sec
  405.2400 -405.2472
• SSA 1861(aa), SSA 1861(r)

• Website addresses:
     •Access transmittals
     •Provider Updates and CMS forms

• Key features
  ₋ Personalized portal pages
  ₋ Searchable Frequently Asked Questions
  ₋ Events Calendar

• Navigational tools
  ⁻ Site Tutorial
  ⁻ Site Map

    NGS Part A Customer Care

• Effective February 1, 2008
• Automated Interactive Voice Response
  (IVR) Inquiries
  – Illinois              1-877-309-4290
  – Indiana               1-866-419-9462
  – Kentucky/Ohio         1-866-289-6501

  * IVR Guide Available on website

     NGS Part A Customer Care

• Customer Care Inquiries
  – Illinois                    1-877-702-0990
  – Indiana                     1-866-758-3856
  – Kentucky/Ohio               1-866-590-6703

  * If a call is placed to Customer Care number with an issue
    that should be addressed via the IVR, the call will be
    referred back to the IVR line

           Written Inquires

• Written Correspondence
  National Government Services, Inc.
  P.O. Box 7191
  Indianapolis, Indiana 46207-7191
• Written Correspondence form available on
  the website for all lines of business
  – Part A, Part B and DME MAC

 Thank You

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