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Medical Therapy Billing document sample
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RHC Update Seminar - Billing
Spring, 2010
A copy of this
presentation is
on our website.
Mark R. Lynn
RHC Consultant
Healthcare Business Specialists
Suite 214, 502 Shadow Parkway
Chattanooga, Tennessee 37421
Telephone: (423) 899-0945
Fax: (800) 268-5055
Email: la_vita_nouva@hotmail.com
Website: www.ruralhealthclinic.com
2
Billing Topics
Intermediaries and Carriers Replaced by
MACs
Mental Health Co-pays are reduced over
the next 4 years.
IPPE and AAA Billing Instructions
Diabetes and Medical
Nutritional therapy
3
Goals and Objectives
To identify tools to
help you bill RHC
services.
To give you
direction and
understanding of
the process.
4
Follow the Golden Rule
He who has the Gold
makes the rules. The
MAC implements
Medicare payment
policies
5
Do RHC regulations apply
to all payer types?
• No. These rules just
apply to Medicare.
• Medicaid follows it’s
own billing rules.
• Commercial insurance
is not affected by RHC
status.
6
You Can’t Teach an Old Dog
New Tricks
• One of the problems
with the RHC program
is that you have to
unlearn things you
have known since
1966.
7
RHC Billing and RBRVS is
Different
RHC RBRVS
Copays are 20% of Medicare
Charges Allowables Only
RHC visit and Hospital Visit Only Hospital Admission
on same day (maybe) is Billable
99211 Nurse only 99211 Nurse visit is
visit is not billable billable
Injection/allergy only is Injection/allergy only is
not billable by itself billabe
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Recent Billing Guidance from Medicare
There are 15 Jurisdictions
and 12 different MACs
If you are an AL, GA, or TN RHC both
your Part A (cost-based) and Part B
(fee for service) will be processed by
Cahaba.
If you are an out-of-jurisdiction
provider (an RHC located in a state
other than AL, GA, TN) then your Part B
(fee for service) claims will be
processed by your local MAC.
If you are a new RHC apply to your
MAC that is assigned for your region.
10
Section 911 of the Medicare Prescription
Drug Improvement and Modernization Act
of 2003 reforms Medicare Contracting
On January 7, 2009, Cahaba Government
Benefits Administrator was awarded the
Jurisdiction 10 A/B MAC contract for
Alabama, Georgia, and Tennessee.
Effective August 3, 2009 Cahaba started
processing RHC claims for all
independent RHCs that had been
processed by Riverbend GBA.
11
Mental health limitation is phased out
effective 1/1/2010 per a Memorandum dated
10/30/2009:
• 2009 62.5%
• 2010 68.75%
• 2012 75.00%
• 2013 81.25%
• 2014 100%
• This will make providing mental
health services more attractive for
rural health clinics in the future.
12
Changes to IPPE (Deductible is waived)
Initial Effective 1/1/2009: Use revenue
Preventive code 052X and HCPCS code
Physician G0402 for professional
Exam component of examination. RHC
(IPPE) Deductible is waived for the
exam; however, coinsurance is
still applicable.
13
Diabetes and Medical Nutritional
Therapy
Diabetes self-management training
Diabetes and medical nutritional therapy are
and not RHC services.
Medical Report these services on the cost
Nutritional report as it is included in the
Therapy computation of the all-inclusive rate.
Do not submit claims with G0108 or
G0109 HCPCS Codes.
14
Medicare will no longer recognize
consultation codes (1/1/2010)
• CMS directs providers to report other
evaluation management (E/M) codes
in lieu of the consultation codes.
• In place of the consultation codes,
CMS increased the work relative value
units (RVUs) for new and established
office visits, increased the work RVUs
for initial hospital and initial nursing
facility visits…
15
Change in E-Prescribing
To obtain the additional funding you
must e-prescribe 25 different times and
use G8553 on 25 claims to qualify. You
can not resubmit a claim just to add the
G8553 code and RHCs are not eligible
for these bonus payments. The clinic
must have 10% of its patients from
primary care.
Previously, a physician practice had to
have at least 75% of its visits e-
prescribed before it qualified for the
bonus; so it will now be much easier to
qualify for these payments.
16
Negative Reimbursement
Cahaba and all MACs are instructed to
withhold payments from RHCs and
physicians (Part B) if the Medicare
deductible is in excess of the reimbursement
rate. For example, if your charge is $155 (the
current Medicare deductible) and your RHC
reimbursement rate is $77.76 (the current
maximum independent RHC cost per visit),
Medicare will not pay you and withhold an
extra $77.24 from your remittance whether
or not you collect the deductible up front or
not.
17
An Example of how Negative
Reimbursement Works
Description Computation Amount
RHC Charge Per Chargemaster $200
Collection from patient Medicare Deductible - 2010 $155
Medicare Rate Determined by Cost Report. $75
Maximum for independent RHC is $77.76
In 2010. (provider-based may get more)
Medicare Net Payment 80% of $75 $60
Co-payment 20% times $200 $40
Medicare computes what You can not receive more than your $75
you should have received
rate.
Medicare Withhold Amount that Medicare computed as what ($80.00)
should have been received minus
collection of deductible
18
Let’s Review some
billing information
There is not much guidance now that
Riverbend is gone.
19
What is a visit in a rural health clinic?
1. Is a face to face encounter with a
physician, nurse practitioner, PA, NP,
Has or Nurse midwife (See Exceptions)
Three 2. There is a medically necessary service
provided (should reach the level of a
Components
99212)
3. Is provided by the appropriately
trained provider within their scope of
practice.
20
Quote from the Riverbend LMRP
“Services that do not medically
require active physician/extender
involvement during any given trip to
the facility lack medical necessity
for a face-to-face encounter even
though the services themselves may
well be medically necessary
ancillary or incidental services.”
21
More than one visit per day
Encounters Encounters with more than one health
That take professional which take place on the
place with same day and at a single location
more than constitute a single visit except:
one health A) after the first encounter, the patient
professional suffers illness or injury requiring
Updated additional diagnosis or treatment
Explanation B) the patient has a medical visit and a
clinical psychologist or clinical social
worker visit.
22
Quote from the Riverbend LMRP
In addition to billing constraints
described in the companion article,
multiple encounters on the same day are
not medically necessary except in the
unusual instance in which a patient
acutely develops a new condition or
complication that medically necessitates
a second evaluation on that same day [42
CFR 405.2463(a)(3) and Pub 100-04, Chpt
9, sect 40.4].
23
Exceptions to the one visit
per day rule
1. An encounter in addition to the payment for the IPPE
visit may be appropriate.
2. A medical visit and psychiatric visit on the same day
(Revenue Code 900) are allowable.
3. More than one clinical visit in one day is allowed if
appropriate. (See new guidance in Chapter 9 of RHC
billing guide.)
4. Some states allow an EPSDT (wellness) screen and a
medical visit on the same day. Check with Medicaid.
24
Can you bill a hospital visit and an
office visit on the same day?
Riverbend was adamant that you
could bill both; however, many of the
MACs reject the claims. Nothing
clear from Cabaha on this yet. I have
heard they reject the claims and I
have heard they pay them. Follow
the Golden Rule on this one.
25
Exceptions to the
Provider/Visit rule
Only a physician, 1.LCSW or CSW for a psych
NP, PA or Nurse or social worker visit
Midwives must 2. Visiting nurse if approved by
have a face to CMS
face for a visit to 3. Telemedicine visit
be billable.
26
Exception to the visit
location rule
Visit must occur in the A visit may occur at the
clinic or patients home scene of an accident.
(home includes SNF, (Revenue Code 0528)
NF, or assisted living
facility)
27
Guidance on Nursing Home Visits
A visit to a beneficiary in a skilled SNF bed or a
swing bed is medically necessary on a monthly
basis to evaluate the patient status as it relates to
the skilled service.
•A visit to a beneficiary in a non-skilled bed,
intermediate care facility or nursing home is not
medically necessary on a routine basis even if the
nursing facility requires it as a condition of patient
residence.
•A visit to a patient in a non-skilled bed, ICF or
nursing home will be considered medically
necessary if it has been approximately 60 days (for
the purposes of medical review at least six weeks)
since the last visit.
28
Exceptions to the rules related
to Preventive Services
Do not apply the deductible to the
Part B deductible Initial Preventive Physical Exams
applies to RHC (IPPE) (G0402) or the Abdominal
services. Aortic Aneurysm (AAA)
Ultrasound Screening (G0389)
Do not place HCPCS For preventive services that are
Codes on the UB- subject to frequency limitations
04 form. HCPCS coding is required.
29
Revenue Codes
0521 -Free-standing clinic-RHC
0522 -Free-standing clinic-RHC - home
0524 -Visit by RHC practitioner to a
member in a covered Part A stay at the SNF
0525 -Visit by RHC practitioner to a
member in a SNF (not in a covered Part A
stay) or NF or ICF MR or other residential
facility
30
Revenue Codes (continued)
•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 (scene of accident)
•0900 -Psychiatric/psychological
treatments-general classification
31
Are Rural Health Clinics subject to
“incident to” regulations?
• Yes and No. NP/PA
services do not have to
meet the “incident to”
regulations while RN’s
and other service
providers are subject to
incident to guidelines.
32
Attributes of “Incident to”
Billing
Physician must see patient for the first visit
Physician must be in office suite at time of
visit
Physician must have ongoing supervision of
patient (some people use one of every three
visits)
Physician must have employment
relationship with provider.
33
What is the impact of
“incident to” billing
In a Part B practice (not a RHC) if
“incident to” guidelines are meet
the visit can be billed under the
physician provider number and is
paid at 100% of the fee schedule.
If not, it is paid using the PA/NP
NPI and paid at 85% of the fee
schedule.
34
What about a hospital surgery that was
billed globally to Part B?
As a rural health clinic, you bill
the procedure only for procedures
in the hospital and bill the RHC
visits; however, if you did bill
globally to Part B do not bill visits
occurring within the global period.
35
Four Attributes of an “Incident To” Visit
• Physician must see patient for the first
visit
• Physician must be in office suite at time of
visit
• Physician must have ongoing supervision
of patient (some people use one of every
three visits)
• Physician must have employment
relationship with provider.
36
Types of Service
Choose Wisely-This is the
key to billing correctly
37
Why is there so much confusion
regarding RHC Billing?
38
RHC’s can provide three
different types of services to
Medicare Patients
Medicare
RHC Non-RHC Non-Covered
Services
39
Medicare
RHC Services Non-RHC
Laboratory
Office Hospital
Home NH
NH Technical
Flu components. 40
Medicare does not cover
Physicals
ABN’s
Pharmacy (self-injectible)
Not Medically Necessary
41
The difference between Revenue
Codes and CPT Codes
Revenue Code CPT-4 Code
No Specific Value – Each RBRVS code has a
used to summarize specific value
different inputs
No specific service Each code has a
identified specific description of
the service rendered
42
Completing the UB-04
Description Information
What Revenue Codes
Who HIC Name & Number
When Date of Service (do
not span bill
Where Provider Number
Who did it? NPI Number
Why ICD-9/10 Codes
43
Codes! Codes! Codes! Codes!
1500 Form UB-04
Modifiers Value, Condition, &
Occurrence
Place of Service Provider Number
CPT-4. Revenue Code
44
Bill Type Codes for UB-04’s
• Description of Bill Type Number
• First Service to Last Service 711
• Interim - first claim 712
• Interim - continuing claim 713
• Interim - last claim 714
• Late Charge 715
• Adjustment 717
• VOID/CANCEL 718
• Request for a Denial 710
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TYPE OF PURPOSE UB-04 EXAMPLES
CODE FORM
LOCATOR
Condition Why is the 24-30 Employment
claim related -02
secondary Hospice
patient - 07
Occurance When is 32-35 Accident/Medi
claim cal Cov - 01
secondary? Accident/Tort
Must - 03
Date
have a insurance
date. denied 24
46
TYPE OF PURPOSE UB-04 EXAMPLES
CODE FORM
LOCATOR
Value How much of 39-41 Medicare
the claim is Coinsurance
secondary? 09
Must have
an amount.
Revenue What was 42 Totals
provided? 001 units &
charges
47
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