Medical Therapy Billing

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Medical Therapy Billing Powered By Docstoc
					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
Billing Topics
Intermediaries and Carriers Replaced by
Mental Health Co-pays are reduced over
           the next 4 years.
    IPPE and AAA Billing Instructions

          Diabetes and Medical
           Nutritional therapy

     Goals and Objectives
To identify tools to
help you bill RHC
To     give     you
direction       and
understanding of
the process.
 Follow the Golden Rule
He who has the Gold
makes the rules. The
MAC implements
Medicare payment

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
   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

      RHC Billing and RBRVS is
         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

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
   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.
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.

   Mental health limitation is phased out
effective 1/1/2010 per a Memorandum dated
  •   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.
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.

 Diabetes and Medical Nutritional

            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.

  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…

    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.
     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

        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
Medicare Withhold          Amount that Medicare computed as what      ($80.00)
                           should have been received minus
                           collection of deductible

    Let’s Review some
    billing information

There is not much guidance now that
         Riverbend is gone.
   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
           3. Is provided by the appropriately
              trained provider within their scope of
    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.”

         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.

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].
   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.

     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.

         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.

        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

    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
   •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.

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.

            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

    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

 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.

    Attributes of “Incident to”

   Physician must see patient for the first visit
   Physician must be in office suite at time of
   Physician must have ongoing supervision of
    patient (some people use one of every three
   Physician must have employment
    relationship with provider.

      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
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.

 Four Attributes of an “Incident To” Visit
• Physician must see patient for the first
• Physician must be in office suite at time of
• Physician must have ongoing supervision
  of patient (some people use one of every
  three visits)
• Physician must have employment
  relationship with provider.
  Types of Service

Choose Wisely-This is the
key to billing correctly

Why is there so much confusion
   regarding RHC Billing?

RHC’s can provide three
different types of services to
Medicare Patients


  RHC      Non-RHC Non-Covered
 RHC Services   Non-RHC
Office          Hospital
Home            NH
NH              Technical
Flu             components.   40
Medicare does not cover

    Pharmacy (self-injectible)
    Not Medically Necessary
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

      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
Codes! Codes! Codes! Codes!
   1500 Form             UB-04
 Modifiers          Value, Condition, &
 Place of Service    Provider Number

 CPT-4.               Revenue Code

      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
   CODE                  FORM

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
             have a                  insurance
             date.                   denied 24

  CODE                    FORM

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 &

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Description: Medical Therapy Billing document sample