RHC Manager 101 - Rural health clinic · Direct Services –51% Primary Care An RHC is required to...

RHC Manager 101

Teresa TreiberManager – Rural Health Team

Spectrum Health

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RHC Manager 101

Objectives:

o Learn some basics that all practice managers need to know to

run a successful RHC

o High-level overview of major differences when managing an RHC

o Discuss tools to help maintain RHC compliance

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RHC Manager 101

What is an RHC?

Rural Health Clinics (RHCs) 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) for medically-necessary primary health services, and qualified preventive health services, furnished by an RHC practitioner.

(Medicare Benefit Policy Manual. Chapter 13. Section 10.1.)

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RHC Manager 101

Staffing

42 CFR 491.8(a)(6) states that a RHC shall have a physician, nurse practitioner, physician assistant, nurse-midwife, clinical social worker, or clinical psychologist available to furnish patient care services at all times the RHC operates.

It further states that at least 50 percent of the time the RHC operates a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services.

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RHC Manager 101

Direct Services – 51% Primary Care

An RHC is required to be primarily engaged in providing outpatient or ambulatory health care services. In accordance with §§ 405.2411 - 2416, RHC services include the services of physicians, NPs, PAs, certified nurse midwives, clinical psychologists and clinical social workers, along with the services and supplies that are incident to these practitioners’ services.

RHCs are not prohibited from furnishing other services, however, they may

not be primarily engaged in providing such specialized services. In the context of an RHC, “primarily engaged” is determined by considering the total hours of an RHC’s operation, and whether a majority, i.e., more than 50 percent, of those hours involve provision of RHC services.

Interpretative Guidelines § 491.9(a)(2) & (c)(1)

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RHC Manager 101

42 CFR 491.8(a)(6) states that a RHC shall have a physician, nurse practitioner, physician assistant, nurse-midwife, clinical social worker, or clinical psychologist available to furnish patient care services at all times the RHC operates.

RHCs may allow beneficiary entry to the waiting room or other non-patient care areas to handle

billing inquiries or to get out of the weather when the mid-level practitioner as defined in §493.2, clinical social worker, clinical psychologist or physician member of the staff is not present under the following circumstances:

An RHC that opens its premises solely to address administrative matters (including allowing patients entry into the building to get out of inclement weather) is not considered to be in operation as an RHC during this period.

CMS emphasizes that no health care services shall be provided until a mid-level practitioner as defined in §493.2, clinical social worker, clinical psychologist or physician staff member is present to provide services.

CMS issues letter to State Surveyors Ref: S&C-07-06

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RHC Manager 101

Process to become a Rural Health Clinic – High level overview

Process can take 8-12 months depending on multiple factors.

1. Initial Application

- Multiple Federal and State forms

2. Site Survey

- Completed by state or by deeming agency

3. Finalization of application

- Assignment of PTAN

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RHC Manager 101

Types of RHC’s

Independent RHC - are stand-alone or freestanding clinics.

Provider-based RHC – is an integral and subordinate part of a hospital. It is very important to understand that provider-based RHC’s are NOThospital departments. They are considered a provider-based entity of the hospital. The RHC bills under the hospital tax ID but is assigned it’s own unique PTAN/CCN number.

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RHC Manager 101

Cost Report

o Must be filed annually

o Determines the cost-per-visit and the all-inclusive payment rates.

o Reconciles Medicare’s interim payment method to actual cost per visit.

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RHC Manager 101

Billing and Reimbursement

An RHC encounter is a medically-necessary visit with an eligible RHC provider (MD,DO,NP,PA,CNM,LCSW,Pyschologists)

RHC’ are paid at an all-inclusive-rate for each billable visit. Rates are established via the cost report based on the formula

Allowable costs /total visits=Rate

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RHC Manager 101


Independent RHC’s and Provider-based RHC’s owned by a hospital with over 50 beds have a capped rate-per-visit of $83.45

Provider-based RHC’s owned by a hospital with less than 50 beds have an uncapped rate-per-visit.

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RHC Manager 101


Medicare RHC visits are billed on a UB-04 claim form

Medicaid RHC visits billing form depends on each state’s rules.

All other commercial claims are billed on a 1500 claim form.

Claims are billed to the Part A MAC and paid under the patients Part B benefit.

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RHC Manager 101


POC lab and technical charges are billed differently depending on the type of RHC.

Independent – billed separately on a 1500 claim form and reimbursed FFS.

Provider-based – billed by parent hospital as an outpatient service.

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RHC Manager 101

Compliance

New RHC applicants are expected to have all RHC requirements implemented at the time the surveyor presents at the clinic.

Established RHC clinics are expected to follow and maintain RHC regulations at all times.

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RHC Manager 101

Certification/Recertification

Certification is the initial application process to become a RHC.Recertification is the continual review of compliance that the clinic is functioning under federal regulations as a RHC.

Both require an on-site inspection by the state or deeming agency. Both visits are unannounced.

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RHC Manager 101

Certification/Recertification site visit

Condition vs Standard

Standards are the clinic operating processes. You may receive deficiencies in Standards such as expired medications or supplies…etc.

Conditions are severe deficiencies. This type of deficiency can result in having to start the application process over for new clinics and losing your RHC status for existing clinics. Examples include items such as -APP not meeting the 50% requirement, policy review not current or annual advisory meeting/program evaluation is not current.

RHC Manager 101

Laboratory

The RHC provides laboratory services in accordance with part 493 of this chapter, which implements the provisions of section 353 of the Public Health Service Act. The RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including:

(i) Chemical examinations of urine by stick or tablet method or both (including urine ketones);

(ii) Hemoglobin or hematocrit;(iii) Blood glucose;

(iv) Examination of stool specimens for occult blood;(v) Pregnancy tests; and

(vi) Primary culturing for transmittal to a certified laboratory.

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RHC Manager 101

Emergency Preparedness –

§ 491.12 Emergency preparedness.

The Rural Health Clinic/Federally Qualified Health Center (RHC/FQHC) must comply with all applicable Federal, State, and local emergency preparedness requirements. The RHC/FQHC must establish and maintain an emergency preparedness program that meets the requirements of this section.

Please review the full list of requirements in CFR 491.12

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RHC Manager 101

§491.11 Program evaluation.

(a) The clinic or center carries out, or arranges for, an annual evaluation of its total program.

(b) The evaluation includes review of:

(1) The utilization of clinic or center services, including at least the number of patients served and the volume of services;

(2) A representative sample of both active and closed clinical records; and

(3) The clinic's or center's health care policies.

(c) The purpose of the evaluation is to determine whether:

(1) The utilization of services was appropriate;

(2) The established policies were followed; and

(3) Any changes are needed.

(d) The clinic or center staff considers the findings of the evaluation and takes corrective action if necessary

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RHC Manager 101

§491.9 Patient Care Policies.

(1) The clinic's or center's health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.

(2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic or center staff.

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RHC Manager 101

RHC Policy and Procedure Manual

(3) The policies include:

(i) A description of the services the clinic or center furnishes directly and those furnished through agreement or arrangement.

(ii) Guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic or center.

(iii) Rules for the storage, handling, and administration of drugs and biologicals.

(4) These policies are reviewed at least annually by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary by the clinic or center.

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RHC Manager 101

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Best Practice

Creating an “Evidence Binder” is recommended.

This binder will house all of your supporting documentation and is your evidence of compliance during a survey.

This will help your survey to be successful and flow smoothly.

Keep the information updated!

Identify key staff who know where this binder is located in the event a surveyor arrives for a survey and the practice manager is not available.

RHC Manager 101

Evidence Binder – recommended list

o Providers State License and DEA

o Health Service Statement – this states the Hours of Operation, and what services the clinic provides, as well as the POC Labs

o Collaboration agreements and prescriptive authority agreements are signed and up to date – annually.

o Yearly electrical inspection report by Bio-Medical Dept

o Fire, evacuation, tornado, EP training logs

o Documented annual training and competency for all staff

o Copy of current organizational chart

o List of current staff, clinical and clerical with job descriptions

o Housekeeping logs

o Current advisory meeting notes/presentation

o Clinical staff BLS certifications

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RHC Manager 101

Additional items that can be housed in the Evidence Binder or a separate binder created for tracking logs

o sample medication Logs

o Medications, biological and sterile supplies checked monthly for expiration dates

o Lab supplies and reagents monthly inventory

o Tracking labs that are referred out

o Patient's rooms checked monthly Log

o Copies of provider-APP chart reviews

A separate hard-copy SDS (safety data sheet) binder should also be available and up to date.

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RHC Manager 101 – RHC Tools

It is recommended that you periodically complete a mock survey assessment to ensure continued compliance.

RHC’s are expected to maintain RHC compliance at ALL TIMES.

**use of the following tools are not required. They are recommended for use to help ensure RHC compliance and identify areas of risk. Links to all of these tools are available to you in your conference material and can be modified to fit your needs.

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Mock Survey/Rounding Tools

This mock survey tool is broken down in the following categories:

➢ Environment of Care

➢ Life Safety

➢ Infection Prevention

➢ Sterilization

➢ POC Testing

➢ Emergency Preparedness

➢ Administration

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RHC MONTHLY QUALITY, SAFETY and INFECTION PREVENTION ROUNDING TOOL • IF "NO" IS MARKED FOR ANY ANSWER, THE ACTION TAKEN AND OTHER COMMENTS MUST BE DOCUMENTED

• TCT = The Compliance Team RHC Deeming Agency

Standard

Rationale

Yes No* N/A

Action Taken/Comments and

Initials

Environment of Care

2

Is general appearance and are all surfaces clean,

uncluttered, and intact? (This includes furniture, walls,

flooring and high areas; look for tears in furniture, peeling

floors, holes in walls/chipped paint, decals peeling, scuffs

on floors/walls, peeling/chipped laminate)

TCT ADM 11.0; CFR 491.6(b)(3)

3 Housekeeping logs are being maintained. TCT ADM 11.0 CFR491.6(b)(1)

4

Is lighting suitable for care, treatment, or services? (This

includes emergency/exit lighting, includes shatterproof

lightbulbs in gooseneck lamps or cover)

TCT REG 1.0

6Is there at least 36 inches of clear space (no obstruction)

in front of all electrical panels? TCT EQP 1.0

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Are tanks of compressed gasses (oxygen, etc.) properly

labeled and secured in holders or chained to the wall?

(labeled "full-ready for patient use" or "empty", storage

clearly separated between full and empty, ambu-bag-

valve-mask ventilation supplies attached to tank, any

used tanks to be considered empty)

TCT EQP 1.0; Adm 10.0 CFR

491.9(c)(3)

8Is staff aware on how to access the SDS Vault in the

event of a chemical spill?TCT REG 2.C


Compliance Rounding Tools

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Date of review:

Reviewed by :

Exam Rooms and Procedure Rooms Medication/nurse area

1. room logs being utilized? 31. signage on fridge - do not unplug, meds only..etc.

2. expired meds/supplies? 32. power outage procedure on door of imms

3. plug protectors? 33. anything stored in doors of fridges?

4. closed trash containers? 34. schedule II drugs are double locked and logged separately?

5. holes or spots in walls that need repair? 35. allergy meds monitored separately for expiration?

6. locks on cabinets as necessary? 36. oxygen tanks secured

7. anything under sinks? 37. oxygen tanks labeled in use and empty? Cannula ready?

8. vials ointments and solutions dated appropriately? 38. emergency drug box easily accessible?

9. any single use items opened and not discarded? 39. sample meds logged?

10. cleaning products secured? 40. eye wash station checked and logged?

11. drawers and cabinets neatly organized? 41. spill kit?

12. sharps containers mounted and dated appropriately? 42. any safety concerns?

13. splash guards present? 43. any auto clave process concerns?

waiting room and hallways

Patient Bathrooms 44. holes or spots in walls that need repair?

14. emergency notice in bathroom? System tested? 45. plug protectors?

16. any chemicals or air freshener cans in bathrooms? 46. clean?

17. restroom labeled correctly? 47. Any safety concerns?

18. holes or spots in walls that need repair? 48. lock on cleaning supply closet

19. plug protectors? 49. exit signs can be clearly seen and lights functioning?

50. Secondary doors are locked?


Chart Reviews- 2 types

Physician Chart Review

RHC regulations state that a physician must periodically review the records of the RHC. §491.8

The amount of records to review and the frequency is based on your specific state guidelines. If your state does not specify, the surveyor will look to your policy.

You must provide proof of this review that shows both the provider and the APP involvement.

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RHC Manager 101

Surveyor Chart Review

Surveyor will conduct a chart review at time of survey to review the following elements

listed in CFR 491.10

For each patient receiving health care services, the clinic or center maintains a record that includes, as applicable:

(i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;

(ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;

(iii) All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress;

(iv) Signatures of the physician or other health care professional.30

RHC Manager 101 –Chart review tool

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Section 1 to be completed by office manager or designated staff for all providers (Physicians and APP's)

Provider Name:_______________________________________ Quarter of review:

MRN Number 1. 2. 3. 4. 5.

Date of Service

For each patient receiving health care services, the clinic maintains a record that includes, as applicable:

Chief complaint or reason for the encounterP A P A P A P A P A

Pertinent medical history and/or surgical historyP A P A P A P A P A

Known long-term medications, including current medications, over-the-counter drugs, and herbal preparationsP A P A P A P A P A

Social data (i.e.. marital status, habits, occupation, etc.)P A P A P A P A P A

Smoking StatusP NA A P NA A P NA A P NA A P NA A

Family hxP A P A P A P A P A

Known adverse and allergic drug reactions;P A P A P A P A P A

Assessment of the health status, including complete vital signs on all patients every visit starting at age 2:

Pain is assessed in all patients. (A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care,

treatment, and services provided.)

P NA A P NA A P NA A P NA A P NA A

HeightP A P A P A P A P A

WeightP A P A P A P A P A

BP (NA under age 3) P NA A P NA A P NA A P NA A P NA A

BMIP A P A P A P A P A

Report of physical examinationP A P A P A P A P A

Clinical impression or diagnosis; Brief summary of each episodeP A P A P A P A P A

Plan for careP A P A P A P A P A

The problem list is initiated for the patient by the third visits and maintained thereafter.P NA A P NA A P NA A P NA A P NA A

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RHC Manager 101 –Chart review tool

Section 2 ( to be filled out by provider for APP charts only)

Physical Exam Adequate

Diagnosis supported by H & P

Appropriate Us of Lab/Xray

Plan/use of meds appropriate

Plan of care appropriate

Provider signature: Date:

APP signature: Date:

Comments:

RHC Manager 101

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RHC Manager 101

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CMS MLN RHC Fact sheet - https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

National Association of Rural Health Clinics –

https://narhc.org/resources/rhc-rules-and-guidelines/

Medicare Benefit Policy Manual – Chapter 13

www.cms.gov/manuals/downloads/clm104c25.pdf

Appendix Z state operations manual

https://www.cms.gov/Medicare/.../Advanced-Copy-SOM-Appendix-Z-

EP-IGs.pdf

ECFR 491 – https://ecfr.io/Title-39/cfr491

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

https://narhc.org/resources/rhc-rules-and-guidelines/

http://www.cms.gov/manuals/downloads/clm104c25.pdf

https://www.cms.gov/Medicare/.../Advanced-Copy-SOM-Appendix-Z-EP-IGs.pdf

https://ecfr.io/Title-39/cfr491

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RHC Basics & Billing 101Sharon Shover

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Agenda

• What is a Rural Health Clinic?

• What are the requirements to be a RHC?

• Independent vs. Provider-Based RHCs?

Back to the Basics

• What qualifies as a RHC encounter?

• How is RHC billing different?

• How do I bill for RHC services?

RHC Billing

• Tomorrow at 11:00am with Janet Lytton

• TCM, CCM, ACP, Care Management

• In depth into non-RHC Services and incident-to

Taking it to the Next Level

What is a RHC?

Established in 1977 by The Rural Health Clinic Services Act:

• Enacted to address an inadequate supply ofphysicians serving Medicare patients in rural areas.

• Enacted to increase the use of non-physicianpractitioners (NPs and PAs) in rural areas.

What is a RHC?

“Facilities that are engaged primarily in providing services that are typically

furnished in an outpatient clinic.”Section 1861(aa)(2) of the Social Security Act

Currently, there are more that 4000 RHCs nationwide providing primary care and preventive health services to patients in rural and underserved areas.

RHC Participation Requirements – Location

• Must be located in a non-urbanized area(determined by U.S. Census Bureau)

• Must be located in an area designated within thelast 4 years by the Health Resources and ServicesAdministration (HRSA) as one of the followingtypes of Federally designated or certified shortageareas:

1. Primary Care Geographic Health Professional Shortage Area (HPSA)

2. Primary Care Population-Group HPSA3. Medically Underserved Area (MUA)4. Governor-designated and Secretary-certified

shortage area

RHC Participation Requirements – Services

• Have arrangements with one or more hospitals to furnish medically-necessary services that are not available at the RHC

• Have available drugs and biologicals necessary for treatingemergencies

• Services provided must be at least 51% primary care

• Directly furnish routine diagnostic and laboratory testing includingthe following six required laboratory tests on site…

RHC Participation Requirements – Labs

• Six Required Laboratory Tests to Provide On-site:

1. Chemical examination of urine by stick, tablet method,or both

2. Hemoglobin or hematocrit

3. Blood sugar

4. Examination of stool specimens for occult blood

5. Pregnancy tests

6. Primary culturing for transmittal to a certifiedlaboratory

RHC Participation Requirements – Staffing

• Must employee at least one NP or PA

• Have an NP, PA, or CNM working at least 50% of the time the RHC operates

• Note: You can have Specialists in a RHC

RHC Participation Requirements – Miscellaneous

• Must have a quality assessment a performance improvement program (QAPI)

• Must post days and hours of operation

• Cannot be a rehabilitation agency or a facility that is primarily for the treatment of mental disease

• Cannot be a Federally Qualified Health Center (FQHC)

• Must meet other applicable State and Federal requirements

Two types of RHCs:

Independent

(free-standing)

Provider-Based

• Free-standing clinics owned by a provider or a provider entity

• Majority are physician owned

• CMS Certification Number (CCN) Range:• xx3800 – xx3974

• Xx8900 – xx8999

• Receive capped reimbursement rate of $83.45 (CY 2018)

• Different billing rules for technical components of lab and diagnostic services

Independent RHC

• Owned and operated as an essential part of ahospital (including CAHs), skilled nursing facility(SNF), or home health agency (HHA) participatingin the Medicare Program

• CMS Certification Number (CCN) Range:• xx3400 – xx3499• xx3975 – xx3999• xx8500 – xx8899

• Receive reimbursement based on actual cost*, also known as the RHC all-inclusive rate (AIR)

• *Hospital must be under 50 beds or reimbursement is capped the same as a free-standing RHC ($83.45)

• Different billing rules for technical components of lab and diagnostic services

Provider-Based RHC

RHC Visit = RHC Encounter

“A RHC visit is a medically-necessary medical ormental health visit, or a qualified preventivehealth visit. The visit must be a face-to-face (one-on-one) encounter between the patient and aphysician, NP, PA, CNM, CP, or a CSW duringwhich time one or more RHC services arerendered.” CMS Internet Only Manual 100-02, Chapter 13

Visits only for medication refills

Visits only for lab results

Visits only for injections (i.e. allergy)

Suture removal or dressing change without an additional face-to-face visit

Visits billed using CPT code 99211 (nursing visit)

What is NOT a RHC Encounter?

Claim Form, Bill Types & Place of Service

• RHC services are billed on a CMS-1450 (also known as a UB-04 form)

• RHCs should use Place of Service

(POS) code 72• These are the

common bill types (TOBs) used on RHC claims:

Original Claim

Non payment/zero claim

Adjustment Claim

Cancelled Claim

711

710

717

718

Independent vs. Provider Based RHC Billing

Independent RHC

Provider-Based RHC

Encounter for RHC Service(s)

CLIA Lab in RHCTechnical Component

(Non-RHC Service)

Bill to Part A on UB-04

Bill to Part B on CMS-1500

Bill to Part B on CMS-1500

Bill to Part A on UB-04

Billed to MAC by Parent EntityPPS Hospital: TOB 141/ 131CAH: TOB 851

Billed to MAC by Parent EntityPPS Hospital: TOB 131CAH: TOB 851

Clinic visit by a member to RHC0521

Home visit by RHC practitioner0522Visit by RHC practitioner to member in a covered Part A stay at a SNF0524Visit by RHC practitioner to member in a non-Part A SNF, NF, ICF, or other residential facility0525RHC visiting nursing services to a member’s home in a Home Health Shortage Area0527Visit by RHC practitioner to another non-RHC site (i.e. scene of an accident)0528

Mental health visit0900

Revenue Codes

Pharmacy – drug with no J-code0250

Venipuncture0300

Drugs with detailed HCPCS J-code0636

Telemedicine originating site0780

Other Common Revenue Codes in RHCs

RHC Claim Details

• RHCs are required to line-item, detail code for all services providedduring the RHC visit

• Include HCPCS codes for all services performed during that visit

• The first line of the RHC claim should be the HCPCS code for thequalifying visit

• Modifier CG should be attached to identify the qualifying visit

• Modifier CG signals to Medicare which line to use when calculating applicablecoinsurance and deductible

RHC Claim Details

• Charges for all services provided during the visit should be “rolled up”to the first line of the claim

• Except for charges for qualifying preventive health services

Qualifying Visit List (QVL)

• Last updated August 1st, 2016

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

QVL consists of “frequently reported HCPCS codes thatqualify as a face-to-face visit between the patient and anRHC practitioner…”

“…NOT an all-inclusive list of stand-alonebillable visits for RHCs.”

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

Claim Example #1

• Scenario: RHC Provider completed a level-3 E/M office visit. Chargefor the visit is $100.00. No additional work (incident-to or non-RHCservices) were required.

RHC Encounter – E/M Office Visit Only

FL42 FL43 FL44 FL45 FL46 FL47

Rev Code Description HCPCS Code DOS Units Total Charge

0521 Office Visit –Established Pt III

99213 CG 10/25/2018 1 $100.00

0001 Total Charge $100.00

Claim Example #2

• Scenario: RHC Provider completed a simple I&D in the office. Chargefor the visit is $150.00.

RHC Encounter – Procedure Only



0521 I&D Abscess 10160 CG 10/25/2018 1 $150.00


Claim Example #3a

• Scenario: RHC Provider completed a level-3 E/M office visit and asimple I&D in the office. Charge for the E/M visit is $100.00 and forthe procedure is $150.00.

RHC Encounter – E/M Office Visit and Procedure




99213 CG 10/25/2018 1 $250.00

0521 I&D Abscess 10160 10/25/2018 1 $150.00


Claim Example #3b

• Scenario: RHC Provider completed a level-3 E/M office visit and asimple I&D in the office. Charge for the E/M visit is $100.00 and forthe procedure is $150.00. Additional charges are reported with $0.01

RHC Encounter – E/M Office Visit and Procedure




99213 CG 10/25/2018 1 $250.00

0521 I&D Abscess 10160 10/25/2018 1 $0.01


Claim Example #4

• Scenario: RHC Provider completed a level-4 E/M office visit and a gavethe patient a Rocephin injection. Charge for the E/M visit is $150.00,for the administration is $12.00 and for the drug is $45.00.

RHC Encounter – E/M Office Visit and Injection



0521 Office Visit –Established Pt IV

99214 CG 10/25/2018 1 $207.00

0521 Inj Admin 96372 10/25/2018 1 $12.00

0636 Rocephin, 250 mg J0696 10/25/2018 1 $45.00


Preventive Health Services

• When billing for preventive health services, DO NOT include chargesfor those services in the “roll up” to the qualifying visit line

• Medicare pays for qualifying preventive health services at 100%

• Coinsurance and deductible do not apply for qualifying preventivehealth services.

• Resource: United States Preventive Services Task Force (Grade A or B)

• Resource: Rural Health Clinic Preventive Services Chart https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf

Claim Example #5

• Scenario: RHC Provider completed a level-4 E/M office visit. While inthe office, the provider completed the patient’s IPPE. Charge for theE/M visit is $150.00, and for the IPPE is $195.00.

RHC Encounter – E/M Office Visit and Preventive




99214 CG 10/25/2018 1 $150.00

0521 IPPE G0402 10/25/2018 1 $195.00


Non-RHC Services

• RHCs may “furnish certain services that are beyond the scope of theRHC benefit”. These are considered “Non-RHC Services”

• Non-RHC services are billed separately to the appropriate MAC underthe payment rules specific to that service.

• All cost associated with non-RHC services (i.e. space, equipment,supplies, facility, overhead, personnel) should be removed from thecost report.

Claim Example #6

• Scenario: RHC Provider completed a level-3 E/M office visit. While inthe office, the provider also did an EKG. Charge for the E/M visit is$100.00, and for the professional fee for the EKG is $25.00.

RHC Encounter – E/M Office Visit and EKG




99213 CG 10/25/2018 1 $125.00

0521 EKG, interpretation and report

93010 10/25/2018 1 $25.00


Claim Example #6

• In this scenario, the technical component of the EKG (a non-RHCservice) is billed differently depending on whether the RHC isindependent or provider-based:

RHC Encounter – E/M Office Visit and EKG

Independent RHC

Provider-Based RHC

Bill HCPCS code 93005 (EKG, tracing only) toPart B on CMS-1500

Parent entity will bill HCPCS code 93005 (EKG,tracing only) to MAC

Claim Example #7

• Scenario: RHC Provider completed psychiatric diagnostic evaluationwith a patient. Charge for the visit is $200.00.

RHC Encounter – Mental Health Visit Only



0900 Psychiatric diagnosticevaluation

90791 CG 10/25/2018 1 $200.00


Multiple Visits on the Same Day

• In general, encounters with more than one RHC practitioner on thesame day, or multiple encounters with the same RHC practitioner onthe same day count as a single RHC visit and will only receive one AIRpayment.

• “This applies regardless of the length or complexity of the visit, thenumber or type of practitioners seen, whether the second visit is ascheduled or unscheduled appointment, or whether the first visit isrelated or unrelated to the subsequent visit.”

• Resource: CMS IOM 100-02, Chapter 13, Section 40.3

• However, there are a few specific exceptions…

Multiple Visits on the Same Day – Exceptions

• Exceptions are for the following circumstances only:

The patient, subsequent to the first visit, suffers an illness or injury that requiresadditional diagnosis or treatment on the same day (for example, a patient seestheir practitioner in the morning for a medical condition and later in the day has afall and returns to the RHC). In this situation only, the RHC would use modifier 59or 25 to attest that the conditions being treated qualify as 2 billable visits.

The patient has a qualified medical visit and a qualified mental health visit on the same day (2 billable visits).

The patient has an initial preventive physical exam (IPPE) and a separate medical and/or mental health visit on the same day (2 or 3 billable visits).

Claim Example #8

• Scenario: RHC Provider completed a level-4 office visit with a patient who hasdiabetes. Later in the day the patient fell and came back to the RHC to be seen.Charge for the first medical visit is $150.00 and for the subsequent visit is $100.00

RHC Encounter – Medical Visit & Subsequent Visit, Same Day




99214 CG 10/25/2018 1 $150.00


99213 CG 25 10/25/2018 1 100.00


Claim Example #9

• Scenario: RHC Provider completed a level-3 office visit with a patient and amental health provider in the same office completed a psychiatric diagnosticevaluation on the same day. Charge for the medical visit is $100.00 and for themental health visit is $200.00

RHC Encounter – Medical Visit & Mental Health Visit, Same Day




99213 CG 10/25/2018 1 $100.00

0900 Psych eval 90791 CG 10/25/2018 1 $200.00


Claim Example #10

• Scenario: RHC Provider completed a patient’s IPPE. While they were in the office,they were seen for their hypertension. The patient also saw a mental healthprovider who had a 30 minute psychotherapy session. Charge for IPPE is $195.00,for the medical visit is $150.00, and for the mental health visit is $220.00.

RHC Encounter – IPPE, Medical Visit, & Mental Health Visit, Same Day



0521 Office Visit – Established Pt IV

99214 CG 10/25/2018 1 $150.00

0521 IPPE G0402 10/25/2018 1 $195.00

0900 Psychotherapy, 30 m 90832 CG 10/25/2018 1 $220.00


Coinsurance & Deductible

• Coinsurance is equal to 20% of the total chargessubmitted on the RHC claim.

• It is not the Medicare allowable amount

• Calculated from the qualifying visit line, as identified by theCG modifier

• Coinsurance and deductible are waived for qualifiedpreventive health services

• The Part B deductible is applied to RHC visits. Patientswho only have Medicare Part A coverage are notcovered.

• Part B Deductible for 2018 = $183.00

Coinsurance Calculation – Example #1

• Coinsurance = 20% of $100.00

• Coinsurance is $20.00

RHC Encounter – E/M Office Visit OnlyFL42 FL43 FL44 FL45 FL46 FL47



99213 CG 10/25/2018 1 $100.00





RHC Encounter – E/M Office Visit and ProcedureFL42 FL43 FL44 FL45 FL46 FL47



99213 CG 10/25/2018 1 $250.00

0521 I&D Abscess 10160 10/25/2018 1 $150.00





• Coinsurance is waived for the IPPE.

RHC Encounter – E/M Office Visit and PreventiveFL42 FL43 FL44 FL45 FL46 FL47



99214 CG 10/25/2018 1 $150.00

0521 IPPE G0402 10/25/2018 1 $195.00


Influenza & Pneumococcal Vaccines

• RHCs are reimbursed for flu and pneumococcalvaccines, and their administration, through the costreport.

• DO NOT report flu and pneumococcal vaccines, northeir administration on the RHC claim.

• You should have a mechanism in place for trackingvaccines and their administration in order to accuratelyreconcile these on your cost report.

• Keep a log with patient’s name, DOB, insurance information,date of immunization, at a minimum.

Non Covered Services

• Non covered services are not consideredmedically-necessary, therefore notcovered by the RHC benefit, nor anyMedicare benefit

• The RHC should complete an AdvanceBeneficiary Notice of Non-Coverage(ABN) for all non covered services.

• Submit these charges using TOB 710

• Payment for charges associated with noncovered services is the responsibility ofthe patient.

ABN Requirements

• The ABN notifies Medicare beneficiaries that a particular service is non covered, or that Medicare may deny payment for a particular service. In these cases, the patient is responsible for the charges.

• The ABN should be given to patients before they receive the service.• If it is given to them after they receive the service, it is not valid, and the RHC

may by liable for any amounts Medicare does not pay. You may not bill the patient for those services.

• The ABN must include a reasonable estimate for the cost of the service to be provided.

• “Reasonable estimate” is defined as within $100 or 25% of the total cost, whichever is greater.

Taking RHC Billing to the Next Level

Tomorrow at 11:00am with Janet Lytton

RHC Advanced Billing

• Learn which revenue codes to use

• Learn how to handle Part D drugs

• Learn how to bill for TCM, CCM, ACP

• Learn how to bill preventive care, non-RHC, & incident to services

Questions?

Breakout Sessions

Go to Regency ABC for

Emerging CostReport Issues

Julie Quinn

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RHC CostReports 101

Katie Jo Raebel

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RHC Cost Reports 101Katie Jo Raebel

CPASenior Manager

Wipfli, LLP

Rural Health Clinic Medicare Cost Report Overview

Allowable Costs

Non-RHC Costs

Provider Staffing

RHC Visits/Provider Productivity

Medicare Flu and Pneumonia Reimbursement

Medicare Bad Debt

Operational Strategies

Today’s Agenda

© Wipfli LLP 87

Rural Health ClinicMedicare Cost Report Overview

The Medicare cost report is the method of reconciling payments

made by Medicare with the allowable costs for providing services.

• If total payments received from Medicare exceed the allowable costs,

the provider must pay the difference to Medicare.

• 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.

Medicare Cost Report

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© Wipfli LLP 89


There are two types of RHCs; cost reporting is slightly different for

each:

• Independent RHCs submit an RHC cost report to one of five regional

fiscal intermediaries (transitioning to MAC).

• Provider-based RHCs submit an RHC cost report as a subset of the

host provider (usually a hospital).

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• The cost report is due five months after the close of the period

covered.

• It must be filed electronically.

• Terminating cost reports are due 150 days after the termination of the

provider agreement.

• An extension to file the cost report may be granted by the

intermediary only for extraordinary circumstances such as a natural

disaster, fire, or flood.

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• What if you don’t file the cost report within the 150 days?

- Currently, there is no penalty imposed for late filing; however,

Medicare will stop payments to the RHC.

- Medicare will ask for the money paid in interim payments to be

paid back.

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What Is Needed to Prepare the Cost Report?

1. Financial statements

2. Cost report software

3. Provider/practitioner FTE data

4. Visits by practitioner

5. Wage and benefit summary, by position

6. Equipment (fixed asset) records

7. PS&R Report (Medicare charges and payments)

8. Influenza/pneumococcal vaccines (injection totals and invoices)

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What Is Needed to Prepare the Cost Report?

9. Laboratory costs

10. Radiology/other diagnostic 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

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Cost Report Components

• Trial Balance of Expenses

• Reclassification and Adjustment of Trial Balance of Expenses

˗ Reclassifications

˗ Adjustments

˗ Related-party adjustments

• RHC Provider Statistics

• Flu/PPV Vaccine Costs

• Visits (part I), Overhead (part II)

• Determination of Medicare Reimbursement (part I) and Payment (part

II)

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Allowable Costs

Allowable RHC Costs:

• Defined at 42 CFR 413.

• Explained in Provider Reimbursement Manual, Pub. 15.

“Allowable costs must be reasonable and necessary and may include

practitioner compensation, overhead, equipment, space, supplies,

personnel, and other costs incident to the delivery of RHC services.”

− RHC Medicare Benefit Policy Manual

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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?

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Non-RHC Costs

Identify Costs of Common Non-RHC Services

• Chronic Care Management

• DME

• Hospital services (inpatient/ER/ASC)

• Laboratory services

• Medical directorships

• Mammography

• Telehealth

• Radiology services

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Non-RHC Costs

Example - Laboratory Services

Most common direct costs associated with lab:

• Lab tech salaries/benefits

• Nursing salaries/benefits

• Reagent costs

• Other lab supplies

• Lab equipment depreciation

• CLIA licensure/reference lab fees

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Provider Staffing

Cost report requires separation of provider time (and cost)

• Health Care Provider FTEs:

˗ Physician

˗ Physician Assistant

˗ Nurse Practitioner

˗ Visiting Nurse

˗ Clinical Psychologist

˗ Clinical Social Worker

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Provider Staffing

• Record provider FTE for clinic time only (this includes charting time):

˗ Time spent in the clinic

˗ Time with SNF patients

˗ Time with swing bed patients

• Do not include non-clinic time in provider productivity:

˗ Hospital time (inpatient or outpatient)

˗ Administrative time

˗ Committee time

• Provider time for visits by physicians under agreement who do not

furnish services to patients on a regular ongoing basis in the RHC

are not subject to productivity standards.

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Provider Staffing

Sample Reconciliation of Provider FTE:

Clinical FTE

Administrative FTE

Hospital FTE

Medical Director FTE

Total FTE

0.70

0.05

0.20

0.05

1.00

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RHC Visits

“A RHC 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 services are rendered. A Transitional Care Management (TCM)

service can also be a RHC or FQHC visit. A RHC visit can also be a visit

between a home-bound patient and an RN or LPN under certain

conditions.”

− RHC Medicare Benefit Policy Manual

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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.

NOTE:The cost-per-visit calculation considers

total costs; therefore, all visits (regardless of

payer type) should be included in the cost report.

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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

• 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; global visits)

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RHC 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 the cost per visit is the greater of the

actual visits or minimum allowed (FTEs x Productivity Standard).

NOTE: The cost report productivity standards cannot be manually

adjusted. Therefore, if a provider only worked a portion of a

year or if the cost report only represents a portion of a year, the

FTE should be adjusted accordingly.

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RHC Productivity

Number Minimum Greater of

of FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4

Positions 1 2 3 4 5

1 Physicians 6.87 25,890 4,200 28,854

2 Physician Assistants 2.16 7,500 2,100 4,536

3 Nurse Practitioners 2,100 -

4 Subtotal (sum of lines 1-3) 9.03 33,390 33,390 33,390

5 Visiting Nurse

6 Clinical Psychologist

7 Clinical Social Worker

8 Total FTEs and Visits (sum of lines 4-7) 9.03 33,390 33,390

Example 1 – Visits Equal Productivity Standards

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RHC Productivity

Example 2 – Productivity Standards Are Greater Than Visits

Number Minimum Greater of

of FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4

Positions 1 2 3 4 5

1 Physicians 6.87 16,221 4,200 28,854

2 Physician Assistants 2.16 4,773 2,100 4,536

3 Nurse Practitioners 2,100 -

4 Subtotal (sum of lines 1-3) 9.03 20,994 33,390 33,390

5 Visiting Nurse

6 Clinical Psychologist

7 Clinical Social Worker

8 Total FTEs and Visits (sum of lines 4-7) 9.03 20,994 33,390

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RHC Productivity

Effect on Cost-Per-Visit Greater of

Actual Visits or

Productivity

Standard Visits

Allowable Costs

for Cost-Per-Visit

Calculation RHC Cost-Per-Visit

5,798,460$

Example 1 33,390 173.66$

Example 2 20,994 276.20

• Independent RHC – no effect; cost-per-visit limit

• Provider-based RHC to a hospital with less than 50 beds, $102.54 per

visit difference

• Could affect Medicaid rate yearly or indefinitely

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Medicare influenza and pneumonia costs are reimbursed on the cost

report:

• Cost includes staff, vaccine, and overhead costs

• These services should not be billed

• Listing of Medicare patients must be

included with the cost report submission:

˗ Name

˗ Medicare number

˗ Date of service

• Vaccine invoices are submitted with the cost report

• Pneumo/Prevnar vaccinations are reimbursable on the cost report

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Worksheet B-1/M-4:CALCULATION AND TOTAL OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST

Part I - Calculation of Cost Pneumococcal Seasonal Influenza

1 2

1 Health Care Staff Cost 537,821 537,821

2

Ratio of Pneumococcal & Influenza Vaccine Staff Time To Total

HC Staff Time 0.000651 0.006340

3 Pneumococcal & Influenza Vaccine Health Care Staff Cost 350 3,410

4 Medical Supplies Cost - Pneumococcal & Influenza Vaccine 2,981 3,648

5 Direct Cost of Pneumococcal & Influenza Vaccine 3,331 7,058

6 Total Direct Cost of the Facility 581,931 581,931

7 Total Facility Overhead 349,902 349,902

8

Ratio of Pneumococcal & Influenza Vaccine Direct Cost to Total

Direct Cost 0.005724 0.012129

9 Overhead Cost - Pneumococcal & Influenza Vaccine 2,003 4,244

10

Total Pneumococcal & Influenza Vaccine Cost & Its

Administration 5,334 11,302

11 Total Number of Pneumococcal & Influezna Vaccine Injections 35 341

12 Cost Per Pneumococcal & Influenza Vaccine Injection 152 33

13

# of Pneumococcal & Influenza Vaccine Injections Admins To

Medicare Beneficiaries - 169

14 Medicare Cost of Pneumococcal & Influenza & Its Administration - 5,601

15

Total Cost of Pneumococcal & Influenza Vaccine & Its

Administration 16,636

16

Total Medicare Cost of Pneumococcal & Influenza Vaccine and

Its Administration 5,601

© Wipfli LLP 121

Medicare Bad Debt

• Medicare bad debt reimbursement is 65% of allowable bad debt claimed.

• Allowable coinsurance and deductible amounts only.

• Debt must be related to covered services.

− Do not include lab, radiology, or other non-RHC services on the cost report.

• Provider must be able to establish that reasonable collection efforts were

made.

− Document that a reasonable and consistent collection effort has been made for 120 days from the date of the initial bill to the patient. (CMS is now insisting that if an account is turned over to an outside collection agency, the account cannot be claimed until returned from the collection agency.)

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Medicare Bad Debt

CMS Pub. 15-I Section 308 states the criteria for allowable Medicare

bad debt:

• Debt must be related to covered services and derived from

deductible and coinsurance.

• Provider must be able to establish that reasonable collection efforts

were made.

• Debt must actually be uncollectible when claimed as worthless.

• Sound business judgment must have been established to determine

there was no likelihood of recovery at any time in the future.

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Medicare Bad Debt

CMS Pub. 15-I Section 310 defines reasonable collection effort:

• Similar to effort for non-Medicare patients.

• Issuance of bill to responsible party.

• May include subsequent statements, collection letters, and

telephone calls.

• Referral to collection agency if used for non-Medicare patients of

“like amounts.”

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Medicare Bad Debt

Presumption of noncollectibility, CMS Pub. 15-I Section 310.2:

• If after reasonable and customary attempts to collect a bill, the

debt remains unpaid more than 120 days from the date the

first bill is mailed to the beneficiary, the debt may be deemed

uncollectible.

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Medicare Bad Debt

Indigent Patients, CMS Pub. 15-I Section 312:

• Clinics can claim bad debt without waiting the 120-day

collection period.

• Determination of indigence must be documented in the patient’s

file.

• Beneficiary considered indigent if eligible for Medicaid.

• Provider must determine that no other source is legally

responsible for payment.

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Medicare Bad Debt

• Denials by Medicaid as secondary payer, as long as actually billed

and denied, can be claimed immediately.

• Documented charity care write-offs can be claimed immediately.

• Provider Reimbursement Manual – Part I Chapter 3

• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Paper-Based-Manuals-

Items/CMS021929.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929.html

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Medicare Bad Debt

Documentation Required With Cost Report:

• Beneficiary name and HIC number

• Date(s) of service

• Date of first bill sent to patient

• Medicare paid date (R/A)

• Write-off date

• Separation of deductible and coinsurance amounts

• Medicaid payment and paid date (if any)

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Filing Consolidated Worksheets Rather Than Individual Cost Reports

(Per the Medicare Claims Processing Manual, Chapter 9)

If RHCs are part of the same organization with one or more RHCs, they

may elect to file consolidated worksheets rather than individual cost

reports. Under this type of reporting, each RHC in the organization need

not file individual cost reports. Rather, the group of RHCs may file a

single report that accumulates the costs and visits for all RHCs in the

organization. In order to qualify for consolidation reporting, all RHCs in

the group must be owned, leased, or through any other device, controlled

by one organization.

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The Provider Statistical and Reimbursement System (PS&R) is an

essential component of cost report reconciliation

• Report summarizes all paid Medicare claims

˗ Visits

˗ Charges (including preventive)

˗ Deductible

˗ Medicare payments

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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 whether the clinic will need to collect special data for the cost report (e.g., 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.

• Review the cost report for reasonableness (e.g., $700 cost per pneumococcal injection is not reasonable).

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Helpful Hints

Independent Provider-Based

RHC Basic Information (address, provider

number, certification date) S S-2/S-8

Expense Information A A/M-1

Reclassifications A-1 A-6

Adjustments A-2 A-8

Related-Party Adjustments A-2-1 A-8-1

Allocation of Overhead (Hospital) - B Part I

Visits and FTEs; Allocation of Overhead to

RHC/Non-RHC B, Part I M-2

Influenza and Pneumonia Cost B-1 M-4

Cost-Per-Visit, Medicare Bad Debt, Settlement C M-3

Medicare Payments Entry - M-5

Cost Report Worksheets:

Questions?

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