RHC
Billing Issues TOP |
Slide 1: HEALTH
SERVICES ASSOCIATES, INC
Ron
L. Nelson, PA
www.hsagroup.net
2 East Main Street
Fremont, Michigan 49412
Ph: 231-924-0244
Fx: 231-924-4882 Email:nelson@hsagroup.net
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RHC
Billing Issues TOP |
Slide 2: Understanding Billing Issues
- RHC Services
- Part B Services
- Provider Based vs. Independent
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RHC
Billing Issues TOP |
Slide 3: Part B Services
- Inpatient - Professional Component
- Lab - Technical
- Xray - Technical
- Diagnostics - Technical
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RHC
Billing Issues TOP |
Slide 4: Vaccines
What information do I need to capture?
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RHC
Billing Issues TOP |
Slide 5: Billing for Procedures
- Endoscopies
- Biopsies
- Surgical Procedures (office based)
- Commingling - defined
How can we correctly carve out procedures?
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RHC
Billing Issues TOP |
Slide 6: MEDICAID What is Covered?
- Core Services
- Other Services
- Managed Care
How to analyze its impact
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RHC
Billing Issues TOP |
Slide 7: Behavioral Health Services
- Clinical Psychologist (PhD)
- Clinical Social Worker (CSW)
- Change in billing - do not use 910 Revenue
Code effective August 2004. Use 900 Revenue Code to bill
therapeutic Behavioral Health.
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RHC
Billing Issues TOP |
Slide 8: Provider-Based Issues
- Only Visits Billed to Intermediary
- Ancillaries Billed Under Hospital Fee
Schedule Hospital provider type
- Exceptions - CAH - offsite clinics
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RHC
Billing Issues TOP |
Slide 9: SNF Visits
- Part A Stay, bill to Part B
- Non-Part A Stay, bill to RHC Program
- January 1, 2005 - bill all to RHC FI
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RHC
Billing Issues TOP |
Slide 10: Telehealth
- Bill to RHC Program
- Q3014 code is paid separately from all
all-inclusive rate
- Bill for $20, transmission fee
- Real Time Audio/Video Transmission
- Separate service not subject to fee schedule
restrictions
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RHC
Billing Issues TOP |
Slide 11: Billing Crossovers
- Problems with EOB
- How to get Paid
- How to Remain Compliant
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RHC
Billing Issues TOP |
Slide 12: What constitutes a visit
- Face to face encounter a patient and
a physician, physician assistant, nurse practitioner, nurse-midwife,
or visiting nurse.
- Encounters with more than one health
professional and/or multiple encounters with the same
health profession that take place on the same day
at a single location constitutes a single visit.
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RHC
Billing Issues TOP |
Slide 13:
Pap/Pelvic
Bill Professional component to FI under
revenue code 521
Bill Technical component to the Part B Carrier
See Medi 913-01
Colorectal Screening/Bone Mass/Prostate
CancerScreening
Bill Professional component to FI under
revenue code 521
Bill Technical component to the Part B Carrier
See Medi 799-00
Diabetic Outpatient Self-Management Training
Services
Not reimbursed by Medicare at this time
for services rendered by RHC.
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RHC
Billing Issues TOP |
Slide 14: SERVICES RENDERED ON NON-VISIT
DAYS
CAN
BE COMBINED WITH CLAIMS WITH VISITS
RECOMMEND THEY BE WITHIN 30 DAYS
LIST ONLY THE DATE OF THE VISIT
SHOW CHARGES FOR ALL SERVICES
ADJUSTMENTS OK
OTHERWISE, HANDLED THRU COST REPORT
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RHC
Billing Issues TOP |
Slide 15: LIST ACTUAL CHARGES
THE RHC SHOULD LIST THEIR ACTUAL CHARGE
FOR EACH SERVICE. DO NOT AUTOMATICALLY DEFAULT TO LISTING
THE ALL-INCLUSIVE RATE AMOUNT ONLY.
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RHC
Billing Issues TOP |
Slide 16: SIGNATURES
MEDICAL RECORDS-
ACCEPTABLE- HANDWRITTEN
ELECTRONIC
STAMPED + HANDWRITTEN
UNACCEPTABLE- STAMPED
STAMPED + INITIALS
CLAIMS-
ACCEPTABLE - HANDWRITTEN
ELECTRONIC
STAMPED
SIGNATURE ON FILE
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RHC
Billing Issues TOP |
Slide 17: Medicare and Medicaid Reimbursement
Medicare reimbursement is on a reasonable
cost basis as determined by the providers Medicare cost
report.
However during the year, Medicare payments
are based on an interim rate that is based on historical
reasonable cost as reflected on filed Medicare cost reports.
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RHC
Billing Issues TOP |
Slide 18: Medicare Reimbursement
Rural Health Clinics provide both
rural health clinic services
and
non-rural health clinic services
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RHC
Billing Issues TOP |
Slide 19: Medicare Reimbursement (continued)
- Rural Health Clinic Services (billed
to intermediary on UB92) include:
- Office Visits
- Most nursing home visits
- Home visits
- Physician and mid-level services are
reimbursed at the same rate
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RHC
Billing Issues TOP |
Slide 20: Medicare Reimbursement (continued)
Non-RHC
99211 |
$20.14 |
99212 |
$35.20 |
99213 |
$48.47 most common |
99214 |
$75.18 |
99215 |
$109.36 |
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RHC
Billing Issues TOP |
Slide 21: Medicare Reimbursement (continued)
99211 |
$68.65 |
99212 |
$68.65 |
99213 |
$68.65 most common |
99214 |
$68.65 |
99215 |
$68.65 |
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RHC
Billing Issues TOP |
Slide 22: Medicare
Reimbursement (continued)
99211 |
$75.00-$125.00 |
99212 |
$75.00-$125.00 |
99213 |
$75.00 most common |
99214 |
$75.00-$125.00 |
99215 |
$75.00-$125.00 |
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RHC
Billing Issues TOP |
Slide 23: Medicare
Reimbursement (continued)
- ONE RHC VISIT PER PATIENT PER DAY WITH
FEW EXCEPTIONS
- SECOND ENCOUNTER ON SAME DAY MAY BE BILLED
IF UNRELATED (SORE THROAT AND BROKEN HAND)
- MAY BILL FOR A PART A RHC VISIT AND A
PART B NON-RHC VISIT (HOSPITAL VISIT) ON SAME DAY
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RHC
Billing Issues TOP |
Slide 24: Medicare RHC Payments
Example if no patient deductible:
Assumptions: |
CPT code 99212 |
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Standard charge $58 |
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Medicare interim
rate $100 |
Medicare
pays 80% of the $100 or $80.00
Patient pays 20% of $58 or $11.60
Total payment $91.60
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RHC
Billing Issues TOP |
Slide 25: Medicare RHC Payments (continued)
Example if no patient deductible:
Assumptions: |
CPT code 99212 |
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Standard charge $58 |
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Medicare interim
rate $100 |
Medicare
pays 80% of the $100 or $80.00
Patient pays 20% of $79 or $6.60
Total payment $95.80
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RHC
Billing Issues TOP |
Slide 26: Medicare RHC Payments (continued)
If the patient owes deductible:
- Patient pays 100% of charges up to the
full deductible due
- Medicare pays 80% of the interim rate
less patient deductible
- Patient pays 20% of charges less patient
deductible
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RHC
Billing Issues TOP |
Slide 27: Medicare
RHC Payments (continued)
Example if patient owes deductible:
Assumptions: |
CPT code 99212 |
|
Standard charge $58 |
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Medicare interim
rate $100 |
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Patient deductible
$25 |
Medicare
pays 80% of the $100 - $25 or $60.00
Patient pays 20% of $58 - $25 or $6.60 plus $25.00
Total payment $91.60
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RHC
Billing Issues TOP |
Slide 28: Medicare
RHC Payments (continued)
Example if patient owes deductible:
Assumptions: |
CPT code 99212 |
|
Standard charge $58 |
|
Medicare interim
rate $100 |
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Patient deductible
$100 |
Medicare
pays 80% of the $100 - $58 or $33.60
Patient pays 20% of $58 - $58 or $0.00 plus $58.00
Total payment $91.60
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RHC
Billing Issues TOP |
Slide 29: Medicare
RHC Payments (continued)
Example if patient owes deductible: EXTREME
EXAMPLE
Assumptions: |
CPT code 99213 |
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Standard charge $79 |
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Medicare interim
rate $70 |
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Patient deductible
$79 |
Medicare
pays 80% of the $70 - $79 or -$7.20
Patient pays 20% of $79 - $79 or $0.00 plus $79.00
Total payment $71.80
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RHC
Billing Issues TOP |
Slide 30: Medicare
RHC Payments (continued)
DOES IT MATTER HOW WE CODE A VISIT?
Patient payment is affected
- Medicare considers over coding
as a violation of the fraud and abuse regulations because
of the additional reimbursement
- Medicare considered under coding as a
violation of the fraud and abuse regulations because it
encourages patients to overuse the clinic
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RHC
Billing Issues TOP |
Slide 31: Medicare non-RHC Billing and
Payments
Services provided in the hospital (hospital
visits, emergency room visits, operating room procedures)
Option A
RHC bill using the physicians Medicare
number on 1500 to part B carrier payment based on fee
scale
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RHC
Billing Issues TOP |
Slide 32: Medicare
non-RHC Billing and Payments
Services provided in the hospital (hospital
visits, emergency room visits, operating room procedures
Option B
critical access hospital
only
Method II Billing Election
Hospital must bill outpatient physician
services with hospital outpatient charges on UB92 physician
portion of payment based on fee scale plus 12% (80% of 15%)
and hospital payment unchanged
RHC bill for inpatient services using
the physicians Medicare number on 1500 to part B carrier
payment based on fee scale
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RHC
Billing Issues TOP |
Slide 33: Medicare
non-RHC Billing and Payments
Other non-RHC services provided (Skilled
nursing home visit)
Until December 31, 2004
RHC bill using the physicians Medicare
number on 1500 to part B carrier payment based on fee
scale
After December 31, 2004
RHC bill using the clinics Medicare
number on UB92 to intermediary payment based RHC rate
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RHC
Billing Issues TOP |
Slide 34: Medicare
non-RHC Billing and Payments
Other non-RHC services provided (laboratory,
radiology, EKG)
Option A
Hospital bill using the hospitals
Medicare number on UB92 to intermediary using bill type 14X
payment based on fee scale
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RHC
Billing Issues TOP |
Slide 35: Medicare
non-RHC Billing and Payments
Other non-RHC services provided (laboratory,
radiology)
Option B
critical access hospital
established
provider-based laboratory
and radiology department
in RHC
Hospital bill using the hospitals
Medicare number on UB92 to intermediary using bill type 85X
payment based on cost
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RHC
Billing Issues TOP |
Slide 36: Medicare
non-RHC Billing and Payments
Other non-RHC services provided (non-encounters,
other immunizations, other)
Option A
Clinic add to other bill which includes
encounter and bill using the clinics Medicare number
on UB92 to intermediary additional reimbursement equal
to 20% of charges (patient coinsurance) and cost will be included
in cost per visit calculation and Medicare will pay 80% of
additional cost
Option B
Clinic writes off charge and no bill
is generated loss of 20% of charges; however cost will
be included in cost per visit calculation and Medicare will
pay 80% of additional cost
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RHC
Billing Issues TOP |
Slide 37: Medicare Reimbursement (continued)
Medicare bad debt reimbursement (part A
deductibles and coinsurance only) at 100 percent of unpaid
amount
- Not paid by the patient as a reasonable/standard
collection effort for 120 days from date of initial bill
to patient has been made
- Any denials by Medicaid as secondary
payor as long as actually billed and denied - immediate
- Documented charity care write-offs -
immediate
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RHC
Billing Issues TOP |
Slide 38: Medicare
Reimbursement (continued)
Pneumonia and Influenza immunizations
- Medicare will pay cost at the end of
the year on the cost report.
- Cost based reimbursement is two to three
times standard payment levels
- Do not bill Medicare. The clinic is only
required to maintain a log
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RHC
Billing Issues TOP |
Slide 39: Medicare
Reimbursement (continued)
Pneumonia and Influenza logs required
Must include all patients
Separate log for pneumonia and for influenza
Information needed:
- Date of service
- Patient name
- Patient Medicare number, if Medicare
patient
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RHC
Billing Issues TOP |
Slide 40: Bonus Payment Non RHC Part B
Services
Health Professional Shortage Area:
HPSA Geographic |
10% |
Physician Scarcity Areas:
PSA |
5% |
Specialty Physician Scarcity Area:
SPSA |
5% |
www.cms.hhs.gov/providers/bonuspayment
Apply to physician services
not services provided by non physicians.
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