Operator:

Good day everyone and welcome to the Capitol and Associates conference call. Just a reminder, this call is being recorded. At this time, I would like to turn the conference over to your host, Mr. (Bill Finerfrock). Please go ahead sir.

(Bill Finerfrock):

Hello, and good afternoon. Welcome everyone to this National (Rural) Health Clinics teleconference call. It is being sponsored by the Federal Office of Rural Health Policy, and the National Association of Rural Health Clinics is organizing and putting this on through - for (ORHP). I want to thank (ORHP) for their support of this initiative, and we're really looking forward to this project. We're anticipating between four and six national telephone conference calls over the next year on various topics we think will be of interest to the (ORHP) community.

Today's presentation will be by (Ron Nelson), with Health Services Associates, and we've asked him to talk about (RHC) billing issues. I wanted to let everyone know that a transcript of this conference call will be made and posted on the (ORHP) Web site, probably within about a week. We'll send out notification of its availability once it is completed and available.

At the end - Ron's going to speak for about 45 minutes. Add the end, we'll take - over the lines up for about 15 minutes for questions. If you have a question, if you'd like to ask a question and you don't have an opportunity to ask it, please send an e-mail to info I-N-F-O@narhc.org, and in the message put Teleconference Question. We will get that to Ron and post back an answer to that question to all of the people who signed up for the list serve. Without having been said, please welcome (Ron Nelson), who's a real expert on Rural Health Clinic issues, rural health issues in general. Ron, the time is yours.

(Ron Nelson):

Thank you Bill. Hello to everyone, and before I started, I would just like to also recognize a couple of individuals who have contributed, either through some of the information contained in the slides or through discussions, which is (Jeff Brahms Reiber), (Jeff Johnson), and (Woosley Bertelson), and (Mike Bell), also (Mike Bell and Associates). These individuals have also contributed a lot of information over the past several months in trying to pull some of this together. Today, what I hope we'll be able to do for you is really highlight some of the areas that we hear the most common concerns and issues as it relates to billing and rural health Clinics. And I think that probably we can distill that down into the problems that people have with understanding the differences between RHC services, what are not RHC services, or part B services, and then some of the differences and distinctions that exist between provider based and independent clinics.

Unfortunately, and many of you have in fact submitted some questions prior to the presentation today. Unfortunately what happens is that frequently people get, I think, confused by confusing information that's sometimes sent out, both from the carrier side, and sometimes from other individuals out there, providing expertise in this area, that confuse people about what's and RHC service versus what's a non RHC or part B service.

So what we hope to do today is to talk about that in a little more in-depth and to also highlight some specific areas related to differences between provider based and independent RHCs.

First of all, I think it's important to recognize that on the part B side, that in an RHC there are part B services provided. And some of you have submitted some questions prior to the conference about issues of certain services being recognized as RHC versus a part B service. Generally, the best rule of thumb to use, looking at the RHC services, to recognize that the professional component of what you provide in the RHC is an RHC service, and that also extends to nursing home visits, also extends to the patient's home, but it's the professional component of the services that you provide, and those services that are immediately incident to those professional services.

So on the part B side we find that those that are not generally RHC services are going to be those things such as inpatient services. Many of you have RHC is that provide care to patients in the hospital, the visits associated with the hospital care, both in the emergency room and inpatient and in outpatient areas of the hospital are considered to be non RHC services. Another area that has created confusion because we have had a flip-flop and change over the last 10 years has to do with the issue of labs, and frequently, people ask the question, well, is lab part of the RHC or not part of the RHC?

Previously, the six require tests were part of the RHC service and the balance could be part B, if in fact one carved the cost out associated with that. Well, that all changed a couple years ago, and in fact, now all laboratory is part B, so the laboratory services that you provide in your clinics is a part B service.

The other area that we find that does frequently cause some confusion has to do with the issue of x-ray and other diagnostic studies done in the clinic, and frequently, in many clinics, x-ray may be a service that's provided in that clinic, and the x-ray service, the obtaining of the x-ray, taking of the x-ray, is really a part B service and should be billed part B and under a technical component, and the professional component of that, i.e. the reading of that film.

For example, if you pay a radiologist to read that x-ray, the radiologist reading fees are in fact part of your rural health clinic cost, and would be included with annual cost of the RHC and captured also through your all-inclusive rate. So it's important to recognize that there's a distinction here between the x-ray, in terms of technical and professional component. Other diagnostics that you might provide in the office might include things like pulmonary function studies.

There may be other types of diagnostic studies that you are providing in your office. I think another example might be if you're doing cardiac stress tests. In some situations, people might be doing cardiac stress tests. In no situations, the technical component of the service would be billed to the part B carrier, and the professional component would become part of the RHC charge.

So it is important for us to recognize and separate those particular areas, and realized that there are part B and there are rural health clinic, or part A., as we say, paid out of part B services that are really rural health clinic services.

The next area I want to touch on has to do with the vaccines, and the importance of capturing the information that you need to adequately get reimbursed for both the flu and pneumococcal vaccines. If you look, the Medicare fee screen has been very low. I understand from the recent changes in the physician fee schedule that fee is going to go up to $18, but when we've looked at many, many costs around the country, what we find is an average probably for flu vaccine runs somewhere around $25. When you do the actual cost finding, which is what you are supposed to do as a rural health clinic.

So again, even though I hear the question often, I'd say to all of you as a rural health clinic you do not bill you're flu vaccine or pneumococcal vaccines to the carrier, but rather you log them with the information which includes the recipient's name, type of vaccine, the beneficiary's Medicare number, and the date that the service was provided. Those can then be used in a cost finding process in the cost report, and you're paid direct cost, and that includes both flu and pneumococcal vaccine.

One of the areas that we hear a lot of questions about has to do with the issue of billing for other procedures in rural health clinics. And before I go into that, I think it's important for us to talk about the whole issue of commingling. Many of you, hopefully all of you, had an opportunity to see the published rule, which has now been withdrawn and hopefully there will be a new rule proposed rule published sometime in 2005. But in that rule, we finally had some written definition of commingling.

And the importance of the concept of code mingling is that clearly, Medicare's goal is not to pay someone twice for providing a service. Which means that we do not want to comingle services that you're providing in your clinic as and RHC with those services that are not RHC services. Now, the logical statement for many of you who around there, and I can't hear you, is going, "Well, that's a pretty stupid statement because the reality is we're required to do that every day when you talk about lab and x-ray," and that is directed.

You are required to, in fact, provide some services that are, quote, "billed to the carrier" and become a non-RHC or a Part B service. But the fact of the matter is that however that is done from a co-mingling perspective, you need to assure that you have a mechanism to provide the service if it is a non-RHC service and a mechanism to allocate cost.

I would also caution people that if you are going to provide additional professional type services, not just diagnostic services in a rural health clinic and you expect to bill those as non-RHC, you need to clearly separate post hours and identify when you are operating a non-RHC part of the practice. That's important and I think is going to be the standard that will be used to scrutinize what we do.

Having said that, the question comes up well what happens if, for example, I do a biopsy in the office and in doing the biopsy how do I get paid for that as an RHC? Well the answer to that is that you bill the biopsy - for example, a skin lesion removal for the purposes of cancerous lesion of the skin and you're doing an incisional biopsy and the charge for that on a facial lesion might be $150. You would charge $150, the patient would be responsible for their co-insurance amount and deductible appropriately to that charge, and you would be paid based upon your all-inclusive rate.

And many people have said, "Well, gee, that's a concern because I would have gotten $110 out of Medicare for that and my rate is currently capped at $66. Why would I want to, you know, do that and give away that kind of money?" The reality is that unless you're doing an extensive number of procedures, on the average this will average out and you'll still do better through the all-inclusive rate for those services that are clearly well below what your charge is and below the Medicare fee screen.

I recognize some of you are probably shaking your head and going however the Medicare fee screen is getting higher and higher and as that happens it makes it less of an incentive under the RHC program to be in the program. And that is a flaw and an issue and there have been several attempts and I think continued attempts to recognize that the RHC cap must be raised to a reasonable level to account for the fact that it is - there is not enough differential between the cap and the current Medicare fee schedule.

Having said that, as we talk about those other procedures that you might provide, the other area that we hear frequently is the issue of things like endoscopies. And I think there's a legitimate argument that if someone takes the time to set up the equipment and the information that they should be - the equipment and the facilities that they should be able to, in fact, bill for those high-cost procedures.

Unfortunately, under the RHC program if those are performed in the RHC unless you have established certain times that are not RHC hours and are clearly posted and you have a mechanism to assure that those are separate employees, separate costs that are providing that service, it is difficult for you to do that in a compliant and correct fashion consistent with the RHC regulations.

Endoscopies performed in the RHC during RHC hours with RHC staff providing assistance to those patients must be billed as an RHC service. One of the things that I frequently recommend to people when they ask about this question is to consider moving those RHCs to the hospital out-patient department whereby they could then capture the professional component of that service via the Part B business and fee schedule, and the hospital is able to bill a hospital fee for the facility portion under the APC and, in fact, you - the patient would still get the service.

Now I've heard from people who point out to me well, what about the fact that I'm 35 miles from the hospital? And there's a legitimate issue and in those cases the only option that I see is that you might look at developing a separate procedure day that is posted as a non-RHC day, hours are posted, staff and costs are allocated separately so that, in fact, you're not co-mingling those costs and services between the RHC and the non-RHC services.

A brief comment that I would like to make about Medicaid is in traveling around I'm hearing more and more discussion again about Medicaid managed care. But it is important as an RHC as you look at how your reimbursement rate is structured, to take a look at what is happening in the arena of managed care.

I know of two, actually three states that are currently in the discussions of moving totally to a new and (capitated) managed care program. Those states have a lot of RHCs in them and, in fact, that could have some significant impact on your current Medicaid rates, recognizing that in your state they may elect - your state may have elected to go - continue to use a full-cost reimbursement formula, or may have elected to use the PPS. But, unfortunately, you need to be able to understand what the impact will be of the managed care and what some of the potential incentives might be for you in managed care.

Many of us have looked at managed care at times as being a real struggle but, in fact, in some RHCs I've seen it actually in the Medicaid program be a significant asset. And the reason is that in some states it is an opportunity in risk contract for RHCs to actually capture their PPS rate and then capture additional dollars on the what's referred to as the risk portion of the contract and keep those risk dollars over and above their PPS rate. And that is allowed for with in the regulations, so again, I would encourage you on the - on the Medicaid side to continue to take a look and watch what's happening within your state as it relates to Medicaid managed care.

Moving back again to some of the issues within the Medicare program. I think it's important for us to point out that there have been some changes in behavioral health relative to how you bill for that service. Currently behavioral health services are a covered service in rural health clinics if they are provided by a clinical psychologist or clinical social worker.

There was a change and this slide is incorrect. The change occurred actually I think in October of '03, but there was a change to change from the revenue code of 910 to 900 as the revenue code to bill for therapeutic behavioral health, an important point for those of you who might be considering adding behavioral health and for those of you who maybe are doing it.

First and foremost, behavioral health is an opportunity for us to truly meet the needs of patients by integrating behavioral health and primary care. And there's an excellent report was recently written by the National Advisory Commission for the Secretary of HHS on that very issue. And clearly, payment policy was one of the issues that they identified as a problem. It's no different in this program.

We're finding Medicaid programs that don't understand how to pay for this. We're finding confusion also many times on the Medicare side as it relates to psychologists and social workers. First of all, it's a requirement for the psychologist currently to provide services to Medicare beneficiary and be paid under the RHC program to be a Ph.D. psychologists. It's a requirement for a clinical social worker to be a master's prepared or CSW clinical social worker in order to be covered under the Medicare program.

An important point for those of you entertaining this or those of you who are doing behavioral health is to recognize that the initial evaluation and diagnosis of this patient is billed under a 521 revenue code and, in fact, is considered to be paid at a hundred percent of the full rate. Those that are billed under the 90 revenue code, subsequently, which are therapeutic visits, not the diagnosis but the therapeutic visit, are, in fact, then paid based upon the Medicare cap - mental health cap which is 62-and-a-half percent and really translates into the patient paying 50 percent of your charge based on the 62-and-a-half mental health limitation.

Another reason that behavioral health is important, if you remember back to the rule that was published and withdrawn, the rule very clearly allowed for the opportunity in the specialty areas, behavioral health to be one of those specialty areas that one might qualify under the essential provider status for those of you who might face decertification because of your health professional shortage area designations.

Some of the other issues that are important for us to talk about relate to the provider-based issues and the fact that there are now unique issues related to provider-based clinics specific to the fact that provider-based clinics bill for that professional component, the office visit, but really must bill then separately as a hospital provider type for the diagnostic studies rather than billing it as part of the clinic through a part B carrier.

And that is an important distinction that has to be made for the provider-based clinics and there are some exceptions, further exceptions or options for critical access hospitals which we're going to talk about in a few minutes.

So it is important to realize that the differences between independent provider based, or one of the many, is that the provider-based (employment) is paid for the visit and those services immediately entered into the visit, but for those diagnostic services, they must be billed under the hospital provider type it paid for under the fee schedule for the hospital.

The next area that I want to touch on, which continues to apparently create some confusion, is the whole area of what this slide refers to as sniff visits, and I think it's more appropriately referred to as long-term care. And we have patients who are in various types and modes of long-term care.

However, there is a specific type of patient, generally those patients who have recently been discharged from the hospital, that stay in a skilled care mode. Those patients, up until January 1, which is now only a few weeks away, are to be billed to part B. After January 1, all the nursing home visits would be billed to the RHC program.

There was a period of time there because of the skilled nursing bundling that occurred a couple of years ago in legislation that recorded this distinction between skilled patients and non-skilled patients in long-term care and created some confusion.

January 1, less than a month from now, all of the RHC, or all of the long-term care visits, should be billed under the RHC and paid under the RHC benefit, unless in fact, for some reason, the person who is providing that is not part of the RHC or is totally separated from the RHC for that portion of the service. And then you would be billing it like any private practice as a part B service.

There was a question posed prior to the conference today that I think is a legitimate question about areas such as senior housing. And it is important for you to remember, and we'll talk about it again in a few minutes, is that you must bill for services appropriate to the CPT code of service that you provide.

And unfortunately, people sometimes get confused because they know they have an all inclusive rating 10 to 1 to default to an all inclusive rate. I would like to point out to you that it's important under this program, or any program that's providing physician type services, to Medicare beneficiaries that you must code and charge based upon the service that's actually documented.

And the same thing exists in some of the long-term care visits, and further, it's important to recognize that while we talk about long-term care in generally those patients that are skilled and non-skilled, and we think of facilities, today we have assisted living facilities. We have various types of step-down units that are used to provide different levels of service to our elderly population.

Generally, unless someone is only in a senior housing project, or one where they receive some potential financial assistance for seniors based on financial income and age, those are generally going to be a home visit which would be coded as a home medical visit and billed as an RHC service.

But those that are in assisted living centers, where there are common areas that provide common services to those individuals, those must be billed under the domiciliary codes, and there is a difference between the domiciliary codes and in fact the home visited codes. And it's important for you to understand that, especially as we move more and more into having different types and levels of services for our elderly.

Another area that we need to - I need to touch on as is it's becoming more and more of an opportunity is the whole area of tele-health. The tele-health program does allow for real-time video and audio transmission to bill the RHC - under the RHC program. The originating facility, the originating site facility where the transmission comes from is eligible for a payment using the Q3014 code and is going to be paid for.

And it's slightly over $20 and that's a fee that is paid for the originating site for Medicare beneficiaries. The reason it's important I think for to hear about this particular situation is, I've had questions from people that required them to bill that $20 transmission originating site fee, as it's called. Are they required to bill that to all payers?

And the answer is no, this particular benefit is not subject to the other restrictions of the physician fee schedule, therefore, it is something that you would bill to your Medicare for your Medicare patients under the RHC program. Certainly if you have other companies that would pay for an originating site fee, I would encourage you to do so to attempt to collect any money that you can from those companies.

Another problem area that we hear about frequently and is commonly discussed is the whole area of billing crossovers. And I hear about that.

In fact, I had a question that was submitted as a prior question to the conference about getting secondary coverage when in fact, what happens in many cases is if your rate is paid at a rate higher than what the secondary insurance or co-insurance sees as the fee screen, they may just reject it and say, you've already been paid above the Medicare fee screen, therefore, we're not going to pay you.

And that raises some issues for you as to how you get paid for those. I wish I could give you a straight and cookie cutter answer is to do A, B, and C, and you will always get paid. Unfortunately, many of us deal with various secondary payers out there who pick up contracts to do the co-insurance amount and become secondary payers for Medicare. And you are going to have to take a look at each of those and find a way to get paid.

I've seen situations where people actually block out the payment from Medicare and do not show that to the secondary insurance, only show them the charge amount so that the secondary insurance can then calculate the 20 percent. It shows them the 20 percent of charge. You're going to have to deal with that individually. It is a problem.

I think it will continue to be a problem because of the lack of understanding of many of those plans out there that do provide that secondary coverage for Medicare beneficiaries. I'd like to just briefly touch and go in a little more detail to some other issues, but I want to briefly touch on the issue of what constitutes a visit because that continues, I think, to raise questions and it continues to be a question from people from time to time.

A visit is a face-to-face encounter between a patient and physician, a physician assistant, nurse practitioner, nurse midwife or visiting nurse, and that's a separate category that we won't spend any time on. It is important for us to understand that that is a medically necessary face-to-face encounter and I would hope, and unfortunately, I hadn't thought of it in the past rounds, but in future updates through the Federal Register, that's an area that we need to clarify in this language that a face-to-face encounter is a face-to-face encounter for a medically necessary visit for that patient.

And unfortunately, people have in the past assumed that just because there's a face-to-face encounter that means it constitutes an RHC visit and they didn't have to worry about whether medical necessity was met. And that's not the case. You still have to meet either the preventive codes on the cancer screening or the medical necessity standard as it relates to the medical necessity of that visit.

And unfortunately, people many times get confused. It is important to recognize, however, that it is a face-to-face encounter. It does not mean that you can talk to the patient on the phone. It does not meant that you can talk to the family members, but rather, it does require a face-to-face encounter with the patient.

(Bill Finerfrock):

Ron, we've got about 15 minutes to go.

(Ron Nelson):

We do?

(Bill Finerfrock):

Yes.

(Ron Nelson):

OK. Fifteen minutes until Q&A? OK. The next one I want to just touch on is the Pap and pelvic because we hear about this and I'm going to touch on a couple of other services that people have asked and have had some questions prior to this telephone conference. Under the Pap and pelvic, the collection of a Pap smear and performing of a pelvic exam requires hands-on encounter face-to-face with the patient.

The Pap smear itself is not an RHC service. In other words, the laboratory function of analyzing the cells, et cetera, to determine whether or not one has an atypical Pap smear is a laboratory service. But the service, the professional component of that, the obtaining of that, is in fact an RHC service and should be billed as an RHC service.

The same with the cancer screening guidelines, consistent with Medicare's periodicity schedule, it is important that you recognize that the professional component of obtaining specimens or conducting cancer screening under Medicare guidelines is considered to be an allowable RHC service that's billed under the 52 revenue code and any laboratory functions or any diagnostic studies that are attentive to that will then be billed separately under part B.

A question that comes up and has come up is specifically, relates to some of the services such as diabetic self management, nutritional services, I've had questions about multiple visits. First of all, those services are generally the professional component of those services are considered to be RHC service.

So if I see a patient and determine, for example, that I'm going to have them come in and see the diabetic educator in my office for the purposes of discussing self management goals, those in fact, that visit with that diabetic educator in my office is not a separate billable service because something face to face has not occurred between myself and that patient.

My discussion and evaluation of the patients for medically necessary visits relative to their diabetes and the appropriate documentation is a medically necessary service and is a billable service as long as that is documented in the record. So to bill for the self management goals and group (vivids) is not a service that is separately billable under the RHC and it is something that you would have to capture within your cost of your client and the all inclusive rate or provided by someone separate and distinct from the RHC.

We've also been asked the question about the issues of the new Medicare, welcome to Medicare patient and how do we deal with the welcome to Medicare patient who is eligible for a one time physical if you will or examination of visit to gather history and information and an EKG is also allowable as I understand from the fee schedule is now allowed as part of that visit.

Well, that charge for that visit would be whatever charge you're using for that current code. And the charge should be consistent, you should not default to another charge, you should establish a charge specific to that code. Your payment however is going to be whatever your RHC rate is. You're going to bill that visit to the RHC.

The EKG on the other hand would in fact be the technical component of that EKG would be billable under the part B program and should be payable under the part B program. One of the questions that people do ask frequently also has to do with same day services and that question has come up previously as well.

I just want to highlight that in fact you cannot perform the two visits on a patient for the same diagnosis in the same day and expect to be paid because that's not going to be paid. However, one that frequently comes up and was asked again yesterday is the question of I have a patient that I see in the clinic. I determine and evaluate that patient, determine they need to be admitted to the hospital. I admit the patient to the hospital, I go over to the hospital later on and I do a complete history and physical and sign the orders that I either phoned in or I write more orders and write it ((inaudible)).

You have two billable services, the one in the RHC is an RHC service, the one that was done in the hospital was a separate service, it's bill number part B. Now, if you only do the one service in your office and you don't go to the hospital and in fact document and provide that documentation.

Then in fact you'd only have one service. I want to clarify that it's important that in fact you do the work for both services in order to get paid for both services. Again, to reemphasize it's important not to default to your current all inclusive rate but in fact ensure that you are using a uniform fee schedule and a charge master that establishes what your charge levels are for CPT codes.

I want to touch base on signatures, just in there's a slide in this presentation that talks about that because it's frequently asked. I think this slide lays out what is acceptable and unacceptable as it relates to signatures for claims and medical records. I may want to move along and kind of recap some of the things that we have talked about and just highlight the fact that real health clinic services include office visits, include long-term care visits and they include home visits and they are generally the services of physicians, non-physicians such as (piasners) practitioners, psychologists and clinical social workers.

The next two slides which have been prepared by Mike (Bell) and Associates demonstrate the type of reimbursement that we currently see under Medicare under the fee schedule and then a comparison of what we see for those RHCs that are participating in the program.

I would point out to you, based on the MEI, it appears that the cap will grow up next year to about $70.78, that I'm sure will be published in the next few months but that looks, based on the current MEI to be what the new cap will be is somewhere close to $71. The next slide does talk about, show you some ranges for provider based RHCs under 50 beds.

I think it's important for us to recognize if we compare the RHC rates with the fee for service rates they show on the first slide it does demonstrate to us generally, there is a significant opportunity for us to capture additional revenue. Again, reviewing that there is one visit per day in an RHC with few exceptions, as I said, you do have the opportunity to bill for services if you provide services in the clinic and then admit to the patient for the hospital to provide a bill for both services.

If you do have two encounters in the same day and they are separate diagnoses, those are generally billed or if they're done also by separate individuals or professionals such as maybe behavioral health visits in the same day as you have medical ((inaudible)) visit in that particular day.

On the remaining slides that exist on page 8 and on page 9 show you some various scenarios that exist as it relates to patient charges with a hypothetical rate and various scenarios where patients may have deductibles or co-insurance amounts that are currently owed.

It is important and it's one that we hear about on page 10 of the handout that talks about the patient that is in the middle of a page, Medicare, RHC payments and it's an extreme example where an individual has a service with a charge of $79, a Medicare rate, their interim rate of $70 and they owe a patient deductible of $79.

Because of that, they in fact end up with a negative impact on their payment and people see this sometimes on their remittance devices and I hear people who question it and say well that can't be right, I think this lays out fairly well how that works and why it works that way and it's not often it has more to do with the patient's deductible status and the amount of your current rate in that first part of the year.

As we get to the end of the presentation, some things that I do want to reemphasize is that is important, I cannot stress to you enough the importance of coding. Those of you who are clinicians and they're out there, don't kid yourself, you are required to code and if an audit occurs, you will be held to a standard that says did you provide, did you document, consistent with what you build for.

So I can't stress enough that coding does make a difference. I think it's also important to recognize that regulators look at over coating and under coating the same. And so it's important that we're consistent and that our goal should be to code correctly according to what we're charging for or charge according to what we have coded.

The next few slides do show some particular areas in critical access and provider based RHCs that offer some opportunity for RHCs that are attached to critical access to take a look at how they're providing service and how they're getting paid. Just to highlight some particular issues that are important, if you are in a critical access hospital and you have an RHC, it is important to first establish whether the RHC is on site of the critical access hospital or offset because that changes how you build free ancillaries depending on how you choose to do that.

Secondly, for those of you who are in critical access hospitals with RHCs, you may want to take a look at the impact currently that the RHC has on your overall overhead in the critical access hospital. I think it's important for people to take a look at how that flows. Thirdly, there's some opportunity in critical access hospitals with some recent changes in the regulations which give you some incentive for the physician reimbursement if you're billing it through the critical access hospital.

And it also gives you some opportunity, then, to capture some of the bonus payments if you're eligible for those bonus payments. I do want to just touch base for a moment, also, on the bad debt in - and encourage you to be certain that you have an effective bad debt policy (which) is consistent with Medicare guidelines.

If the patient has not paid and you've made a reasonable collection effort 120 days from the date of the initial bill and another point to make regarding bad debt was - is captured on your (cost) report is that denials for Medicare - Medicaid as a secondary payer can be claimed as bad debt. You should also document your charity write-offs. We talked about influenza vaccine and the importance of that. I think that's (in) another important area which you need to focus on making sure that you have good, accurate data, collecting information regarding date of service, patient name, Medicare number and the vaccine that was given in order to capture that and to do the cost finding for your - vaccine services.

Finally, I think before we go to the Q&A, it is important for us to talk for a moment about the bonus payments that are out there because on the (non-RHD) services that you provide in your clinic - the Part B services - you are eligible, currently (or) have been up until recently eligible for the 10 percent bonus on geographic area (HIPAAs) which required you to apply a modifier to get paid for (that). Well, because there's some changes in Legislation, now Congress has asked (CMS) to implement a policy that makes that automatic and in addition to that, they have added a couple of other areas.

One called the Physician's Scarcity Areas and the other one is the Specialty Physician Scarcity Areas. Both of those of which can offer you five percent - (the) Physician Scarcity Area can (cost) you five percent. The Specialty Physician Area can also cause - it'd give you an additional five percent bonus. Those are to be calculated automatically by the carrier and paid to you on a quarterly basis.

There are some issues because these were all developed based upon zip code so while the lists were published and are available and we've listed this - the (CMS) website where you can go and check and see if your area is in any of those areas. It - there is an opportunity within that website to look at whether - because your zip code may have been (slit) that it didn't show up on the list but you may still be eligible so it is important for you to go back and check that. This is another opportunity on that Part B service you provide in the (HRC) to enhance and ensure that you're getting maximum reimbursement.

I - that really concludes the presentation at this point because I know we wanted to save some time for question and answers and I'm going - before we go into that, I'm just going to answer one additional question. It was posed to me pre the conference call and that has to do with care plans oversight and the certification of the home health services.

Those services, as many of you may know, can now be also certified by non-physician providers such as (PAs) and ((inaudible)) (practitioners). And there are codes to bill for those services however based upon my research, they still are considered to be part of the (HRC) service unless they're done separate and totally away from and not part of the (HRC). They're considered to be part of the (HRC) service and therefore not a separately billable service to the Part B carrier. With that, I think we're ready for Q&A.

(Bill Finerfrock):

Operator? Hello?

Operator:

Thank you. Our question-and-answer session will be conducted electronically. To ask a question, press the star key followed by the digit one your telephone keypad. We'll proceed in the order that you signal us and take as many questions as time permits. Once again, that is star, one to ask a question. A voice prompt on your telephone line will indicate when your line is open. We ask that you state your name prior to posing your question and we'll pause for just a moment.

(Bill Finerfrock):

While we're pausing, we did get (more) on question about - "So since you're allowed to bill an (HRC encounter) for nursing homes, can you also bill an encounter for a hospital-based (swing bed) visit?

(Ron Nelson):

I don't know that I can answer that. I don't believe that a (swing bed) visit would be included but that's something we can certainly - do we have an e-mail address?

(Bill Finerfrock):

Yes. I'll get that to you an e-mail.

(Ron Nelson):

OK.

(Bill Finerfrock):

Hey, operator?

Operator:

Once again, please state your name prior to posing your question. We'll move to our next question.

Female:

Yes.

Male:

Hello?

(Carol Franc):

My name is (Carol Franc). I'm with the (Mild Loft) Clinic in (Moston). It - in Wisconsin - and my question (is) regards to the "Welcome to Medicare" program. It's basically two of them. One of them is - do you know if there's going to be a tracking mechanism available to providers? For an example, if Medicare recipients goes somewhere else for their "Welcome to Medicare" exam and then presents themselves here and we don't know whether they've had it or not and as you all know, they may not know whether they've had it or not.

And the second question I have is about the (carvo) situation. If a recipient presents themselves and they have not only the "Welcome to Medicare" visit but they also have a sick visit with it. Currently under that situation, we currently bill the sick visit to (the) rural section and the "Welcome to Medicare" visit, so to speak, to the Part B. How will (Riverbend) handle that now because both of them - there'll really be two encounters as we currently have it. Thank you.

(Ron Nelson):

Well, first of all, I can't answer for you. I'm assuming that there's going to be a tracking mechanism but we'll certainly try and get that answer because this is …

Male:

(Issue) a number of providers in Medicare is not yet provided a - an answer to us but it's come up from a lot of different folks …

Male:

Right.

Male:

… but it's one they're working on.

(Ron Nelson):

So we hope to get that answer to you. On the (carvo), let's first talk about - let's talk about, say, a preventive service and not the "Welcome to Medicare." (If) a patient comes in for a physical that is not a welcome to Medicare and has a medical visit which, I think, is similar to your situation. In that situation, you will bill, as you said, to the (HRC) for the medically necessary documented level of service you provided. You would deduct the value of that service from the charge for the preventive physical that would be the patient's responsibility and you would bill the patient the balance.

And, in fact, it doesn't require that you have a (ABM) signed by the patient in order to get paid by the patient for the balance. Now, your issue of the preventive medicine (report) ((inaudible)) the "Welcome to Medicare" visit, I that in that situation what you're going to see is that you're going to bill - you're going to have some mechanisms (to) have some communications that have to be between the "Welcome to Medicare" visit and the sick visit, if you will or the (E&M) visit that you provided. But I think we're still going to have to get some detail, yet, because this is such a new regulation and how they're going to apply that.

(Carol Franc):

One other question on that "Welcome to Medicare," would an (ABN) be required, then?

Male:

(Could an ABN) on the Medicare patient be required?

(Carol Franc):

Right. We're not going to know if that patient had that "Welcome to Medicare."

Male:

Well, I think that might be a safe thing (to) (do) is to have a patient sign an (ABN) because you don't know but I'm still curious to see what we're going to hear from (CMS) is how they expect the providers - those are the ((inaudible)) team Medicare patients that may walk in and say, "I want to be seen," and little do we know that they were 20 miles away yesterday and the similar exam and someone is going to bill for it in that other office. How do you know (that)?

(Carol Franc):

Right. And how do we know (then)?

Male:

To protect yourself, you certainly have the right, I think, to offer the (ABN) (to) the patient.

(Bill Finerfrock):

(Hey), we can move to the next question and try to get a few more in.

Operator:

Moving (on), we'll hear from our next question.

Male:

Hello?

Operator:

Caller, your line is open. Please go ahead. Hearing no response, we'll move on.

(Mark Leon):

This is (Mark Leon) from Healthcare Business Specialists.

Male:

Hey, (Mark).

(Mark Leon):

Hi. How are you all doing? Ron, ((inaudible)) …

(Ron Nelson):

Yes.

(Mark Leon):

… my understanding was that that is - that's considered to be a hospital bed and that that's billable to Medicare Part B and it's not an (HRC) service.

(Ron Nelson):

Right. That was my understanding as well, (Mark), but I wanted to re-clarify (to) make sure that that hasn't changed.

(Mark Leon):

OK. ((inaudible)). My - I guess my comment is going to be that on deductibles, they go up to $110 next year and then they're based upon the amount that the Medicare beneficiary cost increased every year which was 17 percent this year. We're going to be in a world of hurt very, very soon when those rates go way, you know, they go up but it's going to be $128 to $130 in the near future and we're going to be eating a lot of deductibles in the near future so I think that's something we need to work on and my question is, on the x-ray, where the - when a radiologist (over-reads) …

Male:

Yes.

(Mark Leon):

… and is that billable to a Medicare Part B, if that radiologist is a part of the same group?

Male:

You mean in the physician office?

Male:

Yes. He's a part of the same group.

Male:

No. They don't allow you to bill that to Part B.

Male:

OK. That was ...

Male:

You can under - you can in a hospital setting, but you can't in the independent RHC where you may - even if you make the radiologists part of your group, that's considered to be part of your class, and is not a separate billable service, because it's not face-to-face as well.

Male:

OK. Thank you. That's all I had.

Male:

Thanks.

Operator:

Let's take our next question.

(Brenda):

Hi. This is (Brenda) from Ferguson Medical Group. I have a question about the signatures. You'd said you were going to go over the slide, but really didn't mention it, as far as what is acceptable. We're trying to make a new policy for our physicians to go by, and we want to verify what is exactly what they need to do?

(Ron Nelson):

Well, first off, I suggest that you contact your FI.

(Brenda):

All right.

(Ron Nelson):

What state are you in?

(Brenda):

Missouri.

(Ron Nelson):

OK. So, you need to talk to your FI. And you need to be clear what their requirement is. But the slide that's contained in your presentation on page six talks about in the medical record that it's acceptable to have a handwritten signature, an electronic signature, or a stamped signature with a co-signature that is handwritten. That it's unacceptable to just - to just stamp or stamp and initial. And for claims it is acceptable to have handwritten, electronic, or stamped signature on file.

And I think what's important is to take that information and discuss that with your FI to ensure that you are doing what you should be doing as you develop your own policy internally. One of the reasons this is becoming more important is because of the whole electronic signature process. As many of us move more and more to electronic signature, we need to be insured that we have policies that - and to determine what the requirement is. And, secondly, there are some states that require co-signature by a physician to a mid-levels services. Not all states, but some states do require that.

And strictly under the legislation, Medicare says that they cover services as long as you're allowed to provide that service within the state. And so if the state requires that as a contingency of your practice, that signature process is important to have a good sound policy consistent with what your FI is looking for as well.

(Brenda):

Well, our doctor says, "Why would we have a stamp and then them have to hand-write their signature after that?"

(Ron Nelson):

Well, I think that's a logical question. I think that's a very logical question.

(Brenda):

OK.

(Ron Nelson):

And that's why - that's why, for example, I don't use a stamp and sign my name behind it. I use a signature, or an electronic signature. And I think that, you know, that's one of the reasons that I think we're moving more and more to electronic signature, because it makes it easier for us to review and then sign.

(Brenda):

OK. Can I ask a question about the home health certifications, like the G0179, and G0180?

Male:

Yes.

(Brenda):

Why would those be billed under the Rural Health, because it's not a face-to-face encounter? Why couldn't we bill that to Part B?

(Ron Nelson):

Because it's being provided by your RHC provider, so it's still part of the costs, and it's really, the other thing that is felt, is that that's - because it's an RHC patient, it's part of some previous visit that has occurred as it relates to the care of that patient. And it's not a separately billable service.

(Brenda):

OK. Thank you.

(Bill Finerfrock):

All right? Next question.

Operator:

We'll take our next question. Caller, your line is open. Please go ahead.

Male:

Hello?

Operator:

Hearing no response, we'll move on.

Female:

Can you hear me?

Male:

Yeah.

Female:

We were just very interested in when you determine whether swing bed reimbursement, whether it's Medicare or Medicaid at the Part B, or a billable service under Rural Health Clinics? And I don't ((inaudible)) we could give you our email address where you could forward that information to us?

(Ron Nelson):

What I would say, I believe that that is a hospital. That's treated as a hospital service, and it's billable under Part B. Medicaid specifically is another issue. You have to look at what - how you're paid for Medicaid, and how they deal with that service. But under Medicare I believe it is a hospital service. But what I'd like you to do is email the email address that (Bill) gave you, and I'll have him repeat that here in a second, and we'll respond to you and make sure that you get a specific and accurate answer to that.

Female:

OK.

Male:

(Bill)?

(Bill Finerfrock):

The email is info, I-N-F-O@N-A-R-H-C.org. And once we have the answer, we will send that, the question and the answer, out to everyone who did register for the conference. So, if you registered, and we have your email address already on file, and that's why we asked you to register, you will get a copy of the question and the answer. There's no need to put in an additional request, or say, "Send it to me." We'll just go ahead and send that to everyone who registered and gave us their email address.

Female:

OK. I have a second question.

Male:

OK.

Female:

Is there any timeframe that is required for documentation for a visit, to deem that visit to be medically necessary?

(Ron Nelson):

I'm not sure I understand what you mean when you say time.

Female:

Is there a timeframe that the physician needs to complete the charting with the dictation or a note?

(Ron Nelson):

Are you - are you referring to a patient comes in today, and is there some certain requirement of what - how many days after that visit that the note is completed? Is that your question?

Female:

Yes.

(Ron Nelson):

Well, that's generally going to be standard of practice, and standard care in your community. Certainly one could challenge that if you're not doing the documentation for a visit for two weeks after you did the visit, how you really know what you did. The general standard is within a reasonable amount of time, a day or so, you're going to finish that dictation and that documentation.

I don't know of any written requirements that says that there's a certain number of hours it has to be completed in. But that's where standard of care, I think, enters into it. The standard of care would say that you would do that, what any reasonable and prudent individual would do in the same situation would be to complete that usually within a day or two.

(Bill Finerfrock):

Operator, I think we're up on 4:00.

Operator:

Yes, we are sir.

(Bill Finerfrock):

OK. If you have additional questions that you're in the line for, but were not able to ask, please send them in an email, and as I mentioned before, we will get answers to those. I do have one that just came in. I'll ask and we'll close it out with that. How should we bill for a G0107 with preventive visit, and what revenue code do we use?

(Ron Nelson):

G ...

(Bill Finerfrock):

G0107 with a visit.

(Ron Nelson):

I don't - I don't have the CPT in front of me to tell which G code that is.

(Bill Finerfrock):

OK. Send an email then.

(Ron Nelson):

So, we'll respond to that in an email. But generally I do want to just clarify that if that is not a face-to-face encounter with a patient, that occurs and is - and is necessary as part of their care in the RHC, then generally it's going to be included within the RHC costs as part of the all-inclusive rate.

(Bill Finerfrock):

OK. I want to thank Ron and everyone who participated in today's national teleconference call. Operator, do you have an estimate of the number of people on, by any chance?

Operator:

Yes. One moment please ((inaudible)).

(Bill Finerfrock):

... this project. We will be having another conference call probably in about two months, and we will send out information about the call-in information, the speaker, and the topic, and a day and time for that call. As I said, the plan is to do between four and six of these over the next 12 months. If you have topics or suggestions that you'd like to send us, please use that same email address that I've given you already. Any type of feedback you'd like to provide us on this project, we'd greatly appreciate it. Operator, any - do you have - are you back ((inaudible)).