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Slide 1: Why All The Paperwork? Presented For Technical Assistance Conference Call by Janet Lytton, Director of Reimbursement Rural Health Development Box 487, Cambridge, NE 69022 308-647-6455 RHDconsultJL@hotmail.com November 14, 2006

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Slide 2: Objectives Participant will be given an overview of the paperwork required within the RHC, to include policies and procedures, info in the patient record, when to use ABNs, MSPs, NEMBs, administrative reports required and various logs to be kept.

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Slide 3: Policies & Procedures Contents of the patient chart Patient Information Sheet Consent for Treatment Consent for Surgery Medicare Waiver (ABN) Medicare Secondary Questions Asked Coding Guidelines Chart Review Correct Revenue Codes used

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Slide 4: Administrative Program Evaluation/QAPI Credit Balance Report Waiver for Staffing Adding a Provider Change Medical Director NPI Number Cost Reporting Documentation Cost Report Due Statistics needed Flu/pneumonia log & time-study Expenses w/I RHC Medicare Bad Debt Log

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Slide 5: Acronyms Used ABN Advanced beneficiary notice AL Assisted Living Facility CMS Centers for Medicare & Medicaid CNW Certified Nurse Midwife CWF Common Working File E & M Evaluation & Management Visit Level HHA Home Health Agency HIC# Health Insurance Claim Number HPSA Health Professional Shortage Area ICF MR Intermediate Care Facility-Mentally Retarded IRHC Independent Rural Health Clinic MLP Midlevel Practitioner

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Slide 6: Acronyms Used MSP Medicare Secondary Payer MUA Medically Underserved Area NF Nursing Facility NP Nurse Practitioner NPI National Provider Identifier PA Physician Assistant PBRHC Provider Based Rural Health Clinic PS & R Provider Statistical & Reimbursement Summary QAPI Quality Assurance Performance Improvement SNF Skilled Nursing Facility SW Swing Bed

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Slide 7: RHC Policies & Procedures Table of Contents Location Philosophy Organization Staffing Services Provided Patient Records HIPAA Grievances Consultations

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Slide 8: RHC Policies & Procedures Collection Policy Patient Care drugs stored appropriately and locked all electrical equipment checked yearly & documented all scalpels and needles locked Laboratory Safety Quality Assurance/Annual Program Review Corporate Compliance Contracts Employee Handbook

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Slide 9: Med Record Forms & Paperwork Required Consent to be treated Authorization to Bill HIPAA Privacy notification Medicare Secondary Payer Questions Asked Pub 100-5 Chapter 3, section 20 ABN issued if applicable Given when service does not meet medical necessity Routine services contractually non-covered do not require an ABN, I.e. physical, can give NEMB Surgical Consent Coordination of Benefits Customer Service for CWF 1-800-999-1118 8 a.m. - 8 p.m. EST Beneficiaries, providers, attorneys, third party payers

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Slide 10: Documentation in Patient Record All pages of the Medical Record must have patient identifier All documentation must be authenticated Signature Initials Stamped signature (policy that only that person uses) Electronic signature - affirmation and password protected If more than one visit per day, date and time of each If counseling is reason for visit, then time in and out can be used to determine E & M Level

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Slide 11: Documentation in the Patient Chart List patient complaints and concerns Document history taken Describe exam or type of exam accomplished Note any injection to be given and Nurse giving List and number diagnoses pertinent to visit Review lab findings and note abnormalities Note prescriptions and/or requested tests List plan and follow-up SOAP note (subjective, objective, assessment, plan)

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Slide 12: Diagnosis Coding - ICD 9 Be as specific as possible (right, left, RUQ, LLQ, which finger or toe, etc.) Lesions - number, where, size, removal method, closure, benign/malignant, size removed Signs & Symptoms Code to fourth or fifth digit Code as primary the reason that brought patient into clinic If an accident, state what, when, where

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Slide 13: Diagnosis Coding - ICD 9 Do not code "probable", "questionable", "suspected" or "rule out" diagnoses Chronic disease coded as often as treated Only ancillary diagnostic services - V code first, then code diagnosis or problem for service Only ancillary therapeutic services - V code first, then code diagnosis or problem for service Surgery - code reason for surgery postoperative diagnosis if different than preoperative diagnosis Code all documented conditions that coexist at time of visit that require/affect patient care

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Slide 14: Charge Master Description/Fee Schedule One fee schedule only for all payer classes No Medicare Pt B fee schedule as in fee-for-service Set fees at highest rate structure in which you participate, plus 5 -10% If using Medicare B Fee Schedule: Set charge at least 50-100% higher than shown Review at least annually Keep prior charge masters

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Slide 15: RHC CHART REVIEW Documentation !!! Must use either 1995 or 1997 documentation guidelines Support Billing?? Are lab tests warranted by diagnoses If not, do we have an ABN signed? Does the Chart, Claim and Encounter form match for services and level of care?? Have we asked the MSP questions?

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Slide 16: Medicare Part A Revenue Codes Effective DOS July 1, 2006 521 Office visit in clinic 522 Home visit 524 Visit to a Part A SNF or SW patient 525 Visit to a Pt in a SNF, NF, ICF MR, AL Patient not on a Part A SNF Stay. 527 Visiting Nurse Service in a HHA shortage 528 Visit at other site, I.e. scene of accident 780 Telehealth site fee 900 Mental Health Services All other revenue codes, I.e. 250 drugs, 270 supplies, are bundled with the visit code charges to submit a one line item.

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Slide 17: Medicare Timely Filing Must file claims on or before December 31 of the calendar year following the year services were furnished. DOS 10/1/2004 - 9/30/2005 by 12/31/2006

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Slide 18: Cost Reporting IRHC uses form 222-92 to your Independent FI PBRHC is a section of Hospital's Cost Report Filing Dates-Due within 5 months of FYE Determines Payment for past year & interim payment for next year Cost Report Issues Staffing FTE's Flu & Pneumo numbers Costs associated with these Submit invoices to prove vaccine costs General Tips for Filing the Cost Report Pay attention to the PS & R numbers If PBRHC, ask to see your clinic portion

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Slide 19: Statistics needed within the RHC Number of RHC encounters by each Physician, NP, PA or CNM by payer class Number of nonRHC (hospital services) encounters by Physician, NP or PA Log of all Flu and Pneumonia injections to include: date, patient name, HIC#, charge Staffing schedules

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Slide 20: Flu & Pneumonia Injections Keep a log of injections Medicare inj. paid on your Medicare Cost Report both IRHC & PBRHC Medicaid is paid only if in your State benefits Keep track of vaccine and supply costs Determine average nursing hours per week Determine average provider hours per week Generally allow 10 minutes per injection on Cost Report but do a time study LOGS MUST BE LEGIBLE

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Slide 21: Expenses within the RHC Allocate staff expenses by employee type i.e. physician, NP, PA, nurse, office, maint. Allocate payroll tax expenses by employee type Do not code to "Miscellaneous" Reference Lab is not an RHC expense X-ray & Lab expenses must be allocated separately to include staffing for both Equipment >$5000 to be depreciated out Depreciation on straight-line Medicare schedule All expenses "reasonableness" must apply Medicare Bad Debts paid on cost report w/log

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Slide 22: Medicare Bad Debt Expense Must keep patient name, date of service, HIC#, if co-insurance or deductible and dates billed Exhibit 5 of the HCFA 339 Form Presently RHC Medicare Bad Debt paid at 100%

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Slide 23: Quality Improvement/Program Evaluation Ongoing QAPI Program Annual Review of: Utilization of clinic services, including at least the number of patients served and the volume of services A representative sample of both active and closed clinical records Clinic's health care policies There is a determination if: Services were appropriate Policies were followed and if not, what changes made Action was taken

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Slide 24: Utilization of Services Clinic Encounter Form Are we keeping track of the number of visits seen by each provider, by payer class? Both RHC visits and nonRHC visits Listing of patient services by CPT code Tracking the referrals to other facilities/ specialists Are we getting the reports back and filed in the chart

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Slide 25: Medicare Credit Balance Report CMS 838 Usually prepared by the Administration or Billing staff A disclosure of any payments made by Medicare that are overpayments Due the month following each calendar quarter If not received w/i 5 days after due date, then 100% payments withheld Riverbend GBA has an excel file on website

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Slide 26: Waiver For Staffing Waiver of Staffing Requirements Limited Must employ a PA/NP/CNM at least 50% of the time the clinic is open to see patients at the time of certification If lose MLP, can obtain a waiver for a period of up to 1 year. After loss of MLP, must be in staffing compliance within 90 days without obtaining a staffing waiver

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Slide 27: How Do I Add a New Provider? For Part A, no specific paperwork required RHC pays facility and not a provider Provider UPIN is required on claim For Part B, CMS 855 Form sent to Carrier All other insurances require their paperwork and the provider to be listed a covered provider http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

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Slide 28: How Do I Change The Medical Director? Complete and update the CMS-29 (Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide Rural Health Clinic Services) Send the CMS Form and a copy of the collaboration agreement to your State Surveying Agency with a cover letter explaining the change. State Agency will then send the Regional Office a copy of the CMS-29 for their files http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp

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Slide 29: Other Recommended Log Sheets Refrigerator/Freezer Temp Log Blood Glucose Quality Control Record Hemoccult Quality Control Log Laboratory Specimen Log (reference Labs) Chart Review log between Physician/MLP Referral Log Narcotic count log Sample Drug Inventory logs

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Slide 30: Grievances/Complaints "Filing Grievances/Complaint" Policy Must be in writing and signed by the person with grievance Medical Director must review with investigator Findings must be given to the complainant verbally and in writing and what corrective actions taken. All paperwork will be filed in the business office If patient not satisfied they may report to the State Department of Health

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Slide 31: Grievance/Complaint Procedure Report form or Patient Satisfaction Survey Number of Days the complaint will be acted upon What to do if the patient disagrees with findings Investigation Report Grievance/Complaint log Discussed at the Annual meeting

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Slide 32: Medicare Corporate Compliance Hosp/Clinic Corporate Compliance Policy Do we have consents signed? Are we getting ABNs (Advanced Beneficiary Notices) when appropriate, CMS PM AB 02 114 July 31, 2002 Copy of ABNs (must be the form dated June 2002) Are we asking the MSP (Medicare Secondary Payer) questions?

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Slide 33: Internet Websites of Interest www.cms.hhs.gov (Centers of Medicare & Medicaid) www.cms.hhs.gov/MLNMattersArticles/ (CMS Medlearn) www.highmarkmedicareservices.com (Veritus) www.trailblazerhealth.com (Trailblazers) www.riverbendgba.com (Riverbend GBA) www.narhc.org (National Association of RHCs) www.hrsa.gov (Health Resources & Services Adm) www.bhpr.hrsa.gov/shortage/ (MUAs & HPSA Listing) Rural Health Development Website & my e-mail: www.rhdconsult.com RHDconsultJL@hotmail.com

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Slide 34: QUESTIONS ? ? ? ? ? ? ? ?