Good day everyone and welcome to the Rural Health Clinic's technical assistance conference call. Today's topic: why all the paperwork. Just as a reminder, today's call is being recorded.

Now for opening remarks and introductions, I would like to turn the call over to Bill Finerfrock. Please go ahead, sir.

Thank you, Operator. I want to welcome all of our callers today and participants to our conference call, RHC's why all the paperwork. I'm Bill Finerfrock and I'm the Executive Director of the National Association of Rural Health Clinics.

Our presenter today is Janet Lytton who's a Rural Health Clinic consultant with Rural Health Development out of Cambridge, Nebraska. Janet today is going to talk about giving us an overview of the paperwork required within the RHC, including the policy and procedures, information on patient records, when to use ABNs, MSPs, NEMBs, administrative reports required, and various logs to be kept.

Today's program is scheduled for one hour. Our speaker is going to go for about 45 minutes, and then the remaining 15 minutes the phone lines will be open for question and answers.

This call series is sponsored by the Health Resources and Services Administration's Federal Office of Rural Health Policy in conjunction with the National Association of Rural Health Clinics. The purpose of the call is to provide Rural Health Clinic's staff with valuable technical assistance and RHC-specific information. Today's call is the 14th call in this series, which began in late 2004 and will continue for the next five years. There's no charge to participate in this project. Individuals can sign up and receive announcements regarding call dates, topics, and speaker presentations at www.ruralhealth.hrsa.gov/rhc.

If you have questions for future calls that you'd like to send in, you can e-mail those to info info@narhc.org and put teleconference question in the subject line. All question and answers, we will attempt to answer those. I'd like to remind callers that there was a PowerPoint presentation made available and was sent to you via e-mail previously.

Janet, at this point, I'd like to turn the call over to you and we look forward to your presentation.

Thank you, Bill. I would like to welcome everybody on the conference call and I thank you for inviting me to do the presentation.

On slides three and four, you will notice that we have an outline of today's presentation. I'm not going to waste time by going through the outline.

On slide five and six, these are the acronyms that will be used within the presentation today and many of us just fly through acronyms because we use them every day and some people don't understand what we're talking about. If you need to refer back to, it's slide five and six for the acronyms that are going to be used in today's presentation.

One of the very first things with the paperwork that's required within our Rural Health Clinic was our policies and procedures. Every one of us know that in the certification process this is probably one of the main items that the surveyors will be looking at. Those sections of the policy and procedure manual are possibly - now, people can have their own sections; however, I have derived these sections and - within my manual, and as long as you've got the regulations covered the surveyors don't expect a certain format.

You may have the table of contents, the location, where are you located, are you an underserved area, or are you a HIPSA, or are you on a governor's list of shortage areas, what's our philosophy in the clinic, what's our organization, do we have a board, do we have - is it a sole proprietorship, is it a corporation, all of those things pertain to organization.

Staffing, we have to have a medical director so we'll definitely have that person for staff. And also the midlevel practitioner, whether that be a PA, a nurse practitioner, or a certified nurse midwife, those are the main components of your Rural Health Clinic with the - with the support staff required for each of those providers. You may have nurses, RNs, LPNs, medical assistants, office, billing people, lab people, whatever your office requires that's what they expect you to have in your staffing section in your policy manual.

What services do we provide within the Rural Health Clinic? The services within our Rural Health Clinic are those that are typically offered within any physician's clinic and we must note what services we offer. Where do we send our patients for any specialties, what hospital are we using, those types of items are in the services provided. Remember, we have to be able to provide the six basic lab tests. Those will also be a part of our policy and procedure manual. We can supply or offer any number of laboratory tests but we are required to offer at least those six.

Patient records, that's always a big one. Whether it be electronic records or paper records, we have to have policies on we handle our records. The notification of HIPPA is another item. How long do we keep our records, who documents in them, all of those items are patient record entries within your policy manual.

Grievance policy, this is probably one policy that many clinics don't have but there're getting to be more and more all the time. If we have a patient complaint how are we handling that? Are - we need to have it in writing how we handle it, how we investigate it, and what are we going to do about what the outcome of that particular grievance.

Consultations, where do we send our patients to specialists. We need to have a policy on the consultations for our patients within the Rural Health Clinic. Collection policy, we all have accounts receivable and collection's policy. It must be the same over all payer classes and it must be in writing. Patient care policies: how are our drugs stored; is our electrical equipment checked, who is it checked by. Remember that we must have a biotech engineer check our electrical patient equipment at least annually and put their blessing on it, so to speak, for it to comply with the regulation, and all the scalpels and needles, most surveyors at this point are requiring to be in a locked area, whether it's a cabinet or a drawer, or a closet, for that matter.

The laboratory section, how do we do each and every lab procedure within our clinic, this can be a separate lab procedure manual that you refer to in your main policy manual but it doesn't have to be. It can be within your one manual for your Rural Health Clinic. Safety, safety is another section with in the policy manual. How do we handle natural disasters, how do we handle fires how do we handle tornadoes, hurricanes, floods, bomb threats, any of those items and those circumstances that we need to have a policy within our policy manual.

Quality assurance and the annual program review, within the new regulations the quality assurance piece is going to be a big part of our Rural Health Clinic. The annual program review has always been a part of our Rural Health Clinic regulation. Within the new regulations for quality assurance the - if you read it closely, the annual program review pieces, whether it be the review of services or whatever, is a part of the new regulation as well. Each and every provider that provides Medicare and Medicaid services should have a corporate compliance policy. In that policy, it is basically going to state how are we going to be sure that we are billing appropriately for those payer classes and all of our other payer classes as well.

And then we've got our contract section. Do we know or can we prove that we have a place for our particular patients to be referred to, to the hospital, do we have a contract with a medical director, those types of situations become contracts. Do we have a contract with a referenced lab that are receiving our specimens to - for our Rural Health Clinic? And the last but not least is the employee handbook. Each and every one of us have an employee handbook, whether it be five pages or 50 pages or whatever. It tells our employees what we expect of them.

So that's basically an overview of the policy and procedure section.

Our medical record forms and paperwork that's required on slide nine, we need to have a consent-to-be-treated. Every patient that enters our clinic from the beginning of time should have a consent-to-be-treated. This is signed by either themselves, a guardian, or a parent so make sure that you have that consent-to-be-treated. That's going to be one of the very first things that surveyors will look for.

Do we have an authorization to bill? We must have an authorization in order for us to bill any insurance company that particular patient has. Have we given all patients their HIPPA privacy notification? I have noticed in clinic charts, whether they be electronic or paper, that the HIPPA privacy notification is noted as given on the front of the chart or in a notation on an electronic medical record. Also, since we receive Medicare dollars and we are billing Medicare, we are required to ask the Medicare secondary payer questions. You can find the Medicare secondary payer information in publication 100-5, chapter three, section 20 of the CMS manuals.

I would encourage each of you to review that. We must - we must as a clinic get that Medicare secondary - those questions asked of those patients each time they come into the facility to see one of our providers. The only - we've all heard it has to be once a year, every 90 days, or every time. The actual regulation reads that if it is a plan of treatment for the same ailment, you can ask the questions once every 90 days; however, typically, within our Rural Health Clinics, those patients are not coming in for a repeated plan of treatment so it would be required each time that they come in. It's probably an ailment issue, and at that point, it needs to have the secondary payer questions asked at that time. This can be electronic; it can be on paper, whatever the case. Remember, it is not a form created by Medicare, it is questions asked, and who asks the questions and the date that they ask those needs to be documented somewhere, whether it's electronically, or whether it is on paper, within their chart, or within their financial file.

An ABN, advanced beneficiary notice, CMS form 20007, is actually a - excuse me - the ABN form for healthcare items is CMS-R-131-G and that is a general healthcare - for healthcare items, and then they've got the same form, CMS-R-131-L, for laboratory tests. If our diagnosis does not support having either a healthcare item or a laboratory test, we must give the ABN to the patient for them to sign telling them that this will most likely be denied by Medicare and it will be your responsibility to pay. Either at that point, they decide to have the test or the item and they pay for it or they can decide not to have it, it's their choice.

There's also another form that can be used and it's the NEMB, Notice of Exclusion of Medicare Benefits. It's CMS form 20007. This form actually gives the beneficiary a list of items that are excluded from the Medicare benefit. This is all in their Medicare handbook; however, some beneficiaries don't always read the manual clear through and think that Medicare should cover everything. However, this gives them a list of items that are not covered by Medicare and you can give them that when the ABN doesn't apply.

We've also got to have within our clinic what's called a surgical consent. For any incision or excision, we are required to get a surgical consent signed. This should be given to the patient and the consequences of the surgery or whatever needs to be explained to that patient by the provider and have it - have that form signed that they understand and that they want to consent to that surgical procedure.

Many times, we've also got an issue, are these particular patients allowed to have this or that preventive service, or maybe we have a Medicare situation where Medicare is not paying for their services and they should be, then we need to look up on the coordination of benefits for that particular beneficiary on the Common Working File. The Common Working File telephone number is listed: 1-800-999-1118. It's open from 8:00 A.M. to 8:00 P.M. Eastern Standard Time. Any beneficiary, a provider, an attorney, or a third-party payer can call that Common Working File, or look it up on the Common Working File if that beneficiary has those services that are available.

If - (now), I've had this happen - if that particular beneficiary happens to have Medicare discontinued and have been put to a Medicare Advantage plan, the Common Working File will tell you that. There have been some beneficiaries that have signed out, or opted out of the traditional Medicare unbeknownst to them, which has always been a problem, and I think what's happened when the Medicare Part D started, they got the wrong button to click and it changed their whole Medicare package.

Documentation in the patient record, slide 10, all pages of the medical record must have a patient identifier on them. Whether it's the patient name, number, their clinic number, whatever your format is, every page on the medical record must have this identifier. All documentation must be authenticated from signatures to initials to stamped signature. If you use a stamped signature you need a policy that only that particular person on the stamp is the one that uses that stamp.

Electronic signatures as well, there must be a policy for the affirmation and password protection of that electronic signature. If you do use initials, you need to have initials with the signature beside it and then print it out so that you know exactly who that initial stands for. If there happens to be more than one visit per day, in the medical records you're going to want to date and time each visit. They - each visit may or may not be a single billable visit; however, it all needs to be documented in the chart. If counseling happens to the reason for the visit in that particular day, then the date - the time in and out can be used to set the E&M, but we've got to have it documented before we know which E&M, evaluation and management code, to use.

On slide 11, we - within the patient chart for each visit you're going to want to have the patient complaints and concerns listed. Any of the history that has been taken or referred back to needs to be documented. We need to have the type of exam documented; was any injections given and who gave that injection. Remember, the nurse, if they give that injection, must have the order to give that injection from the provider. If that provider routinely dictates their notes and if that nurse is depending on that provider to dictate that order, sometimes that may or may not happen, and in that case, the nurse needs to put a verbal order per the provider and then (them) the nurse giving that particular injection. That way she's covered; our verbal order is there and we are OK within the billing mechanism to bill that particular service.

Also, we need the list and the number of diagnosis pertinent to each visit. Was it the bronchitis that brought him in? Is that number one. Is it the diabetes? Whatever the case may be, we need those listed and the number beside it, or if they list them in the order, which would be the most preferred, in the chart.

We also - if there has been lab tests done, we need to review those lab findings and note any abnormalities. If they're normal labs that's all that needs to be stated: normal labs. And many times, I see providers initialing the normal lab, and that's fine; however, if there are any abnormalities, it needs to be noted in the chart and who is going to follow up with that patient with those abnormalities. Whether it be the doctor that tells the nurse to do it, that's fine, or does the doctor call them or bring them back in, that is another option. Then we also need to have listed a plan and a follow-up. What does the patient do if, you know, if fever persist in five days come back to the clinic; whatever the plan is, it needs to be noted.

Every bit of this stuff that I've just been talking about on each particular visit can be considered a SOAP note: the subjective, objective, assessment, and plan. It's a great format to get in the habit of using and it puts everything in an order so that it's easy to identify an E&M level if you look at those different areas.

Our diagnosis coding, that's another part that is a paperwork issue. Whether it's the billers that are doing the diagnosis coding from the lingo and the words that the providers use, that's fine; however, the providers when they do dictate or document need to be as specific as possible. The right, left, the right upper quadrant, the left lower quadrant, which finger, toe et cetera, all of those different areas need to be noted within that documentation. Lesions, what were the number of lesions, where were they, what size were they, what's our removal method, what's the closures that we're using, were they benign or malignant, and what size was removed. That's the most important because that's what we've set the ICD-9 coding level with is the size that was removed, not the size of the lesion itself.

And many times within our rural health clinic when a patient comes to see us all we're going to have for a diagnosis is the sign or symptoms that brought them in. That's fine because at that point we have no precise diagnosis; it's going to be that sign or symptom. And also make sure that you code to the fourth or fifth digit, whichever applies. Most of our systems right now, whether it's our billing system or our electronic health record, will not allow us to use an incorrect code, which is very, very nice. It makes it easier for the coders.

Also be aware to code as primary the reason that brought them into the clinic. They may have other diagnosis that they're going to be seen for that day but what brought them into the clinic is the primary reason. And if we have an accident situation, we need to make sure that we have stated what, when, where, and also how did it happen. This accident could alert us to a Medicare secondary payer issue, and at that point it could be the liability insurance that is responsible for the payment of that particular visit.

And within our coding on slide 13 note that we in the clinic setting do not code probable, questionable, suspected, or rule out diagnoses. These are only - in the hospital they can; however, in the clinic setting, they cannot code those particular diagnoses. Chronic disease is coded as often as treated, and many times if a patient comes in for an ailment with, let's say, for bronchitis, for instance, if they're going to give him medicine for the bronchitis they're going to take into consideration his diabetes or his hypertension, and in that case, all of those codes need to be on the list of diagnosis codes. But if they happen to come in for something that - like bronchitis and they've had a history of a gall bladder surgery five years ago we don't need that particular code. So it's only what is applicable for that particular day.

Also if they come in for only a diagnostic service, we may have a V code first and then the diagnosis or the problem is stated. Also for therapeutic reasons, it's a V code first and then the diagnosis for the problem or for the service. I will say that some commercial insurance companies and sometimes Medicare do not like to see the V codes first and then you would switch the two around. I don't necessarily agree with that as a coder, but if - I guess if that's the way they want them that's the way we're going to have to submit them when we're submitting the claims.

Surgeries, we code the reason for the surgery, and if the postoperative diagnosis is different than the preoperative diagnosis, we use the postoperative diagnosis. Also, we need to make sure that we code all documented conditions that coexist at the time of the visit that require and affect the patient care. That's what I was talking about earlier on the chronic disease.

Another big, big paperwork issue within the clinic is our charge master. Have we got our charge master where it needs to be? One fee schedule for all payer classes is required within the Rural Health Clinic setting. When we became a Rural Health Clinic, our private pay fee schedule became our Medicare fee schedule, and at that point, we got to set our rates where we need them to be. Now, if we've got an insurance company that's allowing every dollar that we ever charged, then perhaps our fee schedule is not high enough.

I would suggest doing a fee structure analysis with your payers, whether it's a Blue Cross or a Mutual or an AARP or a Midland's Choice, whatever the case may be, and then do a comparison to your fee structure to see where you need to set your fees. Your fees will not be like the person's down the street or in the next town. It needs to be where you need to them to be. And Medicare accepts our fee schedule as the applicable Medicare fee schedule within our Rural Health Clinic.

If you are using the Medicare Part B fee schedule to set your rates, which I would discourage - however, there are still some that do - I would suggest setting it at least 50-to-100 percent higher than is shown on the Medicare Part B fee schedule. Again, review these charges at least annually and then keep all your prior charge masters in case you have to support your billing within an audit situation.

When you're doing your documentation, we must also do a chart review. On slide 15 - remember, within our regulations, we are allowed right now to use the either 1995 or the 1997 documentation guidelines and it should support our billing. Whatever we have documented in the chart should support the level that we have billed and what we have billed; are the lab tests warranted by the diagnosis, if not, do we have an ABN signed; does the chart, the claim, and the encounter form match for the services and level of care. I cannot tell you how many chart reviews that I have done that the three of those don't even look like the same visit except for the date of service so it's very important that all three of those match. And then again, have we asked the Medicare secondary payer questions.

Starting on July 1st of 2006, date of service, we are required within our Rural Health Clinic now to have the different 52X revenue codes. On slide 16, it shows you the different revenue codes that we are now obligated to use within our Rural Health Clinic. Also, our Medicare billing only requires a one-line item. So it's important that we put all the parts and pieces in our billing system so we can decipher what the total line item was; however, when it is submitted to Medicare, it's a one-line item with the 52X revenue code depending on from those places which revenue code we use, and then the other revenue codes, like the 250 drugs, the 270 supplies, are bundled in with our 521.

Now, some Medicaids in the different states will require line-item entry by revenue code. I know that for a fact because Nebraska is one of those particular states. So then you're going to have to have a way to differentiate out the office visit from the supplies to the drugs in each line item entry. I also want to bring up at this time, which I don't have a slide on, that we are going to be required to change our UB92 form to our UB04 form. This goes into - start using it on March 1st and we have to use it by May 23rd of 2007. You can find the information on this in Medlearn Matters with MM5072. So not only the UB04, we're going to be given a new HCFA 1500. So that particular form starts use in January 1 and we have to start using the new form by April 2nd of 2007.

These new forms, they aren't a whole lot different than we're used to using right now; however, they have given us the opportunity to use the NPI numbers. That's another piece of our paperwork that each and every one of us need to have filled out at this time so that we can start building crosswalks from our NPI numbers to our traditional provider numbers within the Rural Health Clinic, and that's a whole other conference call in itself.

The next slide on 17 is many people ask me what's the Medicare timely filing. Well, for our filing of claims for right now, the date of service 10/01/2004 through 09/30/2005 need to be submitted by 12/31/2006. That's by the end of this year. We can right now go back to October 1 of 2004 and submit anything that we've got out there that hasn't been submitted correctly, or we need to do an adjustment on, it needs to be completed by the end of the year.

Another big part of our Rural Health Clinic and it's how we are paid depends upon our cost reporting. The independent Rural Health Clinic uses the 222-92 form and the provider-based Rural Health Clinic is a section of their hospital's cost report. The filing dates for this particular cost report is the - it is due within five months after your fiscal yearend. So if your fiscal yearend is December 31st, you've got until May 31st to have that completed cost report sent to the fiscal intermediary.

That cost report is so very important because it determines our payment for the past year that we have just completed and the interim payment for the next year, and you have to make sure that your staffing FTEs are correct on there. Just because you're paying a full-time doc doesn't mean that they are seeing patients a full-time equivalency, and the staffing productivity levels depend on us showing that our FTEs are correct on our cost report.

Flu and pneumonia numbers, that's how we get paid for our flu and pneumonia shots is on our cost reports so it's very important that we keep those numbers. And the cost of those vaccines, whether we have to submit invoices to prove our vaccine costs, whether we have to produce our time study to the fiscal intermediary on how long it took to do each individual flu and pneumonia shot, whatever the case may be, we need to have that documentation.

Also, some general tips for filing the cost report: pay attention to your PS&R. PS&R is a provider, statistical, and reimbursement summary. This report - this statistic report tells you the number of claims that Medicare has processed in the past year. It should be very, very close to the number of Medicare claims that you've got listed on your data sheets.

If you're a provider-based Rural Health Clinic, I know that many of those office managers do not see their portion of the cost report. It is very important that you ask your administrator to be a part of that cost report because you can tell from looking at it, hopefully, that if they've got the wrong amount of numbers in there, they've got the wrong number of visits, whether it's the flu and pneumonia injections, it's not uncommon - I've been in hospitals and reviewed cost reports, they have zero flu and pneumonia, I know better and I know that they did not submit them to Medicare Part B. So what happened to those? That's a lot of dollars that somebody is not getting paid for.

(In) slide 19, the statistics that we need to keep, are we keeping the number of Rural Health Clinic encounters by physician, nurse practitioner, PA, or certified nurse midwife, by payer class. That's how we need to keep them. If our computer system will do it, then fine, I say use it, but by all means, make sure that your manual count matches your computer count, which I've seen many, many times it doesn't. So have a method in counting your encounters.

Also, we need to know the number of non-RHC visits. (Well), that's the hospital services for the same providers. (Our) log of all flu and pneumonia injections, again, if your computer will print this out, that's fine; however, make sure that it will do it beforehand because this is so dependent on what your clinic is going to get paid for the past year and the following year. Also, keep all of your staffing schedules so that you can collaborate your cost report by the number of hours, the FTEs, all of that information.

Our flu and pneumonia shots, I cannot stress enough, make sure that they are legible, if they are a handwritten form. Sometimes I can't read them and I don't see how the fiscal intermediary could so make sure that that name also matches that health insurance claim number that you have got on that particular log sheet.

On slide 21, expenses within the Rural Health Clinic, make sure that the expenses are allocated appropriately. It makes the cost report so much easier to complete, whether it's a hospital auditor or whether it is a independent Rural Health Clinic cost report person. I know when I do cost reports for the independent clinics that I do, if I have to ask for all of the expenses to be explained to me because they're in such broad categories, it's much easier on them if it's broke out from the beginning, when they're put in instead of me asking for them after the fact. Lab and x-ray expenses, remember, those are non-Rural Health Clinic services, so you're going to have a carve-out in that particular part, make sure that those are kept separately.

Medicare bad debt expense, this is one expense that we can claim on our Medicare cost report at this particular time. We are paid 100 percent right now but we have to complete Exhibit five of the CMS 339 form. It's a part of our cost report every year, and if you've got that log sheet or an Excel file to go right along with that Excel or that exhibit five, you're fine and that must be in that particular format. You can be compensated back for all bad debt co-pays and deductibles that Medicare Rural Health Clinic visits patients did not pay you if you have tried to collect for 120 days and you have to write those off so it's an advantage to keep it. So it's up to you as an administrator to require that.

The QA, the quality improvement per program evaluation, remember, our QA program must be an ongoing program. Our annual review of the utilization of services, we need to know the number of patients, we need to do chart reviews, we need to review all of our healthcare policies, all of that information needs to be reviewed, and if there was any changes that needed to be made, we need to note that. This whole review policy and evaluation needs to be in writing annually and that's every 12 months - annually.

For our utilization of services, we need to look at both Rural Health Clinic services and non-Rural Health Clinic services, and I would suggest printing out a CPT code report by provider and that will tell you your top CPT codes used. Also, you can print off a diagnosis code - your top diagnosis codes, and perhaps one of those top diagnosis codes is one of the QA projects that you would like to do. So there's any number of reasons to review those reports throughout the year.

Medicare credit balances are a report that we have to submit to the fiscal intermediary. It is CMS 838 and it is required the month after each calendar quarter and it is sent to your fiscal intermediary whether you have Medicare credit balances or not. So it is very important that you send this because if you don't they will withhold all of your payments until they do receive it.
Riverbend, one of our fiscal intermediaries for our independent clinics, does have an Excel file on their Web site that will tell you if you have submitted this particular 838 form or not. It's very nice. It works very well.

A waiver for staffing, this becomes very important if we happen to lose our midlevel practitioner. We all know that when we become certified as a Rural Health Clinic, we must have that midlevel on staff at the certification date. If we lose that midlevel practitioner, we are required to be back in compliance of staffing within 90 days after we lose him or her. If we don't, we can obtain a midlevel waiver from the State Department of Health and you can operate for a period of one year as long as you are continually recruiting for a midlevel practitioner.

How do you add a new provider, on slide 27. For Part A the Rural Health Clinic paperwork there is no specific paperwork; however, the provider's UPIN is on the claim and the Rural Health Clinic is actually the provider and not each individual. For Part B, you're going to want to fill out the CMS 855 form and send it to the carrier. And all other commercial insurances require their own specific paperwork, and remember, if you get a new provider within your group and they see a commercial insurance patient and that provider doesn't happen to be a provider in your clinic it will be considered out of network, so make sure that you have added each provider to those commercial insurances as well.

Another change may be what do we do when we change our medical director. This is a form CMS 29. It is also filled out and sent to your state survey agency with a cover letter that explains the change along with the collaboration agreement with you and that medical director - the clinic and the medical director, and then they send it on to regional office for their files so it's very important that we make these changes. Also, any of the forms that I have talked about today can be obtained off the Web site of the CMS and the address is at the bottom of slide 27 or 28. Let me tell you, I use that a lot and not just for clinics, I do consulting with other providers as well, and it is very beneficial to be able to pull those off at any time.

Some of the other log sheets that you may want to use within your clinic would be a refrigerator and temperature log - a freezer log. It's important that we know that our refrigerators and freezers are at the temperatures that they need. Maybe we do a blood glucose quality control record, the hemoccult quality control logs, our lab specimen log, where did we send them to the referenced labs, are we getting those reports back; we need to follow through on those if we are not.

Chart review log between the physician and the midlevel practitioner, how do we prove that our physician and midlevel practitioners have had that meeting together and reviewed certain patients or ways to treat those patients. Referral logs, are we keeping track of where we're sending our patients to specialists or hospitals, or wherever the case may be, are they going, are we getting the reports back, that's very important. Narcotic log sheet, we are required if we have narcotics within our building to keep a narcotic log each and every day. Sample drug inventory logs, that's another recommended log sheet.

Grievances and complaints, are we keeping that log sheet, do we have our policy, we need to have all of that information readily available if we happen to get surveyed and the surveyor may ask for it.

Another - next one - I'm going to skip to slide 32 - Medicare corporate compliance, we must have a corporate compliance policy. We need to be doing our chart reviews. Are we getting our consents signed, do we have our advanced beneficiary notices, are we getting our Medicare secondary payer questions asked, we need to do a compliance check periodically to make sure that we're following all of our guidelines. And that can be done by anybody. It doesn't have to be done just by the billers. These things can be done by anybody.

On slide 33, I have listed several Web sites that are very beneficial. Just because your fiscal intermediary may not be one of them that is listed, these fiscal intermediaries that are listed are very good about a lot of information on there. The CMS Web site has everything you'd ever want to know and probably more. The National Association of Rural Health Clinic's is very good.

Also, I would like to encourage you - each and every one of you to attend the National Rural Health Clinic's seminars that they have. I'm leaving right after this particular call to head to Washington, D.C., as the next meeting is in Washington the rest of this week. They are very beneficial. They have one in Washington, D.C., San Antonio, and Reno, and I will tell you that I attend most of those and I've attended the Washington one almost every year, and there has never been a time that we have not brought something home with us that has been beneficial. And I've been in this business for 17 years and something changes each time and more information is out there, and I would encourage each and every one of you.

If your questions today are not answered, I would encourage you to send me an e-mail. I will answer your questions, but I will tell you I will be gone until next Monday now so it'll be a few days before I could get to it.

I thank you very much for having me present today, and if you have any questions, I'd be glad to answer them at this time.

Thank you, Janet. That was excellent. I really appreciate that. I want to encourage, when we open up here, when you ask your questions, please identify yourself by name and the location of the state that you're calling from just so we can get a sense of where our calls are coming from.

Operator, at this time, we'd like to open it up to questions.

Thank you. To ask a question, please press star one on your touch-tone telephone at this time. A voice prompt on your phone line will indicate when your line is open to ask a question. Also if you are using a speakerphone, please make sure your mute button is turned off to allow your signal to reach our equipment. Once again, it's star one at this time if you do have a question.

We'll go to our first question.

Go ahead, caller.

My name is (Debra Morris) and I wanted to know how we can get the slides e-mailed to us.

Are you on the Rural Health - how did you find out about the call?

Well, to be honest with you, I got it from (Marsha Mars), who's a Rural Health coordinator in Lexington, South Carolina.

OK, we will - give me your e-mail address.

It's Morris - M-O-R-R-I-S ...

OK.

... @KCMC.org.

OK, what I would - I gave out an e-mail address earlier. You can go in and sign up to receive the notices directly, and then we distribute the slides to everyone who signed up for this conference call series. There's no charge for that. You just need to provide your e-mail address and that way you'll get the notices as well as the slides, and as well a notification when the transcript is available.

Is that the e-mail address that was info@narhc.org?

No, that was the HRSA, www.hrsa - I don't have it here in front of me right now but ...

Yes, I tried to write that one down and you'll -you said it so fast ...

Hold on a second.

... I couldn't get it all.

www.ruralhealth - as one word - .hrsa.gov/rhc and there are instructions there as to how to sign up.

OK, I got it then. Thank you.

OK, thank you. Next caller?

Janet ...

Yes.

... this is (Sharon O'Brien) in Benkelman, Nebraska.

Hi, (Sharon).

How you doing? I have a question on the medical director. It says that if she would (resign) a copy of the collaboration agreement, could that be the contract?

Yes, absolutely.

OK.

Before we go to the next call, we had one e-mailed in. This is from (Lisa). I'm not quite sure where (Lisa Fureria). What is the purpose of the following logs and what should be recorded: the blood glucose quality control, hemoccult quality control, and referral. You mentioned those in your presentation?

Yes, I did, Bill. The hemoccult quality control and the blood glucose quality control, basically that tells the surveyors or whomever that we have done quality control checks on each of those pieces of equipment and that we know that our lab tests are accurate.

The referral log, that is needed because when we send our patients to an orthopedist, whether it's a cardiologist, any of those referral physicians that we know that they made it to that particular physician, and that if they did, we want a copy of that particular visit in our chart so that we know what happened at that particular visit. If we have no log and if we have no way of keeping track and our charts are put away, how are we going to know what ones we need to maybe follow up on?

OK. All right. Next caller?

Hi, this is (Deb). I'm in Kansas.

Hi, (Deb).

On page 11, you talked about the injections and the nurse giving those injections.

Right.

We have an injection log in our chart and the nurses put that injection on the log but it may not be referenced in the dictation, does that matter?

It needs to be referenced and that physician needs to make the order for that particular injection. If the order is not in the documentation in the chart, then the - ultimately, if an audit was done, those services could be denied and you would not get paid anything for them. There must always be a physician order for anything that a nurse has done.

OK, and so it ...

((inaudible)) PA or a nurse practitioner.

Yes, anybody ...

Right.

... anybody. Anything that happens to that patient, the provider must have an order in there for that particular service to be completed.

And it needs to be part of that day's dictation.

Absolutely, yes.

All right.

((inaudible))

Thank you very much.

You're welcome.

Next caller?

Yes, this is (Steve Noble) and I'm calling from Glenwood, Georgia. My question concerns the NPI numbers for hospital-base Rural Health Clinics. On some of hospital-based clinics, we understood you could use a taxonomy code instead of a separate NPI for the Rural Health Clinics.

No, a taxonomy code is part of the application process for the NPI but you're going to have to have an NPI for your Rural Health Clinic.

Are you asking if the NPI can be the same for the hospital a well as the RHC ...

Yes.

... hospital?

It's hospital-based.

Right. I believe that because of the way that new UBO4 form - and these crises come up in the independent environment as well - you could - you can use a single NPI for those entities. It may create an accounting problem internally in terms of your ability to differentiate or distinguish, but you could have a single NPI that you use when you did your 855. You would use that NPI for the hospital for the RHC. You would still have to have separate NPIs for the individual providers who work in the RHC to the extent that you wanted to submit claims to Medicare Part B for their services, but I believe that you could use a single NPI for the parent as well as the clinic.

A quite similar question for the independent is, if I have a group that is - that is - and I have an RHC, can I have the same NPI number for the group as well as the RHC, and the answer to that question has been, yes, you can have a single NPI for the group and the - and the RHC. So I believe based on that the answer would be yes, but I do think that we need to get that clarified for the provider-based ...

Well, it is a problem because in the taxonomy codes I could not find an RHC taxonomy code.

There is a Rural Health Clinic taxonomy code.

For hospital-based?

(Well), I think it says Rural Health ...

All the same.

... ((inaudible)) don't know that it makes a distinction.

OK because for the - when you have a hospital-base, for example, a swing bed or a hospital-base psychiatric unit, there's a - there's a letter that goes after your NPI code - your NPI number that distinguishes between those different things and I haven't seen one - that letter, a Z or a W, that would be just, you know, after the hospital's NPI number that distinguishes a subprovider within the hospital.

Well, again, we'll check on that and what we can do is when we get clarification on that we will post it on the list serve.

Because what would happen is if, I get another NPI number with the same tax ID number, I think there may be a problem here when you got two NPIs or three NPIs or four NPIs with the same tax ID number ...

OK.

... if we don't have a separate taxonomy. If we have a separate taxonomy, then it works beautifully.

Yes, there is a Rural Health Clinic taxonomy code. It just does not distinguish between provider-base and independent.

Well, that's the problem.

OK, we will check on it.

How would I hear from you? Would you ...

We will ...

... post ...

... we will post it on the list serve.

OK, good.

Next question?

Caller, your line is open. Please proceed.

Hi. My name is (Cheryl). I'm calling from Sebring, Florida. I just had a quick question on the new smoking cessation procedure code. As a Rural Health Clinic, can we bill that as a separate with a modifier?

If ...

Or do we have to use it as a bundle?

Are they seeing the provider?

Yes, they would be seeing the provider for a regular office visit and then the counseling on the cigarette cessation.

It would all be part of the same visit.

So would we (be able) to use a modifier and get paid for that as a separate ...

You would - you would bundle that with your office visit for the charges.

You would have a single encounter.

Yes, one single encounter with both the charges, but if they're only coming in for the counseling of the smoking cessation as a benefit, you may not have a E&M code to go with it ...

OK, OK. Thank you.

...OK?

Thanks.

Next question?

Hello, Janet. My name is (Julie Westling). I'm in Telluride, Colorado.

Hi, (Julie).

I have several questions. I'll try to limit them. You referred to a face-to-face encounter in making sure that our computer systems could generate that. I know for a fact that our computer system picks it up by claim so we actually have a manual way of telling that. Is that going to work against us?

That's not going to - to me, that's not going to work. Does it - because with commercial insurances, you can have a claim with only a nurse visit, and if you're counting those nurse visits as a visit, then you're overstating your face-to-face visit.

OK, if we categorize them by provider though and only count the face-to-face visits, then it may not be a computer-generated number but we do have access to that number.

OK, just - what I suggest doing is check it for a month and have them be very, very, very close.

OK. OK, and then what did you mean by non-RHC visits?

Like hospital visits, they're considered non-Rural Health Clinic visits. Inpatient, outpatient, ER, and Observation bed-- those are non-Rural Health Clinic visits and are sent to the Medicare Part B payer and not a part of our Rural Health Clinic.

Interesting. OK, we are an RHC but we have never utilized that designation. We've never filed a cost report.

(Ho, ho, ho) ...

Are you - are you independent or provider-based?

Provider-based.

Then ...

((inaudible))

. . . your part of the cost report ...

((inaudible))

... is part of the hospital cost report.

I'm sorry. It's not.

However, I would suggest - are you the office manager?

Yes, and this is independent. It's not provider-based.

Somebody has to ...

((inaudible)) independent, there's no way you can operate without being - having a cost report.

Do ...

We ...

Well, are you Medicaid exclusive?

No.

You see Medicare patients?

Yes.

Somebody must have done a cost report.

Or you wouldn't be getting a dime.

Yes.

We're not getting a dime. That's the point.

Oh, that - yes, you're right. And you're in Colorado?

Yes.

If you want to either e-mail me or e-mail Janet, I think ...

Yes.

. . . we need to have an off-line conversation with you.

I would be glad to help you.

One last question. If the administration changes, is there a notice for that?

No, not necessarily, only the medical director.

Thank you so much.

You're welcome.

We have time for one or two more questions if they're quick. Next question?

Caller, your line is open. Please proceed.

Hearing no response, we'll go to our next question.

This is - can you hear me?

Yes.

Yes.

OK, this is (Donna) at the Kimball Clinic in Kimball, Nebraska, and in about April they quit paying us for our EKGs that are run in the clinic setting and I am . . .

How are you billing them?

Pardon?

How are you billing them?

With a 141 revenue code.

That's because it should be 131.

And I tried billing them that in way and they will not pay those either.

To whom are you submitting the claim?

Medicare.

OK, what CPT code?

93005.

They should be.

Well, they're not and I'm at a loss as to what to do to get them ...

You say Medicare, what do you - who do you - who is it literally going to?

Blue Cross/Blue Shield in Nebraska.

(They're) a critical access hospital with a provider-based clinic.

OK.

(Yes).

(Julie) ...

That was (Donna).

(Donna) ...

Yes.

... can you - fax me that to my house and I'll try to address it with you; however, I won't get to do it till Monday.

OK.

My fax number is 308-647-9124.

OK, thank you.

You're welcome.

We have one last call. One last question, I mean.

OK, just one moment and we'll go to that question.

This is (Connie). I'm calling from California and I'm calling with regard to behavioral health. We - actually, I'm a clinical social worker and when we started seeing clients here in 2003 we were told by the auditor that we could take the option of either doing the formula with collecting the co-pay from the client at the 65 or 85 percent, or whatever it was, or that we could just bill the office visit cap rate, and since it was lower and far easier, we chose to just continue to bill under - she said just use the 521.

That's not appropriate.

OK, that's where my question lies ...

It needs to be the ...

... because ...

... 900-revenue code.

Pardon me?

It needs to be a 900-revenue code for behavioral health.

OK, so if we use like a - was it a 911 ...

No, it's 900. The bill type is 711.

OK.

But a revenue code is 900 ...

OK.

... and the first visit that determines if they need the counseling from the provider is that 521 revenue code; however, when it becomes behavioral health, then it goes to the 900 revenue code.

OK, and then do we bill our cap rate or do we follow the formula?

Bill your charge.

Yes, you're going to get paid based on the cap rate . . .

Right.

... your charge because the beneficiary's co-pay is going to be based on the charge but you're going to get paid based on the cap rate, but you'll not get paid the same as your medical revenue code payment because there is a discount as with regular Medicare for the RHC mental health payment.

OK, so are we then supposed to be collecting that other 15 percent or whatever it is from the patient?

You're supposed to collect ...

Yes.

... (financial) from the patient.

Right and there's a formula in doing that and ...

Yes.

... the patient will owe you at least, at least 37.5 percent of your rate - of your charge.

The patient will.

Yes.

Your RHC rate.

Yes.

OK, then, what do we do - a billed amount or the RHC rate is what the patient will owe?

You're going to collect at least 37.5 percent from the patient ...

Of the ...

... of the RHC rate.

... of the rate or the billed amount because they're two different things?

Of the rate.

Of the rate and then the billed amount gets put in there some way too, and I've got a whole slide on that one. If you will e-mail me, I will send that to you.

OK, and then my last part of that question is what about the crossover patients that have Medicaid, does Medicaid pick up that 37.5 percent or is it bad debt?

It's probably going to depend on your individual Medicaid program. You're going to ...

Exactly.

... have to check with - I guess in our case, MediCal ...

Right.

... to see how they handle that.

With the auditors there?

It's going - it's going to vary from state to state.

Right. Every state can be different.

And let's see, is your e-mail address on here?

Yes it is, on the very first slide.

OK.

We're going to have to cut it off there. This has been a excellent presentation.

I want to thank Janet for her time today and excellent information. I also want to thank the Office of Rural Health Policy for hosting this call series.

A transcript of today's call will be available in the next week - it should be available within the next week to 10 days. It may be a little bit longer since I know Janet's coming to the meeting here and we have to have that reviewed. We are also going to attempt something different for this call, which is to make an audio transcript available. We are working on that and we will notify you as to whether or not there is an option of getting an audio transcript of today's call.

I want to encourage you to continue to participate and encourage others to participate in this conference call series. I want to remind you that the next call, we will send out the information via e-mail. If you're not currently registered, if you're getting information about this through a secondary or a tertiary arrangement, someone's bouncing or forwarding an e-mail to you, you can go in and sign up directly and that will allow you to get the announcements as well as the slides when they are available. I also want to encourage callers to call in a few minutes before so that we're able to get started on time.

Again, thank you to Janet Lytton for her presentation today and thank you to the Office of Rural Health Policy. This concludes our call today. Thank you for your participation.

Thank you, Bill, and thank you, participants.

And that concludes today's conference. We'd like to thank you all for your participation.

END