Understanding RHC
Billing Issues TOP |
Slide 1: HEALTH
SERVICES ASSOCIATES, INC
Ron
L. Nelson, PA
www.hsagroup.net
2 East Main Street
Fremont, Michigan 49412
Ph: 231-924-0244
Fx: 231-924-4882 Email:nelson@hsagroup.net
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Understanding RHC
Billing Issues TOP |
Slide 2: Understanding Billing Issues
- RHC/FQHC Services
- Part B Services
- Provider Based vs. Independent
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Understanding RHC
Billing Issues TOP |
Slide 3: RHC Services
- Physician Services
- PA/NP/CNM
- Psychologist
- Clinical Social Worker
- Services and Supplies "Incident-To" to
the above Services
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Understanding RHC
Billing Issues TOP |
Slide 4: Part B Services
- Inpatient - Professional Component
- Lab - Technical
- X Ray - Technical
- Diagnostic - Technical
- Radiologist Fees (four walls test applies)
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Understanding RHC
Billing Issues TOP |
Slide 5: Billing for PA/NP/CNM
- Obtain UPIN's for PA's, NP's and/or CNM's
- Medicare Advantage - review how PA, NP,
CNM are covered
- Medicaid - review participation agreements
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Understanding RHC
Billing Issues TOP |
Slide 6: Vaccines
What information do I need to capture? |
Understanding RHC
Billing Issues TOP |
Slide 7: Billing for Procedures
- Endoscopies
- Biopsies
- Surgical Procedures (office based)
- Commingling - defined
How can we correctly carve out procedures? |
Understanding RHC
Billing Issues TOP |
Slide 8: MEDICAID What is Covered?
- Core Services
- Other Services
- Managed Care
How to analyze its impact |
Understanding RHC
Billing Issues TOP |
Slide 9: Behavioral Health Services
- Clinical Psychologist (PhD)
- Clinical Social Worker (CSW)
- Initial Diagnostic Visit Paid at 100%
- Four walls test applies
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Understanding RHC
Billing Issues TOP |
Slide 10: Telehealth
- Bill to RHC/FQHC Program
- Q3014 code is paid separately from all
all-inclusive rate
- Bill for $20, transmission fee
- Real Time Audio/Video Transmission
- Separate service not subject to fee schedule
restrictions
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Understanding RHC
Billing Issues TOP |
Slide 11: SNF, Swing Bed Visits
- January 1, 2005 - bill all to RHC FI
- The requirements for visits are every
30 days (not less than 21 days)
- Medical necessity allows acute visits
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Understanding RHC
Billing Issues TOP |
Slide 12: Billing for Procedures
- Endoscopies
- Biopsies
- Surgical Procedures (office based)
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Understanding RHC
Billing Issues TOP |
Slide 13: Billing Crossovers
- Problems with EOB
- How to get Paid
- How to Remain Compliant
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Understanding RHC
Billing Issues TOP |
Slide 14: Provider-Based Issues
- Only Visits Billed to Intermediary
- Ancillaries Billed Under Hospital Fee
Schedule Hospital provider type
- Exceptions - CAH - offsite clinics
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Understanding RHC
Billing Issues TOP |
Slide 15: What constitutes a visit
- Face to face encounter a patient and
a physician, physician assistant, nurse practitioner, nurse-midwife,
or visiting nurse.
- Encounters with more than one health
professional and/or multiple encounters with the same health
profession that take place on the same day at a single location
constitutes a single visit.
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Understanding RHC
Billing Issues TOP |
Slide 16:
Pap/Pelvic
Bill Professional component to FI under
revenue code 521
Bill Technical component to the Part B Carrier
See Medi 913-01
Colorectal Screening/Bone Mass/Prostate
Cancer Screening
Bill Professional component to FI under
revenue code 521
Bill Technical component to the Part B Carrier
See Medi 799-00
Diabetic Outpatient Self-Management Training
Services
Not reimbursed by Medicare at this time
for services rendered by RHC.
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Understanding RHC
Billing Issues TOP |
Slide 17: SERVICES RENDERED ON NON-VISIT
DAYS
Can be combined with claims with visits
Recommend they be within 30 days
List only the date of the visit
Show charges for all services
Adjustments OK
Otherwise, handle thru cost report
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Understanding RHC
Billing Issues TOP |
Slide 18: LIST ACTUAL CHARGES
The RHC should list their actual charge
for each service.
Do not automatically default to listing
the all-inclusive rate amount only.
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Understanding RHC
Billing Issues TOP |
Slide 19: SIGNATURES
MEDICAL RECORDS-
ACCEPTABLE-
HANDWRITTEN
ELECTRONIC
STAMPED + HANDWRITTEN
UNACCEPTABLE-
STAMPED
STAMPED + INITIALS
CLAIMS-
ACCEPTABLE -
HANDWRITTEN
ELECTRONIC
STAMPED
SIGNATURE ON FILE
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Understanding RHC
Billing Issues TOP |
Slide 20: Medicare Reimbursement
- ONE VISIT PER PATIENT PER DAY WITH FEW
EXCEPTIONS
- SECOND ENCOUNTER ON SAME DAY MAY BE BILLED
IF UNRELATED (SORE THROAT AND BROKEN HAND)
- MAY BILL FOR A PART A VISIT AND A PART
B non-RHC/FQHC VISIT (HOSPITAL VISIT) ON SAME DAY
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Understanding RHC
Billing Issues TOP |
Slide 21: Medicare Reimbursement (continued)
- Pneumonia and Influenza immunizations
- Medicare will pay cost at the end of
the year on the cost report.
- Cost based reimbursement is two to three
times standard payment levels
- Do not bill Medicare. The clinic is only
required to maintain a log
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Understanding RHC
Billing Issues TOP |
Slide 22: Medicare
Reimbursement (continued)
- Pneumonia and Influenza logs required
- Must include all patients
- Separate log for pneumonia and for
influenza
- Information needed:
- Date of service
- Patient name
- Patient Medicare number, if Medicare
patient
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Understanding RHC
Billing Issues TOP |
Slide 23: Bonus
Payment Non RHC/FQHC Part B Services
Health Professional Shortage
Area: |
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HPSA Geographic |
10% |
Physician Scarcity Areas:
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PSA |
5% |
Specialty Physician Scarcity
Area:
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SPSA |
5% |
www.cms.hhs.gov/providers/bonuspayment
Apply to physician services
not services provided by non physicians.
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