Operator:
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.
Bill Finerfrock:
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.
Janet Lytton:
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.
Bill Finerfrock:
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.
Operator:
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.
Bill Finerfrock:
Go ahead, caller.
(Debra Morris):
My name is (Debra Morris) and I wanted to know
how we can get the slides e-mailed to us.
Bill Finerfrock:
Are you on the Rural Health - how did you find
out about the call?
(Debra Morris):
Well, to be honest with you, I got it from (Marsha
Mars), who's a Rural Health coordinator in Lexington, South Carolina.
Bill Finerfrock:
OK, we will - give me your e-mail address.
(Debra Morris):
It's Morris - M-O-R-R-I-S ...
Bill Finerfrock:
OK.
(Debra Morris):
... @KCMC.org.
Bill Finerfrock:
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.
(Debra Morris):
Is that the e-mail address that was info@narhc.org?
Bill Finerfrock:
No, that was the HRSA, www.hrsa - I don't have
it here in front of me right now but ...
(Debra Morris):
Yes, I tried to write that one down and you'll
-you said it so fast ...
Bill Finerfrock:
Hold on a second.
(Debra Morris):
... I couldn't get it all.
Bill Finerfrock:
www.ruralhealth - as one word - .hrsa.gov/rhc
and there are instructions there as to how to sign up.
(Debra Morris):
OK, I got it then. Thank you.
Bill Finerfrock:
OK, thank you. Next caller?
(Sharon O'Brien):
Janet ...
Janet Lytton:
Yes.
(Sharon O'Brien):
... this is (Sharon O'Brien) in Benkelman, Nebraska.
Janet Lytton:
Hi, (Sharon).
(Sharon O'Brien):
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?
Janet Lytton:
Yes, absolutely.
(Sharon O'Brien):
OK.
Bill Finerfrock:
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?
Janet Lytton:
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?
Bill Finerfrock:
OK. All right. Next caller?
(Deb):
Hi, this is (Deb). I'm in Kansas.
Janet Lytton:
Hi, (Deb).
(Deb):
On page 11, you talked about the injections and
the nurse giving those injections.
Janet Lytton:
Right.
(Deb):
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?
Janet Lytton:
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.
(Deb):
OK, and so it ...
Bill Finerfrock:
((inaudible)) PA or a nurse practitioner.
Janet Lytton:
Yes, anybody ...
Bill Finerfrock:
Right.
Janet Lytton:
... anybody. Anything that happens to that patient,
the provider must have an order in there for that particular service
to be completed.
(Deb):
And it needs to be part of that day's dictation.
Janet Lytton:
Absolutely, yes.
(Deb):
All right.
Janet Lytton:
((inaudible))
(Deb):
Thank you very much.
Janet Lytton:
You're welcome.
Bill Finerfrock:
Next caller?
(Steve Noble):
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.
Janet Lytton:
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.
Bill Finerfrock:
Are you asking if the NPI can be the same for
the hospital a well as the RHC ...
(Steve Noble):
Yes.
Bill Finerfrock:
... hospital?
(Steve Noble):
It's hospital-based.
Bill Finerfrock:
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 ...
(Steve Noble):
Well, it is a problem because in the taxonomy
codes I could not find an RHC taxonomy code.
Bill Finerfrock:
There is a Rural Health Clinic taxonomy code.
(Steve Noble):
For hospital-based?
Bill Finerfrock:
(Well), I think it says Rural Health ...
Janet Lytton:
All the same.
Bill Finerfrock:
... ((inaudible)) don't know that it makes a
distinction.
(Steve Noble):
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.
Bill Finerfrock:
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.
(Steve Noble):
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 ...
Bill Finerfrock:
OK.
(Steve Noble):
... if we don't have a separate taxonomy. If
we have a separate taxonomy, then it works beautifully.
Bill Finerfrock:
Yes, there is a Rural Health Clinic taxonomy
code. It just does not distinguish between provider-base and independent.
(Steve Noble):
Well, that's the problem.
Bill Finerfrock:
OK, we will check on it.
(Steve Noble):
How would I hear from you? Would you ...
Bill Finerfrock:
We will ...
(Steve Noble):
... post ...
Bill Finerfrock:
... we will post it on the list serve.
(Steve Noble):
OK, good.
Bill Finerfrock:
Next question?
Operator:
Caller, your line is open. Please proceed.
(Cheryl):
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?
Janet Lytton:
If ...
(Cheryl):
Or do we have to use it as a bundle?
Janet Lytton:
Are they seeing the provider?
(Cheryl):
Yes, they would be seeing the provider for a
regular office visit and then the counseling on the cigarette cessation.
Janet Lytton:
It would all be part of the same visit.
(Cheryl):
So would we (be able) to use a modifier and get
paid for that as a separate ...
Janet Lytton:
You would - you would bundle that with your office
visit for the charges.
Bill Finerfrock:
You would have a single encounter.
Janet Lytton:
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 ...
(Cheryl):
OK, OK. Thank you.
Janet Lytton:
...OK?
(Cheryl):
Thanks.
Bill Finerfrock:
Next question?
(Julie Westling):
Hello, Janet. My name is (Julie Westling). I'm
in Telluride, Colorado.
Janet Lytton:
Hi, (Julie).
(Julie Westling):
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?
Janet Lytton:
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.
(Julie Westling):
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.
Janet Lytton:
OK, just - what I suggest doing is check it for
a month and have them be very, very, very close.
(Julie Westling):
OK. OK, and then what did you mean by non-RHC
visits?
Janet Lytton:
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.
(Julie Westling):
Interesting. OK, we are an RHC but we have never
utilized that designation. We've never filed a cost report.
Bill Finerfrock:
(Ho, ho, ho) ...
Janet Lytton:
Are you - are you independent or provider-based?
(Julie Westling):
Provider-based.
Janet Lytton:
Then ...
Bill Finerfrock:
((inaudible))
Janet Lytton:
. . . your part of the cost report ...
(Julie Westling):
((inaudible))
Janet Lytton:
... is part of the hospital cost report.
(Julie Westling):
I'm sorry. It's not.
Janet Lytton:
However, I would suggest - are you the office
manager?
(Julie Westling):
Yes, and this is independent. It's not provider-based.
Bill Finerfrock:
Somebody has to ...
Janet Lytton:
((inaudible)) independent, there's no way you
can operate without being - having a cost report.
Bill Finerfrock:
Do ...
(Julie Westling):
We ...
Bill Finerfrock:
Well, are you Medicaid exclusive?
(Julie Westling):
No.
Bill Finerfrock:
You see Medicare patients?
(Julie Westling):
Yes.
Bill Finerfrock:
Somebody must have done a cost report.
Janet Lytton:
Or you wouldn't be getting a dime.
Bill Finerfrock:
Yes.
(Julie Westling):
We're not getting a dime. That's the point.
Janet Lytton:
Oh, that - yes, you're right. And you're in Colorado?
(Julie Westling):
Yes.
Bill Finerfrock:
If you want to either e-mail me or e-mail Janet,
I think ...
Janet Lytton:
Yes.
Bill Finerfrock:
. . . we need to have an off-line conversation
with you.
Janet Lytton:
I would be glad to help you.
(Julie Westling):
One last question. If the administration changes,
is there a notice for that?
Janet Lytton:
No, not necessarily, only the medical director.
(Julie Westling):
Thank you so much.
Janet Lytton:
You're welcome.
Bill Finerfrock:
We have time for one or two more questions if
they're quick. Next question?
Operator:
Caller, your line is open. Please proceed.
Hearing no response, we'll go to our next question.
(Donna):
This is - can you hear me?
Bill Finerfrock:
Yes.
Janet Lytton:
Yes.
(Donna):
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 . . .
Janet Lytton:
How are you billing them?
(Donna):
Pardon?
Janet Lytton:
How are you billing them?
(Donna):
With a 141 revenue code.
Janet Lytton:
That's because it should be 131.
(Donna):
And I tried billing them that in way and they
will not pay those either.
Bill Finerfrock:
To whom are you submitting the claim?
(Donna):
Medicare.
Janet Lytton:
OK, what CPT code?
(Donna):
93005.
Janet Lytton:
They should be.
(Donna):
Well, they're not and I'm at a loss as to what
to do to get them ...
Bill Finerfrock:
You say Medicare, what do you - who do you -
who is it literally going to?
(Donna):
Blue Cross/Blue Shield in Nebraska.
Janet Lytton:
(They're) a critical access hospital with a provider-based
clinic.
Bill Finerfrock:
OK.
(Donna):
(Yes).
Janet Lytton:
(Julie) ...
Bill Finerfrock:
That was (Donna).
Janet Lytton:
(Donna) ...
(Donna):
Yes.
Janet Lytton:
... 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.
(Donna):
OK.
Janet Lytton:
My fax number is 308-647-9124.
(Donna):
OK, thank you.
Janet Lytton:
You're welcome.
Bill Finerfrock:
We have one last call. One last question, I mean.
Operator:
OK, just one moment and we'll go to that question.
(Connie):
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.
Janet Lytton:
That's not appropriate.
(Connie):
OK, that's where my question lies ...
Janet Lytton:
It needs to be the ...
(Connie):
... because ...
Janet Lytton:
... 900-revenue code.
(Connie):
Pardon me?
Janet Lytton:
It needs to be a 900-revenue code for behavioral
health.
(Connie):
OK, so if we use like a - was it a 911 ...
Janet Lytton:
No, it's 900. The bill type is 711.
(Connie):
OK.
Janet Lytton:
But a revenue code is 900 ...
(Connie):
OK.
Janet Lytton:
... 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.
(Connie):
OK, and then do we bill our cap rate or do we
follow the formula?
Janet Lytton:
Bill your charge.
Bill Finerfrock:
Yes, you're going to get paid based on the cap
rate . . .
Janet Lytton:
Right.
Bill Finerfrock:
... 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.
(Connie):
OK, so are we then supposed to be collecting
that other 15 percent or whatever it is from the patient?
Bill Finerfrock:
You're supposed to collect ...
Janet Lytton:
Yes.
Bill Finerfrock:
... (financial) from the patient.
Janet Lytton:
Right and there's a formula in doing that and
...
(Connie):
Yes.
Janet Lytton:
... the patient will owe you at least, at least
37.5 percent of your rate - of your charge.
(Connie):
The patient will.
Janet Lytton:
Yes.
Bill Finerfrock:
Your RHC rate.
Janet Lytton:
Yes.
(Connie):
OK, then, what do we do - a billed amount or
the RHC rate is what the patient will owe?
Bill Finerfrock:
You're going to collect at least 37.5 percent
from the patient ...
(Connie):
Of the ...
Bill Finerfrock:
... of the RHC rate.
(Connie):
... of the rate or the billed amount because
they're two different things?
Bill Finerfrock:
Of the rate.
Janet Lytton:
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.
(Connie):
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?
Bill Finerfrock:
It's probably going to depend on your individual
Medicaid program. You're going to ...
Janet Lytton:
Exactly.
Bill Finerfrock:
... have to check with - I guess in our case,
MediCal ...
(Connie):
Right.
Bill Finerfrock:
... to see how they handle that.
(Connie):
With the auditors there?
Bill Finerfrock:
It's going - it's going to vary from state to
state.
Janet Lytton:
Right. Every state can be different.
(Connie):
And let's see, is your e-mail address on here?
Janet Lytton:
Yes it is, on the very first slide.
(Connie):
OK.
Bill Finerfrock:
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.
Janet Lytton:
Thank you, Bill, and thank you, participants.
Operator:
And that concludes today's conference. We'd like
to thank you all for your participation.
END
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