Transcript Rural Health Clinic Billing 2013

Final Rule 2016 Components
Chronic Care Management
Advanced Care Planning
Transitional Care Management
HCPCS codes on RHC Claims
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Chronic Care Management - RHCs
Chronic Care Management was introduced as
a Medicare benefit in 2015. It was not
initially payable for RHCs. Effective 1.1.2016,
RHCs can bill a separate line item for CCM
services.
CCM requirements are the same for all
providers.
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CCM Payments to RHC
Medicare will pay CCM services to RHCs
based on current Physician Fee Schedule
rates.
The current Medicare allowable for 2016 is
$40.84.
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Face-to-Face Requirement
The face to face requirement for an RHC
encounter is waived. This is a non-encounter
benefit being paid to RHCs.
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CCM Payments to RHCs
Co-insurance and deductibles will be applied to
these services.
Chronic Care Management Services are not payable
at the same time as Transitional Care Management
services or any other program that provides
additional payment for care management services
(outside of the RHC AIR).
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Chronic Care Management (99490)
Multiple (two or more) chronic conditions
expected to last at least 12 months, or until the
death of the patient.
Chronic conditions place the patient at
significant risk of death, acute exacerbation/
decompensation, or functional decline.
Comprehensive care plan established,
implemented, revised, or monitored.
CMS Chronic Care Management Fact Sheet
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Chronic Condition Examples
Alzheimer’s disease/
related dementia
Depression
Arthritis (osteoarthritis and
rheumatoid)
Diabetes
Asthma
Heart failure
Atrial fibrillation
Hypertension
Autism spectrum disorders
Ischemic heart disease
Cancer
Osteoporosis
Chronic Obstructive Pulmonary
Disease;
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CCM Practitioners
Physicians and the following non-physician
practitioners may bill the new CCM service:
Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants
Only one provider per calendar month may bill
the CCM Service.
CMS Chronic Care Management Fact Sheet
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Emphasis on Care Management
“The CCM service is not within the scope of
practice of limited license physicians and
practitioners such as clinical psychologists,
podiatrists, or dentists, therefore these
practitioners cannot furnish or bill the service.
However, CMS expects referral to or
consultation with such physicians and
practitioners by the billing practitioner to
coordinate and manage care.”
CMS Chronic Care Management Fact Sheet
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Clinical Professionals Only
Services provided directly by an appropriate
physician or non-physician practitioner, or by
clinical staff incident to the billing physician
or non-physician practitioner, count toward
the minimum amount of service time
required to bill the CCM service (20 minutes
per calendar month).
CMS Chronic Care Management Fact Sheet
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Supervision Exception
CMS requires CCM services to be provided
under the direct supervision (rather than
general supervision) of a physician in an RHC.
CMS plans on addressing this, but the change
will not be implemented until at least January
2017.
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Structured Data
“Record the patient’s demographics,
problems, medications, and medication
allergies and create structured clinical
summary records using certified EHR
technology.”
CMS Chronic Care Management Fact Sheet
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Care Plan
Create a patient-centered care plan based on a physical, mental,
cognitive, psychosocial, functional, and environmental (re)assessment,
and an inventory of resources (a comprehensive plan of care for all
health issues).
Provide the patient with a written or electronic copy of the care plan and
document its provision in the medical record.
Ensure the care plan is available electronically at all times to anyone
within the practice providing the CCM service. S
Share the care plan electronically outside the practice as appropriate.
CMS Chronic Care Management Fact Sheet
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Care Availability
Ensure 24-hour-a-day, 7-day-a-week (24/7)
access to care management services,
providing the patient with a means to make
timely contact with health care practitioners
in the practice who have access to the
patient’s electronic care plan to address his
or her urgent chronic care needs.
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Care Availability
Ensure continuity of care with a designated
practitioner or member of the care team with
whom the patient is able to get successive routine
appointments. Provide enhanced opportunities for
the patient and any caregiver to communicate with
the practitioner regarding the patient’s care. Do this
through telephone, secure messaging, secure
Internet, or other asynchronous non-face-to-face
consultation.
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Initial Examination
CCM services may only be initiated after
one of the following:
Welcome to Medicare/IPPE Visit
Annual Wellness/Subsequent Annual
Wellness Visit
Complete/Comprehensive Exam
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CCM Patient Education
The eligible beneficiary must be informed
about the availability of CCM services from
the RHC or FQHC and provide his or her
written agreement to have the services
provided, including the electronic
communication of the patient's information
with other treating providers as part of care
coordination.
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CCM Patient Discussion
This would include a discussion with the patient about what CCM
services are:
how they differ from any care management services the RHC or FQHC
currently offers,
how these services are accessed,
how the patient's information will be shared among others, that a
non RHC or FQHC cannot furnish or bill for CCM services during the
same calendar month that the RHC or FQHC furnishes CCM services,
the applicability of coinsurance even when CCM services are not
delivered face-to-face in the RHC or FQHC, and
any care management services that are currently provided will
continue even if the patient does not agree to have CCM services
provided.
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CCM Discussion Requirements
At the time the agreement is obtained, the eligible
beneficiary must be informed that the agreement
for CCM services could be revoked by the
beneficiary at any time either verbally or in writing,
and the RHC or FQHC practitioner must explain the
effect of a revocation of the agreement for CCM
services.
The RHC or FQHC must provide a written or
electronic copy of the care plan to the beneficiary
and record this in the beneficiary's electronic
medical record.
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Discussion Summary
Document the discussion with the patient.
Note that the patient has been informed of
the co-insurance.
Note that the patient has agreed to the
service.
Explain how the patient can revoke the
agreement.
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Certified EHR
RHCs and FQHCs must use technology certified
to the edition(s) of certification criteria that is, at
a minimum, acceptable for the EHR Incentive
Programs as of December 31st of the year
preceding each CCM payment year to meet the
following core technology capabilities:
Structured recording of demographics,
problems, medications, medication allergies,
and the creation of a structured clinical
summary.
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CCM Cost Reporting
The language regarding how to report costs
on the RHC cost report is misleading. They
are technically allowable on the cost report.
They will be reported in such a manner that
they will not affect the RHC all-inclusive rate.
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Chronic Care Management (99490)
Chronic care management services, at least
20 minutes of clinical staff time directed by a
physician or other qualified health care
professional, per calendar month, with the
following required elements:
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CCM Billing – Stand Alone
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CCM with Billable Visit
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Advanced Care Planning – Surprise!
This was added as a new RHC benefit with in
conjunction with CCM services.
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Advanced Care Planning (99497)
Advance care planning including the
explanation and discussion of advance
directives such as standard forms (with
completion of such forms, when performed),
by the physician or other qualified health
professional; first 30 minutes, face-to-face
with the patient, family member(s) and/or
surrogate).
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Advanced Care Planning (99498)
Advance care planning including the
explanation and discussion of advance
directives such as standard forms (with
completion of such forms, when performed),
by the physician or other qualified health
professional; each additional 30 minutes (List
separately in addition to code for primary
procedure).
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ACP – Stand Alone Encounter
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ACP As part of Annual Wellness
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CCM Med Learn Matters 9234
https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM92
34.pdf
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CCM Cost Reporting
The language regarding how to report costs
on the RHC cost report is misleading. They
are technically allowable on the cost report.
They will be reported in such a manner that
they will not affect the FQHC PPS rate.
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TIPS: Chronic Care Management Services
Don't simply bill on the last day. 99490 is based on
providing at least 20 minutes of care to eligible patients
(i.e. those meeting the chronic conditions requirement).
Because the time is cumulative, you may be tempted to
bill 99490 on the last day of the month. This may result
in no payment if another provider bills 99490 before
you.
source: Kathy Bryant, director of the Division of Practitioner Services,
CMS at AMA CPT Symposium, Nov 2014
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Advanced Care Planning (99497)
Advance care planning including the
explanation and discussion of advance
directives such as standard forms (with
completion of such forms, when performed),
by the physician or other qualified health
professional; first 30 minutes, face-to-face
with the patient, family member(s) and/or
surrogate).
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Advanced Care Planning (99498)
Advance care planning including the
explanation and discussion of advance
directives such as standard forms (with
completion of such forms, when performed),
by the physician or other qualified health
professional; each additional 30 minutes (List
separately in addition to code for primary
procedure).
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Advanced Care Planning
Advanced Care Planning can be billed as a
stand-alone visit.
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100.4 - Transitional Care Mgmt
TCM services can be billed as a stand-alone visit if it
is the only medical service provided on that day
with a RHC or FQHC practitioner and it meets the
TCM billing requirements. If it is furnished on the
same day as another visit, only one visit can be
billed.
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G-Code for ACP/TCM
Advanced Care Planning and Transitional
Care Management should both be reported
using G0467 – Established Patient.
CCM does not require a face-to-face visit.
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Medicare Preventive Reference
Follow these links to:
Medicare Preventive Services Quick Chart
CMS Preventive Services Center
Medlearn Matters 9234. Chronic Care
Management (CCM) Services for Rural Health
Clinics (RHCs) and Federally Qualified Health
Centers (FQHCs). November 15, 2015
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Reporting Services
Beginning on April 1, 2016, RHCs are required
to report the appropriate HCPCS code for
each service line along with a revenue code
on their Medicare claims. RHC qualifying
medical visits are typically Evaluation and
Management (E/M) type of services or
screenings for certain preventive services.
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Total Qualifying Visit Line
Medicare does not adjudicate RHC claims
based on the 0001 Total Charge amount.
Medicare adjudicates RHC claims using the
Qualifying Visit Line.
The qualifying visit line should be the sum
of all RHC charges subtracted by any
preventive services.
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Line Item Messages
Group code CO- Contractual obligation;
CARC 97 – The benefit for this service is included
in the payment/allowance for another
service/procedure that has already been
adjudicated.
RARC M15 - Separately billed services/tests have
been bundled as they are considered components
of the same procedure. Separate payment is not
allowed.
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Qualifying Visit List - Medical
Qualifying Visit Code Sets
From
Through
Office Visit Codes
99201 - 99215
Nursing Home Visit Codes
99304 - 99308
NH Discharge Codes
99315 - 99316
NH Annual Assessment
99318 - -
Domicile Visits - New
99324 - 99328
Domicile Visits – Est Pt
99334 - 99337
Home Visits – New
99341 - 99345
Home Visit – Established
99347 - 99350
Transitional Care
99495 - 99497
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Encounter Codes - Wellness
Qualifying Code
Description
G0402
Initial preventive exam
G0438
Annual Wellness Visit/Personalized Plan, Initial
G0439
Annual Wellness Visit/Personalized Plan, Subsequent
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Behavioral Health – Qualifying Visits
Visit Code
Description
90791
Psychiatric diagnostic evaluation
90792
Psychiatric diagnostic evaluation w/ Medical Services
90832
Psych Therapy Patient/ Family 30 minutes
90834
Psych Therapy Patient/ Family 45 minutes
90837
Psych Therapy Patient/ Family 60 minutes
90839
Psych Therapy Patient/ Family Crisis initial 60 min
90845
Psychoanalysis
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Qualifying Visit List – Eye Exams
HCPCS Code
Short Description
92002
Eye exam new patient
92004
Eye exam new patient
92012
Eye exam establish patient
92014
Eye exam tx estab pt 1/>vst
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Expanded QVL
CMS has expanded the Qualifying Visit List on
multiple occasions. The full list can be found
at:
RHC Qualifying Visit List
https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/FQHCPPS/Downloads/RHCQualifying-Visit-List.pdf
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Revenue Codes
The following revenue codes are used on UB04 claims:
0521 Clinic Visit at RHC by qualified provider;
0522 Home visit by RHC provider;
0524 Visit by RHC provider to a Part A SNF bed;
0525 Visit by RHC provider to a SNF, NF or other
residential facility (non-Part A);
0527 Visiting Nurse service in home health shortage
area
0528 Visit by RHC provider to other non-RHC site
(scene of an accident)
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More Revenue Codes – 4.1.2016
0250 – Pharmacy (Does not need the HCPCS)
0300 – Venipuncture
0636 – Injection/Immunization
0780 – Telehealth
0900 – Behavioral Health
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Revenue Codes
The qualifying visit line must include the total
charges for all the services provided during the
encounter/visit. RHCs can report incident to services
using all valid revenue codes except 002x-024x,
029x, 045x, 054x, 056x, 060x, 065x, 067x-072x,
080x- 088x, 093x, or 096x-310x. RHCs should report
the most appropriate revenue code for the services
being performed. (MLN 9269)
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Billing Example #1
An established patient is seen and a qualifying visit of 99213 for $100
is generated. The applicable coinsurance and/or deductible shall be
based upon $100. Medicare will pay the encounter at 80% of the
AIR. The patient will be responsible for $20.00 in co-insurance.
FL42
Rev CD
0521
0001
FL43
Desc
OV Est 3
Total Charge
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FL44
FL45
HCPCS/CPT DOS
99213
4/2/2016
FL46
Units
1
FL47
Total Charge
$
$
100.00
100.00
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Billing Example #2:
Medical Services Plus Ancillary
A Medicare beneficiary is seen for 99213 for a charge of $100. A Toradol
injection (J1885) for $30 was performed.
Service
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Charge
99213
$100.00
J1885
$30.00
Total Charges
$130.00
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Billing Example #2 – UB Fields
Medical Visit plus Ancillary
FL42
Rev CD
0521
0636
0001
FL43
Desc
OV Est 3
Toradol
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
J1885
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
130.00
30.00
160.00
The charge amount for Toradol ($30.00) will be added to the
99213 ($100) for a qualifying visit line of $130.00. The total
charge line is inaccurate.
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Service Detail
Service detail lines can be reported as $.01 or
greater. The additional services lines CAN be
reported as $.01. This eliminates artificial
inflation of revenue, adjustments, and AR.
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Billing Example #2 – Alternative
Medical Visit plus Ancillary
FL42
Rev CD
0521
0636
0001
FL43
Desc
OV Est 3
Toradol
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
J1885
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
130.01
0.01
130.02
The Toradol charge amount ($30.00) plus $.01 for the line
item is bundled with the $100 charge on the 99213 qualifying
visit line. Medicare will use the line with the qualifying visit
code (99213) to determine the total charge and calculate coinsurance.
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Billing Example #3:
Medical Services Plus EKG
A Medicare beneficiary is seen for 99213 for a charge of $100. A EKG
(93005/93010) for $75/$30.
Service
Charge
99213
$100.00
93005 EKG-TC
$45.00
93010 EKG-PC
$30.00
Total Charges
$175.00
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Billing Example #3 –
Medical Visit plus EKG
FL42
Rev CD
521
521
001
FL43
Desc
OV Est 3
EKG-PC
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
93010
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
145.00
45.00
190.00
The EKG-PC charge amount is bundled with the 99213 on the
RHC claim. A 93005 will be billed to Medicare Part B/FFS
under the physician/group (IRHC) or Hospital P-TAN (PBRHC).
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Billing Example #3 – Alternative
Medical Visit plus EKG
FL42
Rev CD
521
521
001
FL43
Desc
OV Est 3
EKG-PC
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
93010
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
145.01
0.01
145.02
The charge for the EKG-PC ($45.00) is bundled with the
99213 charge ($100.00) on the RHC claim. The EKG-PC is
reported as a $.01 line item. A 93005 will be billed to
Medicare Part B/FFS under the physician/group (IRHC) or
Hospital P-TAN (PBRHC).
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Claim Example #4:
Mental Health Services
Mental Health Services RHCs shall report one service line per
mental health encounter/visit with revenue code 0900 and a
qualifying mental health visit from the RHC Qualifying Visit
List.
FL42
Rev CD
0900
0001
FL43
Desc
BH Session
Total Charge
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FL44
FL45
HCPCS/CPT DOS
90834
4/2/2016
FL46
Units
1
FL47
Total Charge
$
$
120.00
120.00
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Billing Example #5 – Preventive/Ancillary
An established patient is seen and a qualifying visit of 99213 for $100
is generated. A breast/pelvic exam was performed for $75.00. A
venipuncture was taken for $20.00.
Rev CD
0521
0521
0300
0001
Desc
OV Est 3
Breast/Pelvic
Venipuncture
Total Charge
HCPCS/CPT DOS
99213
G0101
36415
4/2/2016
4/2/2016
4/2/2016
Units
1
1
1
Total Charge
$
$
$
$
120.00
75.00
20.00
215.00
The charge for the pelvic exam should NOT be bundled in the 99213
line since there will be no co-insurance applied to the preventive
service. The $20.00 venipuncture charge will be bundled with the
99213 charge for $100.00 .
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Billing Example #5 – Alternative
Preventive/Ancillary
An established patient is seen and a qualifying visit of 99213 for $100
is generated. A breast/pelvic exam was performed for $75.00. A
venipuncture was taken for $20.00.
Rev CD
0521
0521
0300
0001
Desc
OV Est 3
Breast/Pelvic
Venipuncture
Total Charge
HCPCS/CPT DOS
99213
G0101
36415
4/2/2016
4/2/2016
4/2/2016
Units
1
1
1
Total Charge
$
$
$
$
120.01
75.00
0.01
195.02
The charge for the pelvic exam should NOT be bundled in the 99213
line since there will be no co-insurance applied to the preventive
service. The $20.00 venipuncture charge will be bundled with the
99213 charge for $100.00.
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Billing Example #5:
Medical Services Plus Procedure
A Medicare beneficiary is seen for 99213 for a charge of $100. A minor
surgical procedure (11100) for $150 was performed.
Service
Charge
99213
$100.00
11100
$150.00
Total Charges
$250.00
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Billing Example #6 –
Medical Visit plus Procedure
FL42
Rev CD
0521
0521
0001
FL43
Desc
OV Est 3
Procedure
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
11100
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
250.00
150.00
400.00
The laceration repair charge of $150.00 is bundled with the
$100.00 office visit charge. The $400 total charge is
irrelevant.
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Billing Example #6 – Alternative
Medical Visit plus Procedure
FL42
Rev CD
0521
0521
0001
FL43
Desc
OV Est 3
Procedure
Total Charge
FL44
FL45
HCPCS/CPT DOS
99213
11100
4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
250.01
0.01
250.02
Medicare will use the line with the qualifying visit code
(99213) to determine the total charge and calculate coinsurance.
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Encounter Billing – October 1, 2016
In April 2016, CMS instructed RHCs to hold claims only for a
billable visit shown in red on the RHC QVL until October 1,
2016. Upon billing these claims and/or for claim adjustments
beginning on October 1, 2016, RHCs shall add modifier CG
(policy criteria applied) to the line with all the charges
subject to coinsurance and deductible.
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Procedure only (Red QVL) – October 1, 2016
FL42
Rev CD
0521
0001
FL43
Desc
Procedure
Total Charge
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FL44
FL45
HCPCS/CPT DOS
11100 CG 10/2/2016
FL46
Units
1
FL47
Total Charge
$
$
250.00
250.00
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Multiple Encounters
“Encounters with more than one RHC or FQHC
practitioner on the same day, or multiple
encounters with the same RHC or FQHC practitioner
on the same day, constitute a single RHC or FQHC
visit, regardless of the length or complexity of the
visit or whether the second visit is a scheduled or
unscheduled appointment.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Multiple Encounters are allowed when:
The patient, subsequent to the first visit, suffers an illness
or injury that requires additional diagnosis or treatment
on the same day (2 visits), or
The patient has a medical visit and a mental health visit on
the same day (2 visits), or
The patient has his/her IPPE and a separate medical
and/or mental health visit on the same day (2 or 3 visits).
(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
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Modifier - 59
Modifier-59 is used when there are two
encounters on the same day.
Modifier-59 indicates that separate
conditions being treated are totally
unrelated.
This would be used when a patient returns
to the clinic later in the day with a separate
illness or injury.
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Modifier-59 Example
FL42
Rev CD
0521
0521
0001
FL43
Desc
FL44
FL45
HCPCS/CPT DOS
OV Est Level 4 99214
Laceration
12002 59
Total Charge
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4/2/2016
4/2/2016
FL46
Units
1
1
FL47
Total Charge
$
$
$
340.00
200.00
540.00
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Questions?
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My Contact Information
Charles A. James, Jr.
President and CEO
North American Healthcare Management Services
9245 Watson Industrial Park
St. Louis, MO 63126
888.968.0076
314.560.0098 Cell
[email protected]
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