Physician Practice

Ongoing difficulties with new rural health clinic reporting rule

Physician Practice Insider, May 31, 2016

It has been a little over six weeks since the implementation of the new reporting requirements for RHCs, and it has been a very painful process for most involved. This is true not only for the providers, clinic staff, and billing entities, but also for the patients.

In last week’s MLN Connects Provider eNews, CMS officially announced that coinsurance may not be calculated correctly when claims are submitted with the additional lines of medical services, something CMS has required since April 1. RHCs that are reporting the actual charges for the additional lines, rather than the optional $0.01, are most likely experiencing the problem. A system fix was apparently implemented on May 9, and MACs have been directed to adjust any claims that were processed incorrectly. RHCs should be cautious in collecting the incorrectly calculated coinsurance and allow MACs time to reprocess the claims and send corrected Medicare Summary Notices to the patients.

In the same eNews, CMS also directed RHCs that are unable to implement the new billing requirements due to “internal systems constraints” to contact their MAC to find out if a temporary option is available while they update their clinic systems. I had to pause after reading that directive because most RHCs have diligently implemented the new reporting requirements and have had to put cumbersome manual procedures into place to compliantly process claims. The roll-out of these new reporting requirements have caused significant problems for the RHC community and its patients. This includes financial hardships for RHCs that will extend into October and beyond.

Last week CMS released MLN Matters Article SE1611, which has added a new twist to the implementation process.

The way it was

Prior to April 1, RHCs were required to report HCPCS codes for very few services, such as certain covered preventive services, in order to waive the deductible and/or coinsurance and to verify frequency limitations. All charges for additional medically necessary items and services were added to the total visit charge under the appropriate revenue code (052X and/or 0900) without a HCPCS code. Payment was made under the all-inclusive rate (AIR). In limited circumstances, certain other services were also eligible for separate payment outside of the AIR, such as telehealth and chronic care management.

The way it is


For dates of service on or after April 1, RHCs are required to report the appropriate HCPCS code and revenue code for each service line on the claim, which includes the qualifying visit, preventive services, and any additional medically necessary items or services provided during the visit, such as an EKG or venipuncture. RHCs have been struggling with selecting the most appropriate revenue code for the additional lines since they have historically only reported a handful (e.g., 052X, 0900, and 0780).

CMS posted an updated Qualifying Visit List (QVL) and the long awaited Frequently Asked Question document on April 27. These documents further expanded the list of billable stand-alone visit HCPCS codes but also temporarily changed the revenue code reporting requirement.

The way it will be

In what appears to be an effort on CMS’ part to not have to continually update the QVL as it identifies HCPCS codes that were not included in the original April 1 list, yet another change will become effective on October 1. A medically necessary service not in the current QVL can be billed as a stand-alone billable visit if the service: meets Medicare coverage requirements, is within the scope of the RHC benefit, and is not furnished incident to a physician’s service.

This article was originally published on Medicare Compliance Watch. To view the complete article, click here.

Most Popular