Corporate Compliance

Note from the Instructor: Billing for Preventive Services in a Rural Health Clinic

Medicare Insider, June 16, 2015

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This week’s note from the instructor is written byDebbie Mackaman, RHIA, CPCO, CCDS regulatory specialist for HCPro.  
I was recently out teaching HCPro’s Rural Health Clinic (RHC) Boot Camp® and we got into a lengthy discussion about billing for a clinic visit with preventive services. Based on our conversation, I thought it might be helpful to examine specific RHC billing issues.
The Rural Health Clinic Services Act of 1977 was passed to assist Medicare patients’ access healthcare in rural areas, where there is a shortage of physicians, and also to increase the use of non-physician practitioners such as nurse practitioners (NP) and physician assistants (PA) in these areas. Approximately 4,000 RHCs nationwide provide access to primary care services in rural areas, according to the CMS Rural Health Clinic Fact Sheet. These RHCs, certified by CMS as such, experience unique billing scenarios.
In general, when a patient is seen by a physician or non-physician practitioner in the clinic or other designated area, most of the services provided will be bundled into one line for charging purposes. The patient will pay the usual deductible amount and 20% of the total charge for their coinsurance portion. However, when certain Medicare preventive services are provided as part of a clinic visit, the charge for the preventive service must be deducted from the total charge for the visit in order for the correct deductible and coinsurance to be applied to the medical visit and appropriately waived for the preventive service. The waiver of the deductible and coinsurance applies to those services recommended by the U.S. Preventive Services Task Force with a grade A or B and those preventive services limited by frequency. CMS has published an updated interactive table of preventive services, which can be found on the Medicare Learning Network website.
In most cases, the RHC will be paid under the all-inclusive rate (AIR) for all services provided to the patient on that particular date of service. The RHC-specific AIR is based on the clinic’s allowable costs reported on the annual cost report. Further consideration must be given to billing if the RHC has been designated as provider-based under the current regulations. This also allows the clinic to be paid its actual AIR without regard to the national limitation amount set by CMS every calendar year.
In the case of a clinic visit and an Initial Preventive Physical Exam (IPPE) occurring on the same date of service, the RHC will be paid two AIRs–one for the clinic visit, which includes most of the charges for the visit and one for the IPPE. The deductible and coinsurance will be waived for the IPPE, and the patient will be responsible for the coinsurance amount for other services billed on the clinic visit line. Let me walk through a simplified example to demonstrate the complexity of billing RHC services.
A patient presents to a provider-based RHC for an IPPE under his Medicare benefit. After the IPPE is completed, the physician also addresses the patient’s chronic fatigue and blood is drawn for a complete blood count (CBC) test to be performed by the hospital laboratory. In an RHC, an E/M code (e.g., 99213) is not reported for non-preventive services, as the level of service does not drive the actual reimbursement. If the venipuncture is performed by the RHC staff, the venipuncture charge is included in the same line with the visit charge. Laboratory services are not included in the AIR and patients usually do not have any out-of-pocket expenses, so they must be billed separately. 
Key billing points of this example:
  • The RHC will report the IPPE, medical evaluation, and venipuncture on the UB04 claim form using TOB 0711.
  • The clinic will report the medical portion of the visit (chronic fatigue) with revenue code 0521 without an E/M level on the claim.
  • The clinic will include the venipuncture charge in the line with charge for the medical visit.
  • The patient will pay his remaining Part B deductible and 20% of the total charge for the medical portion of the visit, which includes the evaluation for chronic fatigue and the venipuncture.
  • The clinic will report the IPPE on a separate line using revenue code 0521 and HCPCS G0402 in order to waive the patient’s deductible and coinsurance for the preventive service only.
  • The RHC will receive two AIR payments—one for the medical visit and one for the IPPE performed on the same date of service.
  • The main provider of the provider-based RHC will bill for the laboratory services only on the appropriate bill type (i.e., TOB 031 OPPS or TOB 0851 CAH) and be paid under its associated payment methodology.
The key to compliant billing in this setting is to understand how to bill for non-RHC services and when the patient will be financially responsible for a portion of the visit. In a future article, I will address the difference between billing for independent and provider-based non-RHC services.

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