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Sickness billing format for R&D

hello everybody ing to my watch here I've got one o'clock Eastern time which means it is time for us to do the rhc billing 101 with Amanda Dennison I think most of you probably know her by now she's on the board at the National Association of rural health clinics she does presentations all the time for rhcs and they're fantastic and uh she's with blue in company and um you know if you're in Kentucky I'm sure you know her uh I think we're going to get her out to Kansas and so sure so folks in Kansas you're gonna get to see her pretty soon as well so Amanda I will get out of your way and let you let you present all right sounds good absolutely well thanks for having me Mark um I know that these presentations are always incredibly helpful for people um so as Mark said I am with blue and Company I've been at Blue for about 12 years now um for the past nine I've worked almost exclusively with rhcs um and so in my mind that's still relatively new uh to the rhc space considering some of the people like Patty and Charles and Mark himself who have been in this space for a while so I uh tell people all the time I'm still learning things every single day so hopefully you can find some solidarity in that in knowing that you are not alone uh rhc billing is incredibly difficult um and so hopefully we can provide some some help to you all there um so uh just a quick introduction to Blue in company so blue was founded Back in 1970 we currently do have 10 offices in three states so in Kentucky Indiana and Ohio I'm based out of our Louisville Kentucky office which is one of three offices that we have that is solely dedicated to helping healthc care clients um and so we help a variety of different Health Care Facilities um hospitals both big and small um and really small um and then we also help obviously rural health clinics F qc's private buiness physici offices um dental offices mental health practices so we kind of have you know expanded our services as health care has continued to change uh obviously as a CPA firm we do provide a lot of services that are just more sort of accounting in nature but I am not an accountant um and so again our three offices that do Healthcare um we have a lot of Niche Services as well outside of just the typical accounting space so we do revenue cycle management and reimbursement opportunity um we've done a lot of margin Improvement plans lately for people um starting to look at sort of physician reimbursement and some of those types of things um and then I myself work in anything in the rhc space so if you have any questions um my email is going to be at the end of this slide deck so feel free to reach out um I know you all are not here to learn about blue so we will jump right in um and start talking about rhc billing 101 so a couple of disclaimers before we get started today um I generally put these at the beginning of every presentation um even though you know I'm sure you've seen it before okay so the information from this webinar is current as of this morning when I sent it over to Mark right before he posted it on Facebook okay you guys work in healthcare and you know that regulations can change seemingly by the minute sometimes depending on where you're located um so again I might present today and there might be something that happens tomorrow we hope not but just in case make sure you do your due diligence and make sure that any resources or references in this presentation haven't been replaced with any more current guidance okay today we are going to stick to talking about just regular Medicare from ailing standpoint traditional Medicare only I will briefly touch on some Medicare Advantage um issues and things to be aware of um from a Medicaid standpoint we are not going to talk about Medicaid at all just because a lot of States while they may be very similar there are a lot of different nuances from state to state whether it be different eligible providers for an rhc whether it be different Services um and just different requirements of that nature so if you do have questions about Medicaid billing for an rhc in your state reach out to any of us to Mark and Danny myself Patty Charles any of us that work in the rhc space um if we can help you we'll help you if not we'll connect you to the right person um within your state that can help you to get some additional resources okay so these are the things that we're going to cover today okay there are two more billing presentations after the one that I'm doing today so if you don't see a topic listed here that you were hoping I was going to cover that's because it's going to be covered in one of the other two sessions either with Patty on Thursday or Charles I believe a week from today okay so again this is what we're going to try and stick to today if you have questions please hold those questions until the end um just so we don't get off track um also if some of your questions are related to something that's going to be covered in one of those future topics uh in the interest of time I will defer to those presenters um when when you all do that presentation later on in the week um just so that we can cover the topic specific to today okay all right so we're going to start with the definition of an rhc visit okay and this is the typical standard definition that we're all used to however it has since been expanded okay so an rhc visit and this is straight from the Medicare benefits policy manual I didn't make this upu it comes straight from CMS okay a Ral Health Clinic visit is a medically necessary medical or mental health visit or a qualified preventive Health visit it must be face- tace and oneon-one between the patient and one of the provider types you see listed here so a physician an NP a PA a CNM a CP or an LCSW okay now some of that is expanding in terms of the providers that are allowed to provide rhc billable Services okay and we'll talk about that here in just a few minutes there's this word however that was added in um in January of 2022 okay and that was to cover these mental health tella Health visits that we're now able to briide in the rhc space okay so if you go out to the benefits policy manual you're going to see some text in red that CMS added as of January 2022 so all this fluffy flowery language is basically just to tell you that can also provide a mental health tella Health visit and that face-to-face element of that at least for now um is waved okay so what is not considered a rule Health Clinic encounter okay so these are a few examples that CMS gives of things that are not considered an encounter okay so visits only for medication refills okay so if we're not assessing the patient um they're not having any issues that we're needing to address we don't necessarily need to see them just so that we can read fill their medications okay visits only for lab results now the sort of caveat that I give here is if you have a patient who has an abnormal lab result and you need to have them come back into the office because that lab result now changes their medication something about their course of treatment or some sort of therapy that they're going through that would be appropriate to bring that patient in assess them set a new course of treatment and you'd get an enm level visit out of that okay but just for normal lab results um it's not medically necessary for us to communicate those during an office visit okay um another example is visits only for injections so allergy injections is the example here it could be a B12 injection testosterone injection um those are generally things that don't have to be given by a provider they can be given by your clinical staff so again not medically necessary for a provider to be involved in that visit uh suture removal or dressing change without an addition face-to-face visit and then visits that were generally build using that 99211 nursing visit okay now a lot of times I have people say okay well if it's not an rhc encounter that means it's not billable that's not true it means that on their own they don't qualify as an rhc visit okay and we'll talk a little bit about um some of the things and services that do qualify as a visit but again the definition we just looked at it means that these Services here don't meet one of those qualifications okay let's talk about your rhc eligible provider types okay for Medicare okay again so these are the U provider types that are considered to be billable rhc providers okay so a physici whether that's an MD or a do a nurse practitioner a physician assistant certified nurse Midwife certified psychologist licensed clinical social worker we talked about those it's written directly into the definition of an rhc visit there are two additional provider types that Medicare is going to start reimbursing as a billable provider in the rhc space beginning January 1 of 2024 okay and that's a licensed marriage and family therapist or a licensed mental health counselor now it could be that your state doesn't call it a licensed mental health counselor it might be a licensed professional counselor um so that's going to be driven based off of state definition so don't think that because it's not an lmhc that it doesn't qualify there's State specific definitions for what's going to qualify there okay now again do remember that your State Medicaid might have far more provider types that can are considered billable in the rhc space this is just specific to regular Medicare right here okay now undoubtedly when we start talking about providers the question will eventually come up from someone who already provides dental services in their rhc or in their Clinic to say okay well what about about dentists okay so CMS does specifically have a section of the benefit policy manual that addresses dentist podiatrist optometrist and chiropractors okay so you'll see here what CMS says that those are defined as Physicians ing to Medicare statute and qualified Services by a physician are billable visits in the rhc okay so what is that mean it means that an rhc can bill for face-to-face medically necessary services is provided by one of those provider types okay so long as the service that's furnished is a qualifying visit okay it does have to be within the scope of their practice so their state practice and then it cannot be excluded from coverage so that relates to certain services that chiropractors generally provide um there are certain services that are excluded from coverage okay now where you have to be careful with these provider types okay and again this is not anything that I am making up it comes straight from the benefits policy manual rhcs are required to primarily provide Primary Health Care okay those types of providers a dentist podiatrist optometrist and chiropractor are not considered Primary Care Providers okay so what that means is they cannot serve as the physician medical director for your rhc they also don't qualify to be the physician or non-physician practitioner that must be available at all times the clinic is open right so in an rhc there has to be a provider on site during all rhc hours a dentist podiatrist optometrist chiropractor is not going to qualify for that okay now expanding on that further okay what about our other specialist providers because it's a common misconception when I first start talking with clients about you know considering the rhc they're like well we're going to have to move all of our Specialists out to a new space that's not necessarily true okay Specialists can provide billable services in an rhc right you could have um a neurologist a cardiologist um you could have a mid-level provider a nurse practitioner or PA who works in those Specialties okay so think of all of your ologists that you could have they can provide billable services in the rhc space okay you can employ them at the rhc or the parent Hospital can employ them you can also contract with them so they can be a visiting specialist that just comes in from time to time maybe one day a week um to provide services and rhc contracts with those Specialists bills them as rhc providers okay there's a lot more Logistics involved there and and things from a contractual standpoint you would need to make sure an address we're just talking from a billing standpoint you can Bill them as a rural Health Clinic provider a couple of things to remember with that though okay again rhcs must be primarily engaged in providing Primary Health Care Services this is a little bit of a gray area as to how Primary Care care is defined and we're not going to get into that today because that's more of like a a regulatory language or some clarification some guidance um but there is a gray area there okay um so be care if you have a lot of Mental Health Specialists maybe just consider that 51 49% mix that you have and then lastly if you have a bunch of Specialists that are in your rhc if they're seeing both their primary care provider and one of your Specialists who's not a mental health specialist okay on the same day you're only going to have one all-inclusive rate paid okay you're going to put both services on the claim however only one all-inclusive rate is going to get paid okay so just be aware of that let's talk about your claim form that you're going to use to build your rhc services okay so rhc services are build on ubo4 if you're submitting a paper claim the electronic format for that is the 837i okay this gets confusing for people because rhcs do provide what we consider to be Professional Services okay but an rhc is considered to be an institution it is it own facility in the similar to how a hospital is its own facility right we file an 855a which is an Institutional enrollment to become an rhc and it specifically lines this out in the claims processing manual to say that rhcs are institutional claims and all professional services in the rhc benefit are paid through the all-inclusive rate system for each patient encounter or visit okay so that can get a little bit confusing so just remember rhcs are institutional providers as such they do Bill claims to part A but are paid by the part B benefit anybody confused I know that can be very confusing again ubo4 is the correct claim format for your rhc services okay these do have a specific type of Bill sort of a series that they use those are going to fall under the 71x codes um technically speaking this is a four-digit number uh the leading zero CMS just ignores so 71x and that X is going to identify the different types of bill um that you can have in an rhc okay so a 7-Eleven is going to be your original claim okay that's going to probably be the majority of what you're sending out is just your original claim with all the services you provided during that encounter now if you have a non-payment or a zero claim you may have this if um something is not covered by Medicare um but you have a patient who still wants the service provided you provide them with an ABN prior to the service they sign it saying that they're going to be financially responsible you submit that claim to Medicare for a denial so it can fall to Patient responsibility that's when you're going to use a 710 Bill type okay or one of the examples of when you might use that an adjustment claim is Bill type 7 7 uh the two most common times that I see this used are with our injectable medications um getting those units right sometimes can be a little bit confusing from a coding standpoint so we may have to submit a 717 to to fix that if we got the wrong units on there 717 is also an option for our incident 2 Services which we will talk a little bit more about towards the end of this presentation okay and then 718 is a canceled claim let's say you have a duplicate claim and you accidentally you know put two in for the exact same thing 718 would be what you use to cancel one of those claims okay all of this guidance about the bill types um and sort of the different claims requirements is going to be in the claims processing manual um that section 50 there has all these different requirements for each field locator okay so the field locator four is where this all comes from rhc revenue codes so we' talked about our type of Bill that goes in the top right hand corner of our U uh now we'll talk about these Revenue codes that we have to have attached to every service that we report on the rhc claim okay so these five two again X codes are the ones specific to both rhcs and fqhcs um but we're obviously only going to talk about rhcs here today so a 521 is probably going to be your most commonly used Revenue code it's just a clinic visit by one of your patients into the rhc okay your rhc providers can do home visits for your patients okay if they do that it's going to be under a Revenue code 522 there are specific home visit CPT codes that um would be Associated to that 524 and 525 are going to be your nursing facility codes okay and the type of stay that the patient is in is going to help Drive which of those two Revenue codes you use okay so 524 is for a part a covered stay in a nursing facility 525 is a nonp part a stay okay uh 527 is a unique one because it's one of the only times that you might have an RN or an LPN that would be considered a billable provider for an rhc service from a Medicare standpoint and that's because 527 is for visiting nursing services to a member's home okay the catch is that they do have to be in a home health shortage area okay if you are providing those Services um someone asked I think last year when we did this presentation how you you know if you're in a home health shortage area um it is not listed out on the hersa website the same way that your primary care shortage areas are um or anything like that um you should be able to contact your state I believe and your state should be able to let you know if you are located in a home health shortage area okay but there's nowhere that you're necessarily going to be able to look it up in a database 528 is a visit by an rhc provider to another non-rc site and they specifically give the example here of the scene of an accident and the reason they give that example is because they don't want this to be misunderstood to say that the patient is in some other type of facility and our rhc providers go see that patient and that qualifies as an rhc visit okay that's not the case if it has other rules that Medicare has already outlined for that specific facility type that's not what 528 is intended to be used for okay so again scene of an accident is the example there so just kind of keep that in mind and then Revenue code 900 this is the only one that's not a 52x code but 900 is for all our Mental Health visits and that's both inperson and Via tella health and we're not going to cover tella Health today um I believe Patty is covering that later this week um so just be aware of that okay so these are some other common Revenue codes that you might see used in the rhc space okay there are by no means like just a dead set list of codes okay there's a whole list of Medicare Revenue codes out there there that you can look up um the novatos website actually has them organized pretty well so if you go out there and just Google Revenue codes um there's a whole list of them but these are some of the more common ones I see used in the rhc space okay so Revenue code 250 is your your Pharmacy codes okay those are going to be drugs that don't have a detailed J Code okay uh Vena puncture is under Revenue code 300 your drugs that do have that J Code so a lot of our injectable medication are going to be under Revenue code 636 and then the Revenue code 780 is for our tella Health originating site okay originating site is the location of a patient during the tella Health encounter so again CMS is basically paying you a fee for hosting the patient in your rhc they're usually seeing a provider that's physically distant elsewhere okay all right some more rhc claim details to be aware of here okay I'm sure I have like crossed over the rule of how many words you're supposed to have on a slide but there's a lot of things to try and remember when it comes to including everything you need to on an rhc claim Okay so we've kind of already talked about this but rhcs are required to line item detail code for all services provided during a patient encounter okay so that's going to be your rhc services any incident 2 Services provided any professional components of certain Services um and then it could be you know procedures anything else that you did during the patient encounter that is billable on your rhc claim okay all of those services are reported with either actual charges for the services or a penny the only exception to what cannot be reported with a penny is what's going to be on your qualifying visit line and we'll Define the qualifying visit line here in just a second okay whether or not you report your services with actual charges or a penny is largely um a decision based on two things really okay preference and the functionality of your Billing System okay I have a preference for one versus the other but my preference does not matter each of you are going to have to make that determination for yourself as to which is the best option here okay so CMS is accepts either one now regardless of how you report those charges your total charge for the Services based on the actual charges is going to roll up okay that roll up to the qualifying visit line or the CG modifier line okay so if you report with a penny or you report with actual charges what is on that one line should be relatively the same okay the only exception to this rollup requirement is for qualifying preventive Health Services okay and I believe Charles is going to cover preventive Health Services next week if it's a qualifying preventive Health Service we don't roll those charges because co- inssurance and deductible are waved for those and the payment for those is a little bit different than just your like enm office visit okay and Charles will cover that next week your total charges are still going to be reported on that 00001 line that's at the bottom of your claim where you put all your charges okay CMS doesn't use that line item to adjudicate payment for anything okay so just be aware of that it's still going to be reported there but CMS doesn't use that as any sort of like indicator let's talk about this qualifying visit line that we've been talking about okay so every rhc claim must have a qualifying visit line okay the definition of that qualifying visit line okay it serves to identify the primary reason for the patient encounter on a given date of service that could be an enm office it could be a procedure it could be a preventive Health visit okay whatever the primary reason is that the patient is showing up to your rhc that day is what you're going to put as your qualifying visit line okay the qualifying visit is likely listed the CPT code for it is likely listed on the qualifying visit list okay so we have a qualifying visit line we have a qualifying visit list the qualifying visit list is something that was developed by CMS back in 2016 when the CG modifier was P first put into existence for rhcs okay so the whole goal of this qualifying visit list um and there is a link on here so when you get these slides you'll be able to go to that link and it'll take you to the current qualifying visit list for rhcs okay so when they first put the qualifying visit list out in 2016 it only had about 30 codes on it okay and they're the codes you'll see listed in black um and those were the codes that CMS said these are the only codes that qualify for Standalone reimbursement they're the only things that qualify as an rhc encounter and so when they opened it up for comment lots of rhcs started writing in to say hey ing to how you define a visit okay so one of those very first slides that we looked at we have a ton of procedure only codes that we feel should be added to this list so that's what you're going to see listed in red if you go to that link okay are all these different procedur codes that CMS started adding as people were writing in okay so they did add this line here it is not an all-inclusive list of Standalone billable visits for rhcs they basically stopped updating this list on August 1st of 2016 because they kind of realized there is no way we can fully capture every single one of the codes that could possibly stand for rhc reimbursement okay so even though there's not there may not be a CPT code listed on that qualifying visit list doesn't necessarily mean it doesn't qualify for rhc reimbursement but this list is a really good comprehensive list um to get you started um in looking at what services are billable for an rhc okay so just keep in mind it's been seven years since it's been updated any changes to the CPT code sets Okay so we had some this year for like those home visit codes and the rest home codes things of that nature it does not take into account any of those changes okay all right now the CG modifier so the CG modifier and the qualifying visit line are kind of married okay the CG modifier identifies the qualifying visit for a date of service okay and that's why we have to make sure that it is on the claim your specific system may not put it as the top line and that is a common question that I get from people is well what if it's not at the very top what it's not you know it's not first on my list of you know reported codes that's okay um some systems put them in order ing to Revenue code so it's it's not a huge deal as long as that CG modifier is attached to your qualifying visit okay it also tells Medicare what line item they need to use to calculate any applicable co- insurance and deductible for the patient okay and co- inssurance and deductible is something that um excuse me that Patty's going to cover I believe on Thursday okay but again Co insurance is not based on um your all-inclusive rate so it's not based on your payment it's based on the actual charges that are reported on that line so that's why the CG modifier is important generally speaking there is only one CG modifier per rhc claim however there are a few exceptions to that rule that I want to make sure we cover okay so this is a lot of words this is is the guidance directly from CMS um regarding multiple providers um and multiple visits on the same day okay so this is from the claims processing manual and so the first part here says accept as noted below and so those are the exceptions that we're going to talk about encounters with more than one rhc provider on the same day or multiple encounters with the same rhc provider are going to constitute a single rhc visit and they're payable as one visit so that's this whole idea that we're paid on the basis of an encounter okay and it applies regardless of length or complexity of the visit regardless of the number or type of Provider seen whether the second visit is scheduled or unscheduled and whether the first visit is related or unrelated to the subsequent visit okay so you're going to see why there's some exceptions here in just a minute and then lastly this includes situations here and we kind of talked about this already when we talked about having a primary care visit visit with a specialist visit okay this would include situations where an rhc patient has a medically necessary face-to-face visit with an rhc provider and then sees another rhc provider including a specialist for further evaluation of the same condition or a different condition on the same day okay so that's directly what CMS says and then here are the exceptions that they give us to this rule so any time you see one of these exceptions this is going to mean that you're going to have more than one CG modifier on the claim okay so the first one is what we call subsequent illness or injury okay so the example that I always give here is that a patient came in in the morning uh they had a follow up with their primary care provider for their hypertension they went home they were working outside in their yard they fell and they cut their leg okay they had to come back to the rhc on the same day and whether they saw the same provider or a different provider Ider it doesn't matter in this instance they had a they had separate diagnosis and treatment okay that's the key there they had separate diagnosis and treatment okay this section in bold here is really important because we missed this a lot in the rhc space I can't tell you the number of rhc claims that I have reviewed that have had a modifier 25 or 59 used inappropriately on them okay in this situation only the RH would use either 59 or 25 to attest that the conditions being treated qualify as two billable visits okay so if you come from just The Physician Office world and that's like your background as a biller or a coder you use 59 and 2 all the time on claims okay in the rhc space those modifiers mean something completely different than they do for just the private Physician Office Space okay we should very rarely be using 25 and 59 and it's because they should only be used for these subsequent illness or injury examples okay from time to time I have a client who says well I I put that modifier on there and Medicare paid for it just because you got paid for something doesn't mean you were supposed to get paid for something okay and eventually Medicare will figure it out and you will have to pay back that money so make sure that we're using these appropriately okay the other two examples that are exceptions for this multiple visits on the same day are going to be when you have a medical visit and a mental health visit on the same day I do see this happening increasingly as rhcs are looking to see how they can integrate mental health into their Primary Care rhc okay so you're going to have a CG modifier on the medical visit and a CG modifier on the mental health visit okay and the third example um that CMS gives as this exception to the the rule is if there was a medical a mental health and the ipe taking place all on the same day okay so you could have up to three billable services on that day now the ipe does not require a CG modifier except from certain Max so just be aware of that okay now there's a link here to the CMS rhc reporting requirements FAQ um we've been told that this is going to be going away but I checked yesterday and it was still there so I would highly suggest going out to this link and printing and saving it somewhere because it is a really good FAQ to help you understand when you do and do not need a CG modifier uh what the different exceptions are and things of that nature okay one of the uh questions IT addresses here that's actually very common is when you have an enm visit and an annual Wellness visit on the same day and how you assign the CG modifier in that instance okay all right so we've talked about all these different claim requirements and what you would need on the claim now let's cover what your actual payment looks like from Medicare okay so you'll hear me say it I've said it already on this webinar a handful of times if you've ever been in an rhc billing webinar before you have heard us Consultants say rhcs are reimbursed they're all inclusive rate okay and that's only 78.4% correct so rhc actually from Medicare you receive 80% of your all-inclusive rate less 2% sequestration taken out by Medicare okay so when you do that math which I'm not a big math person but when you do that math you're basically going to take your all-inclusive rate multiply it by 78.4% and that's what you can expect to get paid from Medicare okay now just remember that Medicare will not start paying on your rhc CL claims until your patients me their part B deductible each year okay and that continues to just go up so at the beginning of each year it is very common um to see what we call negative reimbursements and uh Patty's going to cover that fun topic for us I think on H Thursday okay so we're g to switch gears a little bit here we've talked about rhc services and how you can build your rhc claims but what about non rhc Services okay okay so there are certain things that are classified as a non rhc service and basically what that means is that there are certain Services the rhc might be providing that are actually beyond the scope of the rhc benefit or they're not a Medicare benefit okay and these are considered non rhc Services okay there are specific sections in both the claims processing manual and the benefit policy manual that cover non rhc Services okay it is a very very common misconception when I say non rhc that people assume that means non-p payable okay non rhc does not mean non-p payable it simply means that the payment mechanism for those non rhc Services is outside the structure for your rhc reimbursement okay in other words it's paid outside of your all-inclusive rate okay and because of that it has different billing requirements okay so because it's a non rhc service we also have to remember and this is like Mark's area of expertise here that all costs associated with those non rhc Services should be removed from your rhc cost report okay so that's the space the equipment supplies you know facility any overhead um your personnel salaries for those non rhc Services would get carved out okay so these are some of the examples that CMS gives for those non rhc Services probably the most common two for most rhcs are these technical components of rhc services okay so the technical components of X-rays and EKGs and then your lab services okay so remember there are six Labs that every rhc has to have the ability to provide okay they're still considered a non rhc service even though you have to have the ability to provide it okay just keep that in mind um I do see some rhcs that provide um DME okay that's another common one that I see um other than that there aren't a whole lot of these that I'm seeing just in the rhc space okay some of these are more hospital um or sort certain specialty providers that I see providing these okay now how are we paid for those non rhc Services okay well our non-rc services get built differently depending on the type of rhc that you you are okay so for all of your rhc services which we've already talked about you build those the same whether you are an independent rhc or a provider-based rhc no difference in how you would Bill the difference in how you Bill comes in here with these non rhc Services okay so independent rhcs are going to build Medicare Part B using your rhc ptan number okay provider-based rhcs also Bill Part B for those services but under the parent Hospital okay so it's going to look to Medicare as if they walked into to the hospital now you can have a different rhc fee schedule that's set up so that those patients aren't getting charged Hospital rates when they had the service done at the rhc that's not a requirement but that is something that you can do because I know that's a concern for some people in the provider-based space okay now the payment for those non rhc Services again differs depending on the type of rhc that you are okay so critical access hospitals or provider-based rhcs that are provider based to a critical access Hospital are going to see receive cost-based reimbursement for those non-rc Services okay PPS hospitals so provider-based rural health clinics to a PPS hospital and then our independent rural health clinics are going to be reimbursed on some sort of fee schedule so if it's a lab service it's ing to the lab fee schedule if it's a technical component it's ing to to that radiology schedule that they have out there both of those things are on the CMS website under all of their different fee schedules so it shouldn't be a surprise to you you can go out there and look those rates up okay so this is a really helpful chart and I hope you've all seen this before um it does get used frequently in some way shape or form by I think all of us um just because it's a very good depiction of how you build depending on the type of service that's being provided and depending on the type of rhc that you are okay so it's pretty much a a pictoral way of looking about what we just talked about okay so like I just said those encounters for rhc services are built to Medicare part A on a u under your rhc P0 number for rhc services that's the same for everybody those Clea labs in the rhc okay as well as those technical components those are going to be build and reimbursed differently depending on the type of rhc that you are okay and some of those details are here any Professional Services so if if you have rhc providers that round on patients in the hospital services that take place in the hospital are not build under your rhc okay those are build ing to your hospital rules usually under some Physician Group group okay so those are not going to be build under the rhc just keep that in mind all right now we're going to talk about a little bit of like the dirty word if you will in the rhc space and that's incident two Services okay so we all provide incident 2 Services more than likely um and those are basically services and supplies that are integral but incidental to your rhc Provider Services okay generally they're going to be services that are done by your clinical staff okay they are done under the physician's direct supervision unless there is some uh there are a few things that can be done under General supervision um it is included in your rhc payment and they're generally Services provided in an outpatient clinic okay now all your services and supplies should result from the patient's encounter with a provider and done with an a medically appr rate time frame so that communicates to you that these incident two Services may not always be taking place on the same date of service as their visit with a provider okay so we're going to look at that here in a second one of the most common examples here is for allergy injections okay and really injections of any kind where they might be done in a series where the patient comes back every week they don't necessarily see the provider every single time that they come in okay and that's why allergy injections are an easy example to kind of talk about here okay so payment for those incident 2 Services again if they're provided in the rhc space they're included in your rhc all-inclusive rate and that's whether they are done on the same day as the provider visit or they're done on a different day okay incident two services are pretty easy to capture when they're done on the same day as a provider visit so that same day as that enm office visit they're more difficult to capture when they're done on a different date of service okay so if you have an encounter and this is where this different dates of service comes in if you have an encounter for only incident two services on its own it is not considered a standalone billable visit so that's why we have to look at options for being able to build that incident two service okay so just remember the incident 2 service is still going to generate Co insurance for the patient it is not going to generate any additional reimbursement from medic here okay so here are two options to consider uh when addressing these incident 2 Services okay and this is incident two Services taking place on a different date of service than the provider visit okay your first option is to add the incident to service to a qualifying claim within a medically appropriate time frame okay you're going to hear this called the 30-day rule a lot which I'm sure you've heard um 30 days is not a hard fast number to technically speaking um it could be 45 days um that could be considered a medically appropriate time frame um but 30 days is uh kind of best practices just because it means at the end of every month you can go back and look at what incident two Services um are not attached to a provider visit and figure out how we need to get them onto a claim in order to be billable okay now this is not a great option because it requires one of two things it either requires the rhc to hold claims until the end of each month and be able to add all those incident 2 Services onto a qualifying visit or it requires the rhc to submit an adjusted claim each time those Ser those incident two services are rendered so that's where that type of Bill 717 comes in that we were talking about neither one of those is a great option right um it's it's usually a very manual process because there's not some sort of uh thing that we can build into our Billing System that says hey you have these incident 2 services that need to get added somewhere right so it's usually um kind of a manual process that can be a headache for a lot of people um when you do have these Services taking place on a different date of service you're still going to use the date of service of the qualifying visit for those incident 2 Services okay so I'm going to use the allergy injection as the example here you have a patient that came in let's say on November the first and they had a visit with the provider okay A 99213 office visit and the provider said I want you to come back every week for the next four weeks and get an allergy injection um and then we'll reassess okay so every week that they come in okay they've got you've got one unit that you're having to figure out how to get onto that claim each time that they come back okay so you have to figure out which of these options is the best for us okay and maybe this option isn't the option that your clinic wants to go with the other option that you have is depending on the volume of those incident two Services you can adjust them off to some sort of adjustment code to help you track them okay any of the associated costs would be reported on your cost report okay um again this is different for different clinics there are some clinics that have a lot of allergy injections that they do there are some clinics who who they just do a handful and so for them to write them off or find another way for those to be provided at a different Clinic they have that's possible I fully understand that some these options are not great options for people okay um the main thing to remember here is that either way you choose to do this you are not going to generate additional reimbursement from Medicare but you are going to increase your patient co-insurance in finding a way to get it onto the claim okay so that can often be um sort of a decision maker in and of itself for some people okay all right now if you're a more visual person in nature I'm going to quickly go through some of these claim examples just to sort of visually represent what we have already talked about okay so this is a very basic straightforward enm office only uh office visit only example okay so you'll see we've got the 521 Revenue code they had a 99213 the CG modifi is attached and you've got the charge pretty simple right uh there's no rolling up that has to happen pretty straightforward now you can also have a procedure only remember that qualifies as an rhc encounter so the difference here we've still got our 521 Revenue code so we know it happened in the rhc here we just have a procedure code instead we've still got our CG modifier we've still got our total charges pretty simple remember that this claim and the claim we just looked at are going to generate the same payment from Medicare but different co- Insurance amounts okay now what if you had that visit in the procedure take place on the same date of service okay when you have that that's where we start to see this roll up that we were talking about okay again our 521 Revenue codes are the same now we have both the 99213 and the procedure in this instance the CG modifier we're saying that the office visit was the primary reason for the patient encounter that day and nine times out of 10 in this instance I see it be the office visit that gets the CG modifier I'm not going to say it doesn't matter in this case because you would be reimbursed the same whether you put the CG modifier here or here but I do see it going on the enm office visit quite frequently so here's where we have the rollup starting to happen okay we have this $250 that encompasses the $100 charart for the office visit and this $150 charge for the procedure okay so that's where we start to see that rollup happen now these next two examples are going to be those um examples showing you if you report with actual charges versus a penny just so you can see what that looks like okay so here we've got a level four visit we have our injection and we have the drug so again you'll see that 636 Revenue code all right for our injectable medication that has a different Revenue code they all roll up to this 207 that's an option if you report with actual charges if you report with just a penny it looks pretty much the same with the exception of you have a penny here and therefore you only have a smaller amount that's being reported on your 0000001 line the reason people like this is because they feel like they're writing off less and so their AR doesn't look as high again you're not doing anything wrong by reporting accoring it one way or the other preference and system capabilities those are the two things to consider okay again I we're not covering preventive Services here but I did want to show you um an example of when you have preventive services on the same claim as um an enm visit okay so in this instance we have our 99213 at $150 and we have the annual Wellness visit the charges are not rolled up obviously because those preventive Services have co- inssurance and deductible wave so that's why we don't want to include it in this line item okay so just note on this with both of those Services together you're only going to get one all-inclusive rate payment um Charles will expand on this a little bit more when he covers preventive Services okay this is where we get into the claim examples for all of our exceptions to the rule for when we would have more than one CG modifier okay so this is that subsequent illness or injury example where again they came in in the morning they went home and cut their leg they could have come back and it was just an office visit too this does not have to be a procedure here that would obviously impact what modifier you used but just beware this is one of the only times when we're going to have that 59 or 25 on the claim okay so there would be two allinclusive rate payments made for this claim okay uh this is the medical visit and the mental health visit that are on the same day this one happens to be an in-person mental health visit so you have a CG modifier identifying the primary reason for the medical visit and then you have a second CG modifier identifying the primary reason for the mental health visit okay they don't roll up because they're each their own separate service and then this is that example of if you were to have the ipe the medical visit and the mental health visit this is kind of a unicorn to be perfectly honest with you um but again you can have it so again you'll have two CG modifiers you will have the IP that does not require a CG modifier just know that the ipe will be paid at a 100% of your all-inclusive rate whereas your other two services will receive the reduction of that 78.4% okay so up to three payments when you have this scenario now this is looking at our like non rhc service examples okay so this is where we have that split billing that starts to happen so in this instance the patient had an office visit and they had an EKG okay so the professional component of that EKG is still going to go on the rhc claim okay so that's that 93010 in The Physician Office Space a lot of times we see the 930000 used that's not going to be used in the rhc from a Medicare standpoint okay because we have to split out the professional versus the technical component okay um I also want to point out the note here at the bottom uh the EKG interpretation and report so the professional component would only be reported on here if it was done by your rhc providers if you have an outside company that reads those for you then it is not going to be build on your claim unless they are contracted providers of the rhc okay and then this is how the technical component of that would look okay build differently ing to what type of rhc you are because it's considered a non rhc service okay so again that 93005 which is the technical component build to Part B but one is build under the rhc ID numbers for fee schedule payment one is build under the hospital or parent Hospital ID numbers um for either fee schedule payment or at cost to pay depending on the type of Hospital okay now I'm quickly going to talk about Medicare Advantage there are literally two slides that I'm going to cover here um I like this slide from the Kaiser Family Foundation because it kind of shows you the penetration of Medicare Advantage plans going back to about 2007 projecting forward to 2033 okay so in 2007 there only about 19% of eligible Medicare beneficiaries that were enrolled with Medicare Advantage plan okay um in 2024 that is surpassing the 50% Mark and they're projecting that by 2033 62% of eligible Medicare beneficiaries are going to be enrolled in a Medicare Advantage plan the only reason I bring this up is to say if you're not paying attention to your Medicare Advantage plans and how you are being paid by your Medicare Advantage plans as an rhc you need to because increasingly patients are being enrolled with these ma plans I think Mark um is probably the famous one for saying that Medicare Advantage plans are not in advantage to your patients okay um a lot of times they don't realize that they're even enrolled with a Medicare Advantage plan and if they are they have no idea what benefits that provides them okay so just be aware of that the question comes across I actually think it came across the Facebook group this morning someone asked um how they're supposed to be paid by Medicare Advantage plans um and the question is who knows not really there are now almost 4,000 Medicare Advantage plans Nationwide when I did this presentation last year um it was 228 plans less than that so it's gone up 6% in just a year okay that means that there are nearly 4,000 different sets of rules and contracts okay there is not a one-sized fits-all approach when it comes to Medicare Advantage plans so the blanket answer you're going to get from any consultant when you ask them how you should be paid is what does your contract say okay so they're not going to automatically pay you as a rural Health Clinic okay if your language is not structured as such that it states that you will Bill them as an rhc and therefore they will pay you as an rhc that's not an automatic thing so we encourage people to reach out early in the process when you're going through um the rhd certification process to ask hey what language do we need to have added some of them will require a new contract some of them will just update your existing contract it's all over the board okay so just know that it is important to pay attention to this you some ma plans are going to pay you the same as regular Medicare some might pay you a little bit more some might pay you a little bit less um hopefully this is something that we can you know get some regulation about um similar to how fqhcs do uh but that's still sort of to be determined at this point okay um here's some helpful resources again you're going to get a copy of this presentation if you haven't already so you can check those out uh we can now take some questions um and then here's my contact information if anybody has any other questions they need to ask after that okay I made it with four minutes to spare yes a whole four minutes and we probably have just enough questions for that Amanda thank you that was excellent as always so we really appreciate that uh our first question here comes from Darla and and you'll be testing me if I get if I get these right or not because I've answered these in the little chat box but okay we'll find we we'll get the right answer now right okay for Amanda can you do a followup and a preventive visit on the same day is the question you can so again Charles I think is going to cover preventive visits next week you can do them both but depending on what the preventive visit is um you're only going to get paid one all-inclusive rate okay the only exception to that rule is for the ippp which is separately reimbursable okay I think I got that one right way to go Mark way to go Amanda okay we're on the same we're on the same page this is good okay this one's gonna be a little this one I'm not sure about obgym visit in the morning for hot flashes and an rhc walk-in visit in the afternoon for a sinus infection I'm assuming this is the same person um how did rhcs build these two visits on the same day multiple visits uh on the same day exception I think what they're asking is are they going to get paid to all-inclusive rates for this situation is it is hot flashes and sinus infection enough different that we can use a 59 or 20 25 to get sure to get additional payment so that's iffy because you know if they didn't have the sinus infection when they came in in the morning um but then they all of a sudden had a sinus infection in the afternoon and they came back maybe when I would see this situation playing out more often is if they came to the OBGYN in the morning and then let's say they got the stomach bug like that's a significant thing that they needed to come back for they needed medication for you know again that's kind of iffy I don't know that there's a great answer there I mean if you put 25 on there then there's you know they're probably going to pay it but I don't know that's kind of a gray area to be really honest with you Amanda my answer was they would probably get an ADR from from Medicare look at some more information and then sort ofre decide it's it's a 5050 deal so some of them may not but generally speaking just remember that just because they see a specialist and then they see a primary care provider those providers are operating under under the same NPI number for the rhc okay generally speaking that's going to constitute one visit okay we're kind of splitting hairs here as to like what specific scenarios might qualify but I agree with you mark okay okay so let's see here and then Jill is asking um are behavioral behavioral health group therapy visits allowable as a payable encounter the last I can find is the is that group visits are considered non rhc service and are listed as such in the Medicare benefits manual chapter 13 and she quotes it group Mental Health visits do not meet the criteria for a one-on-one face-to-face encounter for an fqc or rhc yeah group services are specifically listed as one of those um examples that are considered a non rhc service now I will say several State Medicaid agencies will allow for group services from a mental health aspect yeah and what I put on there is I think that will probably change next year because of that IOP regulation there R health clinics can can start these things called iops that are open like nine hours a week and and you have to do three different services and I'm assuming you'll be doing groups in those types of settings but that's in 2020 yeah we're we've got to get some more guidance in term and details in terms of that but yes that's definitely possible um just with the expansion of those services but again those are set to be built under something completely different those are to be um you know just kind of I don't know we just need a lot more details about what all they're going to allow us to do with that I think at this point yeah yeah they definitely would not be paid under an all-inclusive rate correct correct so absolutely okay and then uh G uh Jillian asked for another another question there are are both vfc and private vaccines that are wasted due to expiration listed as a loss on the cost and I'll answer that since I'm a cost report person they cannot be so so we will not I will not put you on that since Todd wouldn't let you do cost reports I Todd won't let me do cost reports so don't let me answer that one I will jump in on that one okay let's see here next one is and I think we're just have maybe two or three more do you re let's see here do you receive a payment for any jcodes or is that included in your air it's included in your allinclusive rate yeah I know and the key is that do charge it because it does increase your co-pay your co- insurance from the patient you get you get 20% of what you charge for that so do try to build an incident to if you can yes okay when reporting the the mental health uh C got way uh mental health visit uh with the medical visit what provider is reported on the UB if both are on if both are on the the UB can you send separate UBS one for the mental health with the CG and another one with the medical Medical provider with the CG that's a good question I don't know the answer to that because yeah so just remember that when we're billing Medicare as an rhc you're billing as the rhc you're not billing as each separate provider so they're reimbursing the rhc whether or not it has to be on the same claim or separate claims um I know that Charles has addressed that question before and I think he has said that it doesn't matter um but I've not ever seen it on anything but the same claim because it's coming out of the same rhc yeah I have seen at one point paletto would would not pay them if you put it on the same claim you actually had some have specific rules about that too yeah they have weird rules so so you they would put put it on a separate separate one and and the way the UB works is for um uh for field locator 56 you put the MPI number that you're billing under the group NPI number field locer 76 is where you put the attendance the person who did the most for that particular provider so if you for that particular patient so if you are doing if you have two I I think it I think it works just fine to have two different two different UBS where you could put that different person on there if that's if that's cleaner right okay uh let me see here okay uh this thing is doing it's jumping around on me let me see if I can find where we are C reporting uh okay U can you do an LTC visit and a mental health visit on the same day and I don't know what an LC LTC is long-term care okay longterm care okay gotta you could do like a nursing home visit and a mental health visit on the same day if that's what we're talking about yes you can do both of those you just have to make sure the correct Revenue code is assigned for that nursing home and then you'd have the the 900 Revenue code for the mental health visit yeah there's nothing keeping you from doing that okay perfect okay um how would you build in an rhc an office visit and a radiology exam the same day do you add the 25 modifier to Radiology no so you're not going to add the 25 modifier um you're G to have your office visit and then you're going to have the professional component of that radiology service that's provided on your rhc claim now if it doesn't have specific CPT codes for the professional component versus the technical that's when you're going to have the the 26 modifier for the professional and then the TC that goes on the technical component that gets split out separately yeah and and the technical components they're going to be on the 1500 form if they're if they're in independent they're going to be on a ub4 if you're in a provider based clinic and it's gonna be a bill type was it 851 is if car and or 141 Bill otherwise okay correct yep you got it uh let's see I know a little bit about billing yeah you know more about billing than you claim to know Mark okay all right I try to hide okay uh let me see here okay wa okay I moved the slides let's see here okay I gotta find okay radi okay on the o the enm visit for addressing chronic care man chronic conditions then also had an annual wellness exam can we can we get paid for both a 99214 CG and a g 0439 you cannot so um the annual Wellness visit specifically is not a separately billable visit if it's done on the same day as another billable encounter and if you go to that CMS reporting requirements FAQ it covers that scenario specifically and in fact the CG modifier has to go on the enm visit and not on the annual lonus visit regardless of which was actually the primary reason for the patient encounter that day yeah yeah that's that's a frustrating thing because IP is handled different and uh the doctors really want that want that to change the ones I've talked now you should always do what best for the patient like don't separate them out onto separate days in fact Charles will probably cover this when he talks about preventive services but CMS specifically says that it's not appropriate to bring that patient back on a separate day just so you can get separate reimbursement basically yeah yeah that's that's not a good thing okay um in our R if our rhc is using the penny rollup and the qualifying VIs it with the CG is online too uh it will reflect the Penny the the penny is that okay for reimbursement um yeah so that's actually a really good question that comes up a lot is does the CG modifier line have to be like line one on my claim and it does not um it's okay if it's not online one the CG modifier is what's going to indicate to Medicare what um amount needs to be used now if it's online too but then your total are rolling up to line one that's a problem okay because you want all of your total charges to roll to that CG modifier line wherever it ends up falling on your claim um next question is it better for the patient and the office to not build the jcodes to rhc or can you send those to noncore um if you do it in the rhc space should be on your rhc claim yeah I don't know what she saying can we build it the Medicare Part B and the answer is no you can't you can't build it we're not getting so let's just build it the part B no do not pass thing that I will bring up is there are certain vaccines that mig