RHC Medicare Billing Update GRHA Rural Health Clinic Conference May 1, 2019 Mercer University School of Medicine

What is new to RHC Billing? Definition of an Encounter and exceptions Care Management/Care Coordination Virtual Communications RHC Modernization Act S.B. 1037

It’s All About the Encounter! RHC visits (encounters) are medically necessary face-to-face medical or mental health visits or qualified preventive visits between the patient and a physician, NP, PA, CNM, CP, or CSW during which a qualified RHC service is furnished. Qualified preventive and screening services may also be standalone RHC visits. Transitional Care Management Services are qualified RHC encounters. Citations: IOM, Medicare Policy Benefit Manual, Chapter 13, Section 40 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

FACE-TO-FACE, ONE ON ONE (PHYSICIAN, NP, PA or LCSW) MEDICALLY NECESSARY LEVEL 2 OR HIGHER Requires a Provider* RHC ENCOUNTER (Billable) * Or a procedure on QVL or Preventive Service or TCM or ACP

Exceptions to Face-to-Face Encounter Care Management and Care Coordination Services CCM BHI Psychiatric CoCM Virtual Communication Services Telehealth Services are considered face-to-face because of synchronous, live interaction between provider and patient.

Care Management & Care Coordination Services Chronic Care Management (CCM) Behavioral Health Integration (BHI) Psychiatric Collaborative Care Model (CoCM)

CCM and BHI Service Effective January 1, 2018, RHCs can receive payment for Chronic Care Management (CCM) or general Behavioral Health Integration (BHI) services when 20 minutes or more of CCM or general BHI services are furnished and G0511 is billed either alone or with other payable services on an RHC claim. For 2019, G0511 reimburses $67.03 There are care management program requirements which must be met. There are difference between how CCM and BHI are performed in the RHC than in fee-for-service clinics.

CCM and BHI Service Effective January 1, 2018, RHCs can receive payment for Chronic Care Management (CCM) or general Behavioral Health Integration (BHI) services when 20 minutes or more of CCM or general BHI services are furnished and G0511 is billed either alone or with other payable services on an RHC claim. For 2019, G0511 reimburses $67.03 There are care management program requirements which must be met. There are difference between how CCM and BHI are performed in the RHC than in fee-for-service clinics.

Chronic Care Management Two or more chronic comorbidities that if left untreated/unmanaged for 12 months could result in the patient’s decline, decompensation or death. The decision for CCM has to be made by the RHC provider. Ancillary staff can provider subsequent services. Consent must be obtained. Deductible and Coinsurance Apply Only one provider can bill for CCM per month At least 20 minutes of documented care management Must have designated care management staff Must have technology in place for 24/7 coordination of care.

Example of CCM Billing CCM Reported Alone FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 CCM G0511 02/01/2018 1 75.00 0001 The –CG Modifier is NOT appended to G0511 because the service is paid under fee-for-service reimbursement. The RHC will receive $67.03. Deductibles and co-insurance apply. The patient will have a cost share. These amount are for 2019.

Example of CCM Billed with an Encounter FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 OV Est 3 99213-CG 02/28/2018 1 100.00 CCM G0511 75.00 0001 175.00 If CCM is billed with another RHC service, the charge for CCM is NOT added to the first line. The –CG modifier is only added on the first line. The clinic will receive the RHC all-inclusive rate for the office visit/encounter and the $62.28 for the CCM. The coinsurance will be $20.00 for the office visit and another $13.40 for the CCM (Total $33.40). It is important to explain to the patient the value of the CCM when enrolling them.

Psychiatric CoCM Rural health clinic or federally qualified health center (RHC or FQHC) only, psychiatric collaborative care model (psychiatric CoCM), 60 minutes or more of clinical staff time for psychiatric CoCM services directed by an RHC of FQHC practitioner and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month. G0512 is billed either alone or with other payable services on an RHC claim. For 2019, G0512 reimburses $145.96.

RHC Care Management Services Resources/Citations RHC Care Management FAQ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf MedLearn Matters Article: MM10175 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10175.pdf

Virtual Communication Services Effective January 1, 2019 RHCs can receive payment for Virtual Communication Services. 2019 Reimbursement = $13.69 At least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC practitioner to a patient who has had an RHC billable visit within the previous year, and; The medical discussion or remote evaluation is for a condition not related to an RHC service provided within the previous 7 days and; The medical discussion or remote evaluation does not lead to an RHC visit within the next 24 hours or at the soonest available appointment.

Virtual Communication Services To receive payment for Virtual Communication services, RHCs must submit an RHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. Payment for G0071 is set at the average of the national non-facility PFS payment rates for HCPCS code G2012 (communication technology-based services) and HCPCS code G2010 (remote evaluation services) and is updated annually based on the PFS national non-facility payment rate for these codes. RHC face-to-face requirements are waived when these services are furnished to an RHC patient, and coinsurance and deductibles apply.

Who can perform virtual communication services? The services cannot be performed by ancillary staff or nursing staff. The services must be provided by a qualified RHC provider: Physician NP PA CNM Clinical Psychologist Licensed Clinical Social Worker Virtual Communication Services must be documented.

The fine print: RHCs must report the RHC-specific HCPCS® Code G0071. No other virtual or remote codes can be billed. No limit to the number of virtual communication services per beneficiary as long as the conditions are met. Deductible and Co-Insurance apply. The Coinsurance is 20% of the lesser of the charge or the payment amount. Coinsurance cannot be waived. Communication must be initiated by the patient. Consent must be obtained prior to providing virtual communication services. The cost of providing virtual services is an allowable cost. Telemedicine is a synchronous, live service that replaces a face-to-face. In Contrast, Virtual Communication is a screening service to determine if a face-to-face is necessary.

Virtual Communication Services Resources/Citations: CMS RHC Virtual Communication Services FAQ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/VCS-FAQs.pdf Medlearn Matters Article: MM11019 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11019.pdf CMS IOM Policy Benefit Manual Updates for 2019 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-FQHC-bp102c13.pdf

Transitional Care Management (TCM) Billing & Coding 30-day transitional period after discharge from inpatient hospital and next 29 days Face-to-face visit within 14 days of discharge 99495 – moderate medical decision complexity 99496 – high medical decision complexity Only 1 health care professional may report TCM Report once per beneficiary during TCM For RHC, Date of service used is the Face-to-Face visit day Reimburses the AIR rate TCM cannot be billed during a global period Documentation required: Date of discharge Date of interactive contact with bene and/or caregiver Date of face-to-face visit Complexity of Medical Decision making

Preventative Services Guide https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf This CMS reference give examples of preventative services and indicates when the AIR is received and how the deductible and coinsurance amounts are applied. The –CG modifier is appended if the only service provided is the preventative service. The –CG modifier if not needed for the IPPE but may be added. Preventative services provided on the same day as a qualifying medical visit are reported but are not bundled into the –CG line. IPPE is the ONLY preventive service which will qualify for an additional AIR on the same DOS as a sick visit. Preventive services should be tracked for cost-reporting.

Advanced Care Planning https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Sample-Billing.pdf As a standalone service, the AIR is paid. When provided on same dos as AWV, the service is included in the one AIR payment.

RHC Encounter: IPPE Only FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 IPPE G0402 11/01/2017 1 200.00 0001 The physician performed IPPE (Welcome to Medicare) service on this date of service. No –CG modifier is required. The patient has no cost share for this visit because the deductible and co-insurance is waived. Is the IPPE the same as a beneficiary’s yearly physical? No. The IPPE is not a routine physical checkup that some seniors may get periodically from their physician or other qualified non-physician practitioner. The IPPE is an introduction to Medicare and covered benefits and focuses on health promotion and disease prevention and detection to help beneficiaries stay well. Medicare does not cover routine physical examinations. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

RHC Encounter: IPPE and Sick Visit on same date of service FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 OV Est III 99213 CG 11/01/2017 1 150.00 IPPE G0402 200.00 0001 350.00 The physician performed IPPE ($200) and an E & M ($150) for a problem visit on the same date of service. The office visit is listed first with the -CG modifier. The patient has no cost share for the IPPE service because the deductible and co-insurance is waived. The co-insurance amount due for the sick visit is $30.00. The RHC will receive two AIR payments for this visit. You should track all preventive services for cost-reporting purposes.

RHC Encounter: IPPE with EKG Interpretation/Report as Part of IPPE FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 IPPE G0402 11/01/2017 1 200.00 EKG IPPE Interpret/Report G0405 100.00 0001 300.00 The RHC physician performed IPPE ($200) and also interpreted the EKG ($100) performed as part of the IPPE. Only the HCPCS codes for the two services are reported on each respective line. The clinic will receive one AIR rate but the coinsurance and deductible will be waived per HCPCS code. Use the G-code when EKG is performed as part of IPPE. You should track all preventive services for cost-reporting purposes.

EKG Billing in Rural Health Clinics Code Description RHC UB-04 Independent RHC Part B PBRHC Hospital side 93000 EKG, 12 Lead with interpretation/report NO 93005 EKG, 12 lead, tracing only YES 93010 EKG, 12 lead, interpretation and report only. Maybe* * Depends on the provider who does the interpretation and the report.

Medicare Annual Wellness Visit Is NOT a routine physical exam. Must include certain components Is payable as a stand-alone RHC visit when it is the only service performed Is not payable as a separate service when performed on the same day of service as other medical or screening services. Is the AWV the same as a beneficiary’s yearly physical? No. The AWV is not a routine physical checkup that some seniors may get periodically from their physician or other qualified non-physician practitioner. Medicare does not cover routine physical examinations. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf

RHC Encounter: “Woman Well Visit” AWV and Other Screenings FL 42 Rev Code FL43 Description FL44 HCPCS FL 45 Date of Service FL46 Units FL47 Total Charge 0521 AWV- Subsequent G0439 CG 11/01/2017 1 150.00 Breast/Pelvic G0101 100.00 Pap Smear Q0091 50.00 0001 300.00 The patient received a subsequent AWV along with other preventive services on the same date of service. The –CG is appended to the AWV. There is no cost share for this visit.

RHC Modernization Act S. B. 1037- Introduced by Senator Barraso and Senator Tina Smith last month Need more Senate co-sponsors Still need House Sponsor Will raise independent RHC cap to $100, incremental increase over time Will redefine lab services Will allow RHC to be both distance and originating site for telemedicine Will allow NP/PA to practice at the top of their license per state regulation Allows NP/PA to be contracted and not employed

RHC Modernization Bill Advocacy Page https://www.web.narhc.org/narhc/RHC_Modernization_Act_Advocacy.asp Official Publication of Bill https://www.congress.gov/bill/116th-congress/senate-bill/1037

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