1. NE Rural Health Association
Rural Health Clinic Preventive Billing
& Care Management Services
Janet Lytton, Director of Reimbursement
Rural Health Development
Kearney, NE April 24, 2019

2. OBJECTIVES Learn how to bill preventive care
Learn how to bill for TCM, CCM, ACP
Learn what is and how to bill for the Virtual Communication Services

3. Preventive Services
Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB04
Technical Components, labs, EKG tracing are billed on the nonRHC side
PBRHC through the Hospital OP provider number
IRHC to MCR Pt B
Each preventive service MUST be on a separate line on the UB
CG modifier on main preventive service when all services are preventive
IPPE does not require the CG modifier; if other preventive services on same day as IPPE, one must have a CG modifier
ARE NOT bundled
Some claims may have more than one G-code

5. How Do We Bill: Preventive Physical
Medicare Does not pay for physicals
Exception for the Introduction to Medicare Physical (IPPE)
If visit is for a physical, not ailments = bill the patient
The “routine visits” for NH residents – code to their ailments and sign the recertification incidentally and bill to Medicare
Does not require an Advance Beneficiary Notice (ABN)
If billing to Medicare is requested by patient, RHC required to send a “no-pay” claim to Medicare for denial
710 TOB with all charges noncovered and CC 21

6. HOW TO BILL: WELL WOMAN EXAM
How does a RHC bill for a "Well Woman Exam"?
Medicare does not have a "Well Woman Exam" as a covered preventive service, CPT codes
Each component of the "Well Woman Exam" billed on separate line items i.e.:
G initial Annual Wellness Visit (covered once in a lifetime)
G subsequent Annual Wellness Visit (covered annually).
Provider must see the patient, not just the nurse
Screening Pap Tests Q0091 and Screening Breast and Pelvic Examinations G0101 covered every 24 months for low risk.
Each Code billed separately, if beneficiary is eligible, with 052x rev code
If ailments are addressed, then appropriate to assign E&M

7. Only Veni & OV bundled, all others separate charges; 1 AIR pd, copay on CG line amount = $30; copay on preventive services is in settlement on your annual cost report

8. Care Management Services
Transitional Care Management (TCM)
General Chronic Care Management (CCM)
General Behavioral Health Integration (BHI)
Psychiatric Collaborative Care Model (CoCM)
Visual Communications Services
FQHCPPS/ Downloads/FQHC-RHC-FAQs.pdf

9. Transitional Care Management
30-day transitional period of next 29 days after discharge from:
Inpatient Acute Care Hospital
Inpatient Psychiatric Hospital
Long Term Care Hospital
Skilled Nursing Facility
Inpatient Rehabilitation Facility
Hospital outpatient observation or partial hospitalization
Partial hospitalization at a Community Mental Health Center
Discharge to:
His or her home
His or her domiciliary
A rest home
Assisted living
MLN ICN

10. Transitional Care Management
Face-to-face visit
99495 – moderate medical decision complexity w/I 14 days
99496 – high medical decision complexity w/I 7 days
Only 1 health care professional may report TCM
Report once per beneficiary during TCM
For RHC, Date of service used is the F-T-F visit day
RHC paid their RHC all-inclusive 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
MLN ICN

11. General Care Management – G0511 Behavioral Health Integration – G0511
Reimbursed as nonRHC service
Avg of 99490, 99487, 99484, 99491
G0511 General Care Management = $67.03
Services for primary care conditions
G0511 Behavioral Health Integration = $67.03
Services for primary care and/or mental or behavior health conditions
Patient must have been seen in the last year or initiate CCM at an AWV or a physician visit
Billed under: Physicians, NPs, PA s, CNMs, and CNMs
General supervision allowed; allows for offsite management
Co-pays apply
MM10175

12. General Care Management – G0511 Behavioral Health Integration – G0511
At least 20 minutes of clinical staff time per calendar month to address ailments that include:
Option A – General Care Management – Pt with multiple (2 or more) chronic conditions to last at least 12 mo with significant risk of death, acute exacerbation/ decompensation, or functional decline
Option B – BHI – Pt with any behavioral health or psychiatric condition being treated by an RHC provider that is determined to warrant BHI services
Patient cannot on ESRD; Home Health; TCM; or Hospice
Must have Pt verbal or written consent with method to opt out
Must develop a comprehensive care plan with patient receiving a copy
24/7 Access to Care – “access to physicians or other qualified health care professionals/clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week” (Can use secure or phone calls or an answering service)
Must use EHR;
Allows transmission of the care plan by fax
MM10175

13. G0511 Billed on the RHC/FQHC UB-04 to Medicare Part A
Revenue code – 521
Can be billed with other services or billed alone
Will receive payment alone or in addition to your visit rate
Payment allowance
Made under the Physician Fee Schedule Non-Facility Rate
No geographic adjustment
Average of the comparable CPT codes (99490, 99487, 99484, 99491)
2019 allowance: $67.03
Coinsurance/deductible are applicable

15. Psychiatric Collaborative Care Model – G0512
G0512 CoCM = $ – Paid at national non-facility avg & 99493
Patient must have been seen in the last year or initiate CCM at an AWV or a physician visit
Billed under: Physicians, NPs, PA s, CNMs, and CNMs
General supervision allowed; allows for offsite management
Must have Pt verbal or written consent with method to opt out
70 minutes or more of initial psychiatric CoCM services; 60 minutes or more of subsequent psychiatric CoCM services
Initial assessment by a behavioral health manager
Primary care practitioner determines if the patient is eligible for psychiatric CoCM
Psychiatric consultant
Participates in regular reviews of the clinical status of the patient
Advises the medical care provider
MM 10175

17. Advance Care Planning 99497
Advance care planning including the explanation and discussion of advance directives such as standard forms – first 30 minutes (but does not have to have forms completed)
Can be a “stand alone” service and paid as a visit
Or, is an add-on element of the AWV
No frequency limits, but if performed again there should be a change in status or change in end-of-life wishes documented
FTF with patient, family member(s), and/or surrogate
No deductible or copay when with the AWV
Deductible and copay applies when billed otherwise
99498 can be billed for each additional 30 minutes
No specific diagnosis required
Make sure your charge is appropriate - $86.49 MPFS National
ICN June 2018

19. Virtual Communication Services – G0071
At least 5 minutes of communication technology-based or remote evaluation services
Discussion for a condition not related to an RHC service provided within last 7 days
And, does not lead to an RHC visit within 24 hrs or soonest available appointment
Rate paid is avg of G2012 & G2010 and updated annually--$13.69
This is not a telehealth visit
No frequency limits
Must require the skills of a provider. If could be conducted by a nurse, health educator or clinical personnel, then not billable as VCS

20. Virtual Communication Services – G0071
Deductibles and copays apply
Patient consent should be obtained before services are furnished in order to bill for the service
Same provider that patient seen prior is not required
Billing for this service will not impact the RHC AIR
Services would be initiated by patient by telephone, integrated audio/video system, or through a store-and-forward method such as sending a picture or video to the RHC provider for evaluation and follow up within 24 hrs.
RHC practitioner may respond by telephone, audio/video, secure text, or use of a patient portal.

21. Virtual Communication Services – G0071
Cannot be billed if initiated by the RHC practitioner
Secondary payers recognize service and code
VCS are recognized as RHC services
Can be billed in the same month as CCM services provided
Suggest billing VCS as a separate claim due to no previous visit to be within past 7 days
Costs allowable on cost report but put in the “other than RHC/FQHC services” section

23. KNOW THE RHC REGULATIONS
Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 220 issued 1/ Manuals/ Downloads/bp102c13.pdf
RHC CMS Claims Manual Ch 9 Rev 3434 issues 12/31/15
Manuals/Downloads/clm104c09.pdf
CMS clarification of stand-alone preventive services 8/10/16
CMS Rural Health Clinics Center

24. Preventive Services
Preventive Services Quick Reference Guide (interactive tool):
IPPE Quick Reference Guide:
Annual Wellness Visit Quick Reference Guide:
Beneficiary Preventive Services Coverage
Noncovered ICD-10 codes for Labs

25. Internet Websites of Interest
preventive-services/MPS-QuickReferenceChart-1.html (interactive preventive service web tool)
Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
Network-MLN/MLNProducts/downloads/AWV_chart_ICN pdf
Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf (CMS State Operations Manual updated 1/26/18)
(National Association of RHCs)
Make sure you are subscribed to your MAC listserve for updated info!
Rural Health Development Website & my

26. Any ?’s