NE Rural Health Association Rural Health Clinic Preventive

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

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

Preventive Services Allowed Medicare Preventive Services are billed through the Rural Health Clinic on the UB 04 § Technical Components, labs, EKG tracing are billed on the non. RHC 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 3

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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 5

HOW TO BILL: WELL WOMAN EXAM How does a RHC bill for a "Well Woman Exam"? Ø Medicare does not have a "Well Woman Exam" as a covered preventive service, CPT codes 99381 -99387. Ø Each component of the "Well Woman Exam" billed on separate line items i. e. : Ø Ø G 0438 - initial Annual Wellness Visit (covered once in a lifetime) Ø G 0439 - subsequent Annual Wellness Visit (covered annually). Ø Provider must see the patient, not just the nurse Ø Screening Pap Tests Q 0091 and Screening Breast and Pelvic Examinations G 0101 covered every 24 months for low risk. Ø Each Code billed separately, if beneficiary is eligible, with 052 x rev code Ø If ailments are addressed, then appropriate to assign E&M 6

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 7

Care Management Services • Transitional Care Management (TCM) • General Chronic Care Management (CCM) • General Behavioral Health Integration (BHI) • Psychiatric Collaborative Care Model (Co. CM) • Visual Communications Services https: //www. cms. gov/Medicare-Fee-for-Service-Payment/ FQHCPPS/ Downloads/FQHC-RHC-FAQs. pdf 8

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 908628 9

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 908628 10

General Care Management – G 0511 Behavioral Health Integration – G 0511 • Reimbursed as non. RHC service • Avg of 99490, 99487, 99484, 99491 • G 0511 General Care Management = $67. 03 • Services for primary care conditions • G 0511 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 MM 10175 11

General Care Management – G 0511 Behavioral Health Integration – G 0511 • 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 email or phone calls or an answering service) • Must use EHR; • Allows transmission of the care plan by fax MM 10175 12

G 0511 • • • 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 13

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Psychiatric Collaborative Care Model – G 0512 Co. CM = $145. 96 – Paid at national non-facility avg 99492 & 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 Co. CM services; 60 minutes or more of subsequent psychiatric Co. CM services • Initial assessment by a behavioral health manager • Primary care practitioner determines if the patient is eligible for psychiatric Co. CM • Psychiatric consultant • Participates in regular reviews of the clinical status of the patient • Advises the medical care provider • MM 10175 15

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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 909289 June 2018 17

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Virtual Communication Services – G 0071 • Virtual Communication Services G 0071 • 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 G 2012 & G 2010 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 19

Virtual Communication Services – G 0071 • 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, email or use of a patient portal. 20

Virtual Communication Services – G 0071 • 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 21

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KNOW THE RHC REGULATIONS Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 220 issued 1/2019 https: //www. cms. gov/Regulations-and-Guidance/ Manuals/ Downloads/bp 102 c 13. pdf § RHC CMS Claims Manual Ch 9 Rev 3434 issues 12/31/15 https: //www. cms. gov/Regulations-and-Guidance/ Manuals/Downloads/clm 104 c 09. pdf § CMS clarification of stand-alone preventive services 8/10/16 https: //www. cms. gov/Medicare-Fee-for-Service. Payment/FQHCPPS/Downloads/RHC-Preventive. Services. pdf § CMS Rural Health Clinics Center https: //www. cms. gov/center/provider-type/rural-healthclinics-center. html § 23

Preventive Services Quick Reference Guide (interactive tool): https: //www. cms. gov/Medicare/Prevention/Prevntion. Gen. Info/medica re-preventive-services/MPS-Quick. Reference. Chart-1. html IPPE Quick Reference Guide: https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/downloads/mps_qri_ippe 001 a. pdf Annual Wellness Visit Quick Reference Guide: https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/Downloads/AWV-Chart. ICN 905706 Text. Only. pdf Beneficiary Preventive Services Coverage https: //www. medicare. gov/coverage/preventive-and-screening-services. html Noncovered ICD-10 codes for Labs http: //www. healthnetworklabs. com/pdf/icd 10/4 NONCOVEREDICD 10 CM CODESFORALLLABNCDS. pdf 24

INTERNET WEBSITES OF INTEREST https: //www. cms. gov/Medicare/Prevention/Prevntion. Gen. Info/medicarepreventive-services/MPS-Quick. Reference. Chart-1. html (interactive preventive service web tool) https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE 001 a. pdf https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/downloads/AWV_chart_ICN 905706. pdf https: //www. cms. gov/MLNProducts/downloads/MLNCatalog. pdf https: //www. cms. gov/Regulations-and. Guidance/Manuals/downloads/som 107 ap_g_rhc. pdf (CMS State Operations Manual updated 1/26/18) www. narhc. org (National Association of RHCs) Make sure you are subscribed to your MAC listserve for updated info! Rural Health Development Website & my e-mail: www. rhdconsult. com janet. lytton@rhdconsult. com 25

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