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Rural Health Clinics: Navigating the April 1 Billing Changes

Rural Health Clinics (RHCs) continue to be paid under the all-inclusive rate (AIR) for face-to-face encounters with a qualifying provider; however, the billing process has significantly changed. Effective April 1, 2016, claims must include detail codes to show all services provided during the patient visit. This includes revenue code reporting along with the appropriate HCPCS code associated with the services. CMS has outlined these instructions in the MLN Matters article MM9269 released in February with multiple amendments made well into March.

What Didn't Change

RHCs continue to roll all non-preventive charges into the line reporting the face-to-face provider visit. The total charges reported on this line will be used for calculating the 20 percent coinsurance and/or deductible due from the patient. See the RHC Preventive Services Chart which details the codes and corresponding charges that are separately billed.

What Changed

In addition to the provider visit total being reported as above, the practice management system will now be required to include detail billing for all additional services provided. The claim will appear to be inflated as compared to the accounts receivable for the patient balance due to the detail charge amounts being again reported to the claim total.

EXAMPLE: Patient has a code 11000 for biopsy of a skin lesion $175 during an office visit code 99213 $75, including a venipuncture for labs drawn $5 and 1GM Rocephin injection $20.

	Revenue Code	HCPCS Code	Quantity	Total
Prior to April 1, 2016	0521	None	1	$275
Total Claim Report				$275

Effective April 1, 2016	0521	99213	1	$275
	0521	11100	1	$175
	0300	36415	1	$5
	0636	J0696	4	$20
Total Claim Report				$475

When CMS released the MM9269, it came with a very limited list of codes for services that were deemed a "Qualifying Visit." There was no consideration made for procedure-only services that are commonly provided during a follow-up visit to an office visit. As a result of responses from the RHC community, additional HCPCS codes have been included that are effective April 1, 2016; however, those codes listed in "red" cannot be billed until October 1, 2016. The RHC Qualifying Visit List was released March 24, 2016.

There are a couple other codes that are now billable by RHCs effective January 1, 2016. The Advanced Care Planning (ACP) code 99497 is now separately billable from the AWV (Annual Wellness Visit) and payable at the AIR (See Sample Billing for ACP furnished by RHCs). Also billable is Chronic Care Management (CCM) billed with code 99490 which is payable at fee schedule amount. Currently CMS has this under consideration as this code is only billable under direct supervision of the RHC provider, which is unachievable due to the 24-hour-per-day, seven-days-per-week requirement (Read the MLN Matters Article ).

Considerations for Implementing Changes

As you implement these billing changes, please consider the following:

Focus on the Medicare claims not yet adjudicated, as those services provided prior to March 31, 2016, continue to be billed under the previous billing instruction.
Review and update chargemaster for appropriate revenue and HCPCS codes for compliant billing.
Work with practice management system and clearing house vendors to assure only non-preventive services are rolled into the qualifying visit line total.
Follow the claim detail between the services provided, billing system and clearinghouse to validate the Medicare intermediary received the same information.
Consider the payment posting process and manual intervention that may be required due to the inflated claim reporting and how this effects contractual reporting.
Implement a system for holding claims that are not billable until the October 1, 2016, release of procedure-only visits.

Impact of These Billing Changes on RHC Operations

These billing changes will impact the operations of your RHC in many areas, including:

Increased accounts receivables (A/R), while holding claims not billable until October 1, 2016.
Denial management for face-to-face services previously paid, but omitted from the current CMS "Qualifying Visit List."
A/R inflation, depending on your vendor's ability to accommodate the claim requirement to include all charges in the "Qualifying Visit" billing line-as well as line-item detail reporting.
Necessary process changes to accommodate revised workflows and changes in payment posting. These process changes will be due to increased contractual adjustments reported on Medicare remittance for the inflated claim detail vs. actual charges in the A/R. This will create the need for a process change when posting payments.
Negative effects on patient satisfaction when reviewing explanations of benefits. As a result, patients will see not only additional charges rolled-up into the face-to-face visit, but also separate lines for these additional charges.

Questions?

To learn more about how Eide Bailly can help you with compliant RHC billing, please Contact Deyon Suchla at 701.476.8414 or dsuchla@eidebailly.com, or contact your Eide Bailly client relationship executive.

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