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NE Rural Health Association

Learn how to bill for preventive care, Transitional Care Management (TCM), Chronic Care Management (CCM), and Virtual Communication Services. Understand the billing process for Medicare preventive services and well-woman exams. Explore care management services such as TCM, CCM, Behavioral Health Integration (BHI), and the Psychiatric Collaborative Care Model (CoCM).

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NE Rural Health Association

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  1. 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

  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

  4. 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"? Medicare does nothave a "Well Woman Exam" as a covered preventive service, CPT codes 99381-99387. Each component of the "Well Woman Exam" billed on separate line items i.e.: G0438 - initial Annual Wellness Visit (covered once in a lifetime) G0439 - 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

  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 (CoCM) Visual Communications Services https://www.cms.gov/Medicare/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 – 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

  11. 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 mowith 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 MM10175

  12. 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

  13. Psychiatric Collaborative Care Model – G0512 G0512 CoCM = $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 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

  14. 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

  15. Virtual Communication Services – G0071 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

  16. 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, email or use of a patient portal.

  17. 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

  18. 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/Guidance/ Manuals/ Downloads/bp102c13.pdf RHC CMS Claims Manual Ch 9 Rev 3434 issues 12/31/15 https://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/clm104c09.pdf CMS clarification of stand-alone preventive services 8/10/16 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf CMS Rural Health Clinics Center https://www.cms.gov/center/provider-type/rural-health-clinics-center.html

  19. Preventive Services Preventive Services Quick Reference Guide (interactive tool): https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html IPPE Quick Reference Guide: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/mps_qri_ippe001a.pdf Annual Wellness Visit Quick Reference Guide: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV-Chart-ICN905706TextOnly.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/icd10/4NONCOVEREDICD10CMCODESFORALLLABNCDS.pdf

  20. Internet Websites of Interest https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html (interactive preventive service web tool) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf https://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_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

  21. Any ?’s

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