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CMS has issued another update to the Rural Health Clinic Line-Item billing requirements being implemented on April 1, 2016. Many Rural Health Clinics, independent and provider-based, will have to make significant software changes to deal with this. The change is described in the MedLearn Matters MM9269, which was updated again today.
CMS has been making consistent updates to this policy. The latest issue is that there is no accurate means to code a procedure only visit. Rural Health Clinics have many questions about this change to line-item billing. The main issue is the CMS has issued a Rural Health Clinic Qualifying Visit List. The list only has evaluation and management codes, but no CPT codes for minor surgical procedures. This means that the only way to bill a minor surgical procedure is with an inaccurate code. CMS has not yet updated the Qualifying Visit list with minor surgical procedure.
Rural Health Clinics will no longer bundle many of their services. Rural Health Clinics will need to list the service detail along with the relevant revenue code. This will include the ability to separately list venipuncture, preventive services, injections, and other incident-to services. This is a “sea-change” for most Rural Health Clinics.
This WILL go into effect – do not wait for it to be delayed.
“Effective April 1, 2016, RHCs, including RHCs exempt from electronic reporting under Section 424.32(d)(3), are required to report the appropriate HCPCS code for each service line along with the revenue code, and other required billing codes. Payment for RHC services will continue to be made under the All-Inclusive Rate (AIR) system when all of the program requirements are met. There is no change to the AIR system and payment methodology, including the “carve out” methodology for coinsurance calculation, due to this reporting requirement. ”
The full CMS guidance for Rural Health Clinics can be found here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9269.pdf
As we all know, there has been a large migration of Freestanding Rural Health Clinic certifications to Provider-Based Rural Health Clinic status. Provider-Based Rural Health Clinics attached to a parent hospital – and it is required to be a hospital – of fewer than 50 beds enjoys an uncapped RHC Encounter Rate. Preliminary data suggests that Provider-Based Rural Health Clinics increase costs to the Medicare program by 50% as a result of this migration. Be assured, this has garnered attention.
The Office of Inspector General’s recently released work plan formalizes this scrutiny:
“We will determine the number of provider-based facilities that hospitals own and the extent to which CMS has methods to oversee provider-based billing. We will also determine the extent to which provider-based facilities meet requirements described in 42 CFR Sec. 413.65 and CMS Transmittal A-03-030, and whether there were any challenges associated with the provider-based attestation review process. Provider-Based status allows facilities owned and operated by hospitals to bill as hospital outpatient departments. Provider-based status can result in higher Medicare payments for services furnished at provider-based facilities and may increase beneficiaries’ coinsurance liabilities.
The Medicare Payment Advisory Commission (MedPAC) has expressed concerns about the financial incentives presented by provider-based status and stated that Medicare should seek to pay similar amounts for similar services. (OEI; 04-12-00380; expected issue date: FY 2016)
Comparison of Provider-Based and Freestanding Clinics
We will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures and assess the potential impact on Medicare of hospitals’ claiming provider-based status for such facilities. Provider-based facilities often receive higher payments for some services than do freestanding clinics. The requirements to be met for a facility to be treated as provider based are at
42 CFR § 413.65(d). (OAS; W-00-14-35724; W-00-15-35724; expected issue date: FY 2016)”
OFFICE OF INSPECTOR GENERAL
U.S. Department of Health and Human Services
WORK PLAN Fiscal Year 2016 Page 6 and 7
North American Healthcare Management Services has specific expertise in successfully attesting to Provider-Based Rural Health Clinic status for clients. We are encouraging all of our Provider- Based Rural Health Clinics let us assess their provider-based compliance so that when a re-attestation request comes (giving the clinic 10 days to respond), it is not a reason to panic. Please call for a consultation.
President and CEO
North American Healthcare Management Services
Dear Rural Health Clinics –
I presented the following information to the National Association of Rural Health Clinics (NARHC) Spring Conference in 2015. This presentation provides and overview of the Merit-Based Incentive Program announced by CMS. This program was codified in the Medicare and S-CHIP Re-Authorization Act of 2015.
To date: Rural Health Clinics are largely unable to participate in Medicare Quality Incentives. As person passionate about Rural Health Clinics, I believe this is to our detriment. If Rural Health Clinics to not get in the quality game, we will be left behind. We all know that the Rural Health Clinic program is essential to our ability to provider primary care in rural areas.
Please let me know how we can help your Rural Health Clinic navigate these issues.
President and CEO
North American Healthcare Management Services
Your Rural Health Clinic experts!
The following Rural Health Clinic Survey and Certification Letter was released updating some CMS guidance relative to staffing.
• Definitions, §491.2 The definition of a “physician” has been revised to include a doctor of dental surgery or dental medicine, a doctor of podiatry or surgical chiropody, or a chiropractor, within the limitations of services these types of physicians are permitted to offer under Section 1861(r) of the Social Security Act. However, it continues to be the case that only MDs or DOs may fulfill the requirements for supervision, collaboration and oversight of non-physician practitioners in an RHC or FQHC.
• Staffing and Staff Responsibilities, §491.8 §491.8(a)(3) was revised to permit an RHC to have a nurse practitioner or physician assistant provide services under contract to the RHC. This increased flexibility does not eliminate the longstanding statutory and regulatory requirement that the RHC must have at least one employee who is a nurse practitioner or physician assistant. This change was effective July 1, 2014. §491.8(a)(6) was revised to require for RHCs that a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services at least 50% of the time the RHC operates.
This aligns the regulatory language with the current statutory requirement. Note that since the statutory provision was self-implementing, CMS has enforced the 50% standard even prior to this regulation change. (See S&C 09-14) §491.8(b) has been revised to delete the requirement formerly at §491.8(b)(2) for a physician to be present in the RHC or FQHC at least once every two weeks. This recognizes that many of the physician’s required functions may be performed remotely via electronic means, but does not remove the requirement that a practitioner, whether a physician or non-physician practitioner, must be present at all times the RHC or FQHC operates. Provisions formerly at §491.8(b)(1)(i) – (iii) have been renumbered to be §491.8(b)(1) – (3), but are otherwise the same.