Rural Health Clinic: Topics in Billing, Cost Reporting & Reimbursement

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1 Rural Health Clinic: Topics in Billing, Cost Reporting & Reimbursement Discussion Overview RHC Billing Resources CMS Charts; CMS Manuals 2012 RHC Maximum Rates; Fee Schedule Payment Changes RHC Billing/Reimbursement; Preventive Services Wisconsin Medicaid Quarterly Reports/Annual Filing Medicare Bad Debts Date or subtitle November 14, Title goes here 1

2 Medicare Billing Information for Rural Providers Medicare Billing Information for Rural Providers Download on CMS website at: Title goes here 2

3 Medicare Billing Information for Rural Providers Medicare Billing Information for Rural Providers Title goes here 3

4 Medicare Billing Information for Rural Providers Title goes here 4

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6 2012 Medicare RHC Maximum Payment Rates RHC Reimbursement Limits * Maximum $ $ $ $ $ $ $ Increase 2.8% 2.8% 1.8% 1.6% 1.2% 0.4% 0.6% * Effective 7/1/2001, all RHCs that are provider-based to a hospital of <50 beds (staffed) regardless of MSA (but are in rural area as defined by Census Bureau) are not limited to independent reimbursement limit Title goes here 6

7 Medicare Fee Schedule Amounts Non-RHC Fee Schedule Amounts Wisconsin Wisconsin Fee Change Fee Change Transitional Transitional Initial Revised From 2011 From 2011 Office Medicare Office Medicare Medicare To To Total RVUs Office Fee Total RVUs Office Fee Office Fee Initial 2012 Revised Office/outpatient visit new 1.17 $ $ 30 $ 41-25% 3% Office/outpatient visit new 2.02 $ $ 50 $ 70-27% 2% Office/outpatient visit new 2.91 $ $ 73 $ % 2% Office/outpatient visit new 4.47 $ $ 111 $ % 2% Office/outpatient visit new 5.58 $ $ 138 $ % 1% Office/outpatient visit est 0.56 $ $ 14 $ 19-28% 0% Office/outpatient visit est 1.17 $ $ 30 $ 41-26% 3% Office/outpatient visit est 1.96 $ $ 49 $ 68-26% 2% Office/outpatient visit est 2.91 $ $ 72 $ % 2% Office/outpatient visit est 3.91 $ $ 97 $ % 2% Medicare Fee Schedule Amounts Non-RHC Fee Schedule Amounts Wisconsin Wisconsin Fee Change Transitional Transitional Initial Revised From 2012 Office Medicare Office Medicare Medicare To Total RVUs Office Fee Total RVUs Office Fee Office Fee Initial Office/outpatient visit new 1.25 $ $ 31-25% Office/outpatient visit new 2.13 $ $ 52-25% Office/outpatient visit new 3.09 $ $ 76-25% Office/outpatient visit new 4.72 $ $ % Office/outpatient visit new 5.86 $ $ % Office/outpatient visit est 0.58 $ $ 14-24% Office/outpatient visit est 1.25 $ $ 31-25% Office/outpatient visit est 2.07 $ $ 51-25% Office/outpatient visit est 3.06 $ $ 75-25% Office/outpatient visit est 4.11 $ $ % Conversion Factor Conversion Factor Change -27.4% 0.2% Conversion Factor Conversion Factor Change 0.2% -26.5% Title goes here 7

8 Medicaid Primary Care Match Medicaid Primary Care Match Family practitioners, internists and pediatricians will receive fee-for-service Medicaid payment increases beginning Jan. 1, 2013 under a CMS final rule published Nov. 6, 2012 in the Federal Register. The services to receive increased Medicaid payment are those billed with E/M codes including those not reimbursed by Medicare and vaccine administration codes and There is a two-year limit on this increase. Non-RHC Fee Schedule Amounts WI Medicare WI Medicare WI Medicaid Projected Increase From Medicare 2013 Medicare Actual (26% reduction) Adult - HPSA (26% reduction) Office/outpatient visit, new $ 41 $ 31 $ 26 $ 15 $ Office/outpatient visit, new $ 70 $ 52 $ 44 $ 26 $ Office/outpatient visit, new $ 101 $ 76 $ 66 $ 35 $ Office/outpatient visit, new $ 154 $ 115 $ 95 $ 59 $ Office/outpatient visit, new $ 192 $ 143 $ 121 $ 71 $ Office/outpatient visit, est $ 19 $ 14 $ 15 $ 4 $ (1) Office/outpatient visit, est $ 41 $ 31 $ 26 $ 15 $ Office/outpatient visit, est $ 68 $ 51 $ 36 $ 32 $ Office/outpatient visit, est $ 101 $ 75 $ 57 $ 44 $ Office/outpatient visit, est $ 135 $ 101 $ 84 $ 51 $ Title goes here 8

9 Transitional Care New Codes/Services Transitional Care New Codes/Services (cont.) Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of at least moderate complexity during the service period. Face-to-face visit, within 14 calendar days of discharge Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge. Medical decision making of high complexity during the service period. Face-to-face visit, within 7 calendar days of discharge. TCM code covers services of moderate MDM and includes one face-to-face visit within 14 calendar days of the discharge. For patients requiring high-complexity MDM who are seen within 7 calendar days of discharge, bill Unlike the proposed rule, which allowed the face-to-face visit to occur within 30 days prior to the discharge, the final fee schedule requires a post-discharge face-to-face visit. TCM services require communication within two business days of discharge with the patient or caregiver. The communication can be direct contact, by telephone or electronically. The service may be billed by only one caregiver for each patient and only after 30 calendar days have passed since the discharge. The billing provider does not need to have had a prior relationship with the patient Title goes here 9

10 Transitional Care New Codes/Services (cont.) Non-face-to-face services are considered the essential piece of the care and must include the following services, unless a provider deems it not applicable: Communication with a home health agency or other community service; Patient or caretaker education to support self-management, independent living and activities of daily living ; Assessment and support for treatment-regimen adherence and medication management ; Reviewing discharge information, such as discharge summary; and Reviewing need for or follow-up on pending diagnostic tests and treatments. Transitional Care New Codes/Services (cont.) Federal Register Comment: Several commenters requested that we extend recognition of care coordination to RHC physicians and providers as well or at least clarify whether providers practicing in rural health clinics may utilize the new HCPCS G-code. Response: While we recognize that RHCs have an important role in furnishing care in their communities, RHCs are paid an all-inclusive rate per visit. Since RHCs are not paid under the PFS, physicians and other RHC providers whose services are paid within the RHC all-inclusive rate cannot bill using the CPT TCM codes for services furnished in the RHC. However, an RHC physician or other qualified provider who has a separate fee-for-service practice when not working at the RHC may bill the CPT TCM codes, subject to the other existing requirements for billing under the MPFS. What is wrong with this response? Title goes here 10

11 Medicare Coverage Preventive Services Medicare Coverage Preventive Services See Medicare Learning Matters MM7079 Effective for dates of service on or after January 1, 2011, Medicare beneficiaries receive an annual wellness visit (AWV), with a personalized prevention plan service (PPPS). The two HCPCS codes: G0438 Annual wellness visit, includes PPPS, first visit G Annual wellness visit, includes PPPS, subsequent visit G0438/G0439 are paid under the RHC all-inclusive rate. G0438 (initial visit) is a once-in-a-lifetime benefit; cannot be billed within 12 months after effective date of Medicare coverage (should be preceded by IPPE). G0438 cannot be submitted within 12 months of IPPE (Welcome to Medicare Visit, G0402) or G0439 (AWV, subsequent visit) Title goes here 11

12 Medicare Coverage Preventive Services Medicare Coverage Preventive Services Medicare Learning Matters SE 1039 Effective for dates of service on or after January 1, 2011, coinsurance and deductible are not applicable for the Initial Preventive Physical Examination (IPPE) or Welcome to Medicare Visit. To ensure coinsurance and deductible are not applied, detailed HCPCS coding must be provided for preventive services. Professional component of covered preventive service billed as RHC encounter on TOB 71x using 052x revenue code along with the HCPCS code of G0402. If covered preventive services are provided as part of RHC encounter, charges for the preventive services must be deducted from the total charge for calculating deductible and coinsurance. The ACA also waives the deductible for planned colorectal cancer screening tests that become diagnostic Title goes here 12

13 Medicare Coverage Preventive Services To ensure coinsurance and deductible are waived for qualified preventive services, RHCs must report an additional revenue line with the appropriate site of service revenue code in the 052X series with the approved preventive service HCPCS code and the associated charges. For example, the service lines should be reported as follows: Line Revenue Code HCPCS code DOS Charges 1 052X 01/01/ X Preventive Service Code 01/01/ Title goes here 13

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15 Preventive Service Charges on Cost Report Preventive Service Charges on Cost Report Charges for Preventive Services NOTE: Section 4104 of ACA eliminates coinsurance and deductible for preventive services, effective for dates of service on or after January 1, RHCs and FQHCs must provide detailed healthcare common procedure coding system (HCPCS) coding for preventive services to ensure coinsurance and deductible are not applied. Providers will need to maintain this documentation in order to apply the appropriate reductions on lines and (per instructions for Form CMS dated August 2011) Reimbursable Cost Program visits (per PS&R) times rate per encounter equals program costs. Medicare pays 80% of cost to allow for coinsurance. New lines (16.xx) added in 2011 to exclude preventive services from coinsurance calculation. AMOUNT 16 Total Program cost (sum of lines 11, 14, and 15, columns 1, 2 and 3) 662, Total program charges (see instructions)(from contractor's records) 728, Total program preventive charges (see instructions)(from provider's records) 15, Total program preventive costs ((line 16.02/line 16.01) times line 16) 13, Total program non-preventive costs ((line 16 minus line 16.03) times 80%) 495, Total program cost (see instructions) (line line 16.04) 508, Primary payer amounts 18 Beneficiary deductible (see instructions) (from contractor records) (informational) 30, Beneficiary coinsurance for RHC services (from contractor records) (informational) 142, Net Medicare cost excluding vaccines (see instructions) 508, Program cost of vaccines and their administration (from Worksheet M-4, line 16) 8, Total reimbursable Program cost (line 20 plus line 21) 516, Title goes here 15

16 Wisconsin Medicaid Quarterly Reports Wisconsin Medicaid Cost Reports Quarterly Payments When a clinic has provided services as an RHC for 12 continuous months, it has the option of receiving quarterly payments by submitting a quarterly Medicaid Rural Health Clinic Quarterly Cost Report (referred to as "quarterly cost reports") in addition to the annual cost report. Wisconsin Medicaid's quarterly payments enable RHCs to increase cash flow throughout the year. Quarterly cost reports must be submitted within three months of the quarter's end. Report Submission The Medicaid annual cost report and supplemental documents are due 30 days after the Medicare cost report due date, as determined in the Medicare Rural Health Clinic and Federally Qualified Health Center Manual. A 30-day extension of the Wisconsin Medicaid due date may be granted if Wisconsin Medicaid receives a written request before the original due date expires. If an extension is requested, Wisconsin Medicaid provides a written response to the request. Failure to submit the annual cost report and supplemental documents within the specified timeframe will result in suspension of all cost settlement payments Title goes here 16

17 Medicare Bad Debts Medicare Bad Debts Medicare will reimburse the rural health clinic for all uncollectible Medicare deductibles and coinsurance, if considered to be allowable bad debts. The amount of allowable Medicare bad debts is added to the RHC cost report settlement. Medicare bad debts are being disallowed if they are still being worked by a collection agency. Intermediaries are requesting a copy of the correspondence from the collection agency as to which claims have been returned to the provider as being noncollectible before they are allowing the bad debt to be claimed on the cost report Title goes here 17

18 Medicare Bad Debts Medicare Bad Debts CMS Pub. 15-I Section 308 states the criteria for allowable Medicare bad debts: Debt must be related to covered services and derived from deductible and coinsurance. Provider must be able to establish that reasonable collection efforts were made. Debt must be actually uncollectible when claimed as worthless. Sound business judgment must have been established that there was no likelihood of recovery at any time in the future. CMS Pub. 15-I Section 310 defines reasonable collection effort: Similar to effort for non-medicare patients. Issuance of bill to responsible party. May include subsequent statements, collection letters, and telephone calls. Referral to collection agency if used for non-medicare patients of like amounts Title goes here 18

19 Medicare Bad Debts Medicare Bad Debts Presumption of Non-collectibility, CMS Pub. 15-I Section 310.2: If after reasonable and customary attempts to collect a bill, the dept remains unpaid more than 120 days from the date the first bill is mailed to the beneficiary, the debt may be deemed uncollectible. Indigent Patients, CMS Pub. 15-I Section 312: Clinics can claim bad debt without waiting the 120-day collection period. Determination of indigence must be documented in the patient s file. Beneficiary considered indigent if eligible for Medicaid. Provider must determine that no other source is legally responsible for payment Title goes here 19

20 Medicare Bad Debts For More Information Documentation Required With Cost Report: Beneficiary name and HIC number. Date(s) of service. Date of first bill sent to patient. Medicare paid date (R/A). Write-off date. Separation of deductible and coinsurance amounts. Medicaid payment and paid date (if any). This presentation was prepared by: Jeff Bramschreiber, CPA Health Care Partner Wipfli LLP (920) Title goes here 20

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