Rural Health Forum

Can you provide outpatient infusion to commercial patients in a provider based RHC?
To my knowledge, there are no federal RHC rules that would prevent you from providing this service to a commercially insured individual in the RHC setting. 

I have a question regarding allergy shots.  Are we supposed to be billing them by themselves out under our parent facility’s NPI number(we share the same tax id) or billed with another visit 30 days prior or 30 days after the visit.  There is a lot of confusion on this subject and nowhere can I find a clear answer. Also for provider based  RHC’s, do we cost report injections?  Of course not allergy. If in a RHC a provider performs an EKG on a patient, the office is billing 93005.  No report is being sent anywhere for someone else to read.  Should we be billing 93000  or 93010 instead?
You should still bill the 93010 with the E/M code.  It is bundled and is included in the 20% coinsurance not covered by Medicare.  My provider interprets ours too.  If I were sending it out for interpretation it would be different.  We bill our allergy shots to insurance also.  If they are Medicare I bill them when they have an encounter within the 30 day before/after rule.  Otherwise they get written off.  We are an independent RHC.  I am pretty sure we are not supposed to bill injections to Part B.  I do bill the CLIA waived tests such as Flu, Strep, and others to Part B.

Need some clarification regarding immunization administration codes… we have historically used 90471 – 90742 for all our pediatric immunizations, but recently was told 90460 – 90461 might be a better option.
We always use 90460/61 for children under 19 years of age.  The ones you have been using we use for patients 19 years and older.  The 90471/72 denotes no counseling was provided by a physician.

We are reviewing our revenue billing codes and ran across 99354 and 99355—both for prolonged E&M in the office setting.  Would we still use a 521 RBC on them?   They would never be a stand-alone visit, so would it be okay to have them room up into the 521 line?
HCPCS codes such as 99354 are itemized on the claim since it is an additional service code being billed to the visit.  MLN #MM9269 has an example (Example 5) when there are additional CPT codes to the qualifying visit code. We won’t roll up 521 CPTs, but detail them on the claim. Another reference is MLN #SE1611.

Medicare Chapter 13 discusses the Staffing requirements for a RHC to be in operation.   A Clinical Social Worker is on  the list of practitioners for the RHC.    Can a RHC be in full operation (draw labs, nurse visits) if the only practitioner on site is the CSW?
If the CSW is doing this periodically, there would be no federal prohibition.  You would need to check with state law to determine whether there would be limitations on performance of services by RNs or others without a “medical” professional on-site.  Note that an RHC could not operate full-time under this type of arrangement as it would be in violation of the requirement that there be a PA or NP or CNM onsite 50% of the time the clinic is operating as an RHC.  But if this were episodic events and the total time did not become a majority of the time, I am not aware of anything in the RHC regulations that would prevent the RHC from providing lab or other auxiliary services during RHC hours when there is only a CSW on-site.

We are looking to merge two rural health clinics into one consolidated clinic.  What is the process for doing this?
The process is three steps. Process for Merging Rural Health Clinics.

Can anyone tell me the revenue code to use with the J codes for Medicare rural health clinic?
We use 0636 on our J-Codes.

I have 5 providers that go to 17 nursing homes. We have a very hard time getting face sheets with patient’s info and billing. We have some patient balances in the thousands. Can we bill the nursing home if the pt runs out of days and sets up private pay with the nursing home but the nursing home doesn’t tell us about the change so we can bill the responsible party?
I believe the billing party is responsible for collecting the appropriate data from the patient and/or nursing home prior to rendering a service.  I recommend sending a front office staff person to the NH once the provider has the list of patients to be seen that month and collect and verify the demographics prior to billing the service.  It’s unfortunate that your local NH doesn’t have a better relationship with their primary care providers, but in my opinion, it’s the providers responsibility to collect accurate data.

Can audiology services be billed under a rural health clinic?
The Mississippi  Board of Medical Licensure does not license audiologists.  In the United States they are not required to be masters level prepared either.  In a RHC environment they are not considered one of the 5 provider types eligible for reimbursement.  Their services can be “incident to” a medically necessary visit done by one of the 5 provider types, but it can’t stand on its own.

As a Rural Health Clinic, are there regulations against my ability to bill for private or commercial insurance due to our maintaining this status?
No, you are able to bill as normal.  RHC status is essentially an agreement between you and CMS.  It does not affect your relationship with other payers, with the exception of speciality programs like MSCAN.

For obstetric care, how do you bill the delivery and post partum visit?  Do you bill the delivery only and then the post partum or do you bill the global delivery and the post partum visit.  Are there rural health guidelines for deliveries and surgeries with follow-up care?
The information below can be found in our Administrative Code Part 222 Chapter 1 Rule 1.5:  Medicaid reimburses delivering physicians for maternity services provided to eligible Medicaid beneficiaries. Providers must utilize evaluation and management procedure codes to bill antepartum visits.  A. Providers must utilize appropriate procedure codes to be reimbursed for deliveries, postpartum care, postpartum hospital visits and office visits. Postpartum care is inclusive of both hospital and office visits following vaginal and cesarean section deliveries.  B. Physicians may bill the appropriate evaluation and management procedure code for reimbursement when the postpartum office visit is the only service provided by the physician.  C. The applicable modifier which identifies “obstetrical treatment/services, prenatal and postpartum” must be reported with each procedure code for antepartum visits and deliveries and postpartum care.   1. Medicaid utilizes this modifier to track data and to bypass the physician visit limitation of twelve (12) visits per fiscal year.  2. Antepartum office visits are not subject to this limitation.

Must a Rural Health Clinic employ an RN?
No, RHC regs don’t specifically require an RN.   However, you must employ (W-2) a mid level practitioner (NP, PA, Certified Mid-Wife) to be present 50% of the time the clinic is open.  CMS does not direct the type of support staff you use for that provider.  One benefit of using an RN is if you want him/her to order labs based on the history they take from the patient before the provider sees them.

Our staff seems to be spending as much time maintaining logs as they do with actual patient care. Is it necessary to have written forms of all of the following log books in rural clinic?  Urine Control for patient/control; Hemoglobin for patient/controlIcon (Pregnancy test) for patient/control; Glucose for control/patient; Pap Smear for patient’s results; Temp of Room/Fridge for Lab and Med Room – I know that VFC requires the temp and room log; Blood draw – This is to check off that we did check the patient lab in front of them; Medication Sample Log – What’s going in and out with Lot #’s and Exp dates; STD Log- Who has an STD and the treatment received 
Some logs, whether electronic or on paper are necessary for RHC designation.  You must keep a control log on all the machines you use in your lab…just follow the manufacturer’s directions.  Fridge logs and in/out logs for sample medications are required along with your monthly check for all medicines whether stock or samples for outdates is required.  The STD, blood draw and Pap Smear result logs may just be a safety net for your clinic…they are not required by RHC regulations.  I know…it’s a bit of a pain, but in order to stay in compliance you must keep some of these logs.

What medications need to be included in a clinic crash cart?
The clinic or center provides medical emergency procedures as a first response to common life-threatening injuries and acute illness and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics, antibiotics, anticonvulsants, antidotes, and emetics, serums, and toxoids.

If we are changing medical directors and clinic hours who specifically, and to what address, do we send the notification to?
For any change in the medical director, hours of operation or ownership, you need to notify the Mississippi State Department of Health’s Office of Survey and Certification.  In addition, you need to notify in writing the CMS regional office in Atlanta.  The contact information is below:  Centers for Medicare & Medicaid Services (CMS) Region IV Atlanta Federal Center  |  61 Forsyth Street, S.W., Suite 4T20  |  Atlanta, Georgia 30303-8909  |  Phone: (404) 562-7500

Our clinics have been considering charging to fill out FMLA forms. Do you do this, and can we charge Medicaid patients?
Filling out FMLA forms does not meet the face-to-face requirements to Medicare and Medicaid patients in the RHC setting.  If you see the patient and fill out the forms, I recommend billing the E&M and 99080 for the FMLA paperwork.  Bundle the cost and submit it to Medicare on one line and collect the 20% from the patient.  For all other carriers, you can simply bill the 99080.

Are there special staffing requirements for RHCs?
RHCs must be staffed by at least one nurse practitioner (NP) or physician assistant (PA) or certified nurse midwife (CNM). The NP, PA, or CNM   must be on-site to see patients at least 50% of the time the clinic is open. A physician (MD or DO) must supervise the midlevel practitioner in a manner consistent with state and federal law. There is no specific FTE percentage or employed/contracted agreement for physicians in an RHC, however there is a minimum federal RHC requirement that the medical director be present at least once every two weeks to assure quality of care and see patients, if necessary.from this link:

Can anyone tell me where to find more info on the Rural Health Clinic regulations for nurse practitioners, opening a new Rural Health Clinic, what percentage of medicaid/medicare is required, etc? 
Some good information on how to start an RHC…  There are no federal requirements on the % of Medicare/Medicaid patients you treat.

Does our sample drug closet need to be locked?  Do we need a log in and out sheet for it?  Do we log in our drugs we give patients? 
Yes. Your sample drug closet needs to be locked…all your medicines need to be locked along with your sharps. You do not have to keep a separate log for stock medications, but you do need to keep a log on all sample medications.  It should have the name of the drug, lot number, name of patient and the quantity you gave them.

We are a critical access rural hospital.  Our doctors make rounds in the hospital, acute and swing bed facilities, and nursing homes.  Do we bill these services to Pinnacle? 
Acute visits are billed to Medicare Part B (1500 claim form), by the RHC unless your CAH is option II billing methodology, if that is the case then the hospital business office would bill the professional charges.  The swing beds can be billed as a RHC visit – Please see the attached document.

Are the service codes for acute and swing beds the same?  What is the revenue code? 
Nursing Home claims go to Pinnacle on a UB04 form using either revenue code 524 or 535

We are a provider-based rural health clinic.  You stated that we can bill services rendered for medicare and medicaid through the hospital.  Is that just for the 6 CLIA waved test or injections or for breathing treatments, mole removal, and other services?  

You should be billing all lab tests (including the 6 required) under the “main hospital” provider number.  These are now cost based and it is a good advantage for your hospital lab.  Mole removal, and various other procedures completed in the RHC should indeed be coded and charged for, but for Medicare patients you’re only going to receive your all inclusive rate and the charges should be bundled into one line item under revenue code 521.  It is important to charge for all services rendered so you can collect your 20% co-pay.

Update for CMS – Centers for Medicare and Medicaid Contracts 
Effective Sunday, January 1, 2012, Diversified Service Options, Inc, a wholly-owned subsidiary of Blue Cross and Blue Shield of Florida Inc, acquired Highmark Medicare Services from its parent company, Highmark Inc. As a result, Highmark Medicare Services changed its name to Novitas Solutions, Inc. Novitas Solutions, Inc. will process Medicare fee-for-services claims and other administrative services for hospitals and other institutional providers, physicians, and health care practitioners in these states following the transition.

A question on how to bill flu vaccines to the Medicare Advantage Plans.  Are these on the cost report just like the traditional Medicare patients, or on the Plan?
I only include Medicare Part A patients, not Medicare Managed Care Part C, on the cost report. Since the HIC # must be included on the log, those Part C claims could easily be identified and rejected. The plan should be billed, very similar to Medicare Part B physician billing.