ICD-10 ushered in thousands of new codes to provide more clarity for the types of treatment being provided, and a new requirement effective today refines the process even more. Not only does the requirement focus on codes of service, but it also covers the “billable side” of treatment received: when and how each claim will be billed for payment. 

Dating back to July 15, 2015, when the Centers for Medicare & Medicaid Services (CMS) first issued a new physician fee schedule, CMS has been refining its stance on a final version. So, with an effort to improve quality of patient care and increase transparency and tracking, the purpose of the new rural health clinic (RHC) Healthcare Common Procedure Reporting Requirements focus on:

  • Billing: Compliance with national coding standards and requirements.
  • Rural health clinic payment policies: Collecting data on RHC services to better inform policies.
  • Accuracy: touching on RHC claims processing.

It is important to note that this new ruling affects all RHCs (including those exempt from electronic reporting) that are submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. It will require them to report the appropriate Healthcare Common Code Procedure for each billable service received (whether medically necessary, face-to-face, mental health, or qualified preventive health visits with a RHC practitioner), along with the revenue code and other required billing codes.  

All RHC teams and providers should refer to the CMS website https://www.cms.gov/center/provider-type/rural-health-clinics-center.html for additional information and to make sure the new coding process provides each of the following:

  1. Qualifying visit list
  2. Appearance of charges
  3. Crossover for secondary claims to make sure all are submitted properly

Nine Critical Areas of New Coding:

  1. The aforementioned RHC lists were updated to include additional medically necessary billable visits, effective April 1, 2016, but not payable until Oct. 1, 2016. RHCs should hold claims for these additional billable visits recently added to the RHC Qualifying Visit List until Oct. 1, when RHCs can bill these claims for payment.
  2. The reporting requirements are effective for dates of service on or after April 1, 2016. Claims for services furnished until March 31 should be billed under the previous guidelines, with no HCPCS codes.
  3. CMS will not delay the April 1, 2016 implementation of the reporting requirements, as Medicare changes are already in place.
  4. Medicare covered services not on the RHC qualifying visit list are allowable but not payable as a standalone service. CMS will update the qualifying visit list quarterly, as needed.
  5. Charges for all services furnished should be reported on the qualifying visit line, minus charges for preventive services. Charges represent the amount that will be used to assess coinsurance and deductibles. Additional service line(s) should be reported for each additional service rendered with charges greater to or equal to $0.01.
  6. There is a “total line (0001 revenue code),” which represents the sum of all of the charges reported on the claim. Some charges are displayed twice: once on the qualifying visit service line and once on the line for the specific service.
  7. Medicare does not pay or adjudicate the total line (0001 revenue line). Payment is based on the qualifying visit line.
  8. RHCs should report the most appropriate revenue code for the services being performed. The qualifying visit line should be reported with revenue code 052x or 0900. For additional lines, RHCs can report services using all valid revenue codes, but the National Uniform Billing Committee publication should be referred to.
  9. There is also a “unique reference” to Modifier 59: This is reported when the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day. Modifier 59signifies that the conditions being treated are totally unrelated and services are provided at separate times of the day, and that the condition being treated was not present during the visit earlier in the day. This is the only circumstance in which modifier 59 should be used. 

In summary, it appears that this new development is an effort to reduce exorbitant healthcare costs and provide precision coding to reduce fraud, create better tracking of individual patient care, and produce greater efficiency in claims data – and a process for better, prompt payment.

Let’s see in the Patient Protection and Affordable Care Act (PPACA) world if precision creates a better pathway to positive patient outcomes and better measurements, which is a direction we all want to go toward in healthcare!

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill.  A former hospital CEO and regional rural strategy executive, Janelle is a past National Rural Health Association Rural Fellow, Rural Congress member Nebraska Rural Health Association President.  She is currently the Nebraska DHHS Chair of The Office of Minority Health Statewide Council addressing needs of rural, public, minority, tribal and refugee health and is serves on the Regional Health Equity Region VII council as Co-Chair of Rural Health and Partnerships.  Janelle holds a masters and doctorate in communications and recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGENTEX. 

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