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RHC FAQ Answers

RHC FAQ's

Can our doctors, during RHC time, treat patients at a residential care facility and assisted living care facility and be reimbursed? Can our doctors do house calls and get paid?

If the medical provider treats patients in a Skilled Nursing Facility (SNF) (100-day part A bed) in a nursing home, those services are billed to Part B, and cannot be included in Part A encounters like other nursing home visits. Only those patients in the 100-day Part A bed have to billed to Part B. The rest of the nursing home visits are billed through Part A as a regular RHC encounter, at the RHC encounter rate. Any time Part B is billed for a service provided, you must also "carve out" the associated cost of that service from the RHC cost report. Certainly, medical providers still provide treatment for patients in a residential care facility - if that is the patients place of residence, it is handled the same as a house call or home visit billed to Part A as an encounter. The three places of service where the medical provider can bill as an RHC encounter:

  • In the RHC
  • In a nursing home (not 100-day Part A stay) or other medical facility
  • In the patients place of residence or at the scene of an accident

Do you have information on the different types of ownership/governance options available for a RHCs?

RHCs can operate as a For-profit, Non-profit, or as a Public organization. The type of ownership will depend on several factors that meet the needs of the individual community. This process begins by answering whom they are accountable to for their actions.

How do we set up a program with ours schools to provide health screening and other wellness services?

To obtain more information about school-based programs contact Oregon School-Based Health Care Network, (503) 731-4021. 

Can our clinic, at a satellite location, offer health services outside of the RHC?

No. The Medicare program makes payment to the RHC for covered RHC services when furnished to a patient at the clinic, skilled nursing facility or other medical facility, the patient's place of residence, or elsewhere (e.g., at the scene of an accident).

Are other clinics having trouble with the Medicare software?What software are other clinics using?

Some of the other RHCs do not have Medicare software yet. More information needs to be gathered.

Where do I find used medical equipment for our clinic?

Check with local hospitals and ask where they purchase their medical supplies. Find out if they know of any place that provided used medical equipment. Also, the web has sites that sell used medical equipment.

How does the organizational relationships between an RHC and a Critical Access Hospital (CAH) operate?

The RHC and CAH programs are two separate programs and two distinct programs with different participation criteria. It is possible for the two to co-exist, as long as the facilities meet the individual criteria of the respective programs. A CAH could be the owner of an RHC and operate the RHC as either a provider-based or independent. I would presume that the preferable method would be to operate the RHC as provider based if the CAH has fewer than 50 beds. From an economic standpoint, the CAH would be well advised to compare the payments for the clinic if operated as an RHC or as an outpatient department of the CAH. CAH outpatient payments are typically better than outpatient payment for traditional hospitals.

We are an RHC all day. For Medicare patients regarding CPT coding, can we use minutes vs. time spent with the patient?

Time cannot be a factor when deciding to code up or down. Coding depends on history, examination, and the medical decision needed.  For example, a patient with really nothing wrong except enjoying the medical visit may take 30 minutes vs. someone who comes in and within 2 minutes is shipped to the ER for heart trouble.  Coding depends on the medical decision making not the amount of time.

I was told in a meeting that if you are a Rural Health clinic and you do a procedure in the office that a surgery or procedure code cannot charge; that you can only charge an E&M code.

You charge procedure code — charge but Medicare will pay you the RHC rate only patient pays co-insurance amount based upon procedure charge. If the procedure was done in hospital or ASC, you could bill Part B for a procedure.

If you are an RHC and do a colonoscopy or a tonsillectomy as an out patient procedure in the hospital, upon follow up with the patient in your office, can you charge the patient a regular visit that there is no global in

The follow-up visit is an RHC visit and billable in addition to the procedure billed to Part B fee.

If you make rounds at the nursing home and you see a patient who is on hospice, can you not bill an RHC visit?

The hospice patient can receive services from you if unrelated to terminal condition — you can then bill to RHC. If you are adjusting pain meds or supportive care you must bill hospice.

Regarding supplies, in order to be covered in the RHC the supply or service must be:

Of a type that would be furnished in a physician's office:

  • A type that commonly is provided without charge or included in the RHCs bill; and
  • Provided as incidental to the service of the physicians, nurse practitioner, physicians assistant, clinical social worker, certified mid-wife, or clinical psychologist.

Are RHCs subject to 'incident to' regulations as it relates to the provision of services by the midlevel provider?

No. Specifically, the physician does not need to be present in the facility when a midlevel provider sees the patient and midlevel providers can see patients new to the clinic.

When does the "incident to" the physician rule apply to a rural health clinic?

Nurses' services. Specifically, a nurse cannot render a service unless an approved provider is in the facility.

How are visits to patients admitted to long-term beds in a skilled nursing facility (SNF) billed?

Bill them to the rural health clinic intermediary using revenue code 522.

How are visits to patients admitted to a SNF bed in a skilled nursing facility billed?

Bill the Part B Carrier for Professional changes only under the physician's individual provider number in a manner similar to hospital services. All non-physician services must be billed directly to the SNF.

Can you have more than one visit per day?

Yes, with different diagnosis. Encounters with more than on health professional and multiple encounters with the same health professional that take place on the same day and at a single location, constitute a single visit except when the patient, after the first encounter, suffers an unrelated illness or injury requiring additional diagnosis or treatment.

If a physician or midlevel goes to a church or another designated place (other than an approved RHC office site, nursing home, or patient's home) is it a RHC visit?

No, if it is a regularly scheduled event. RHC services are only paid when performed in the RHC, a nursing home, or the patient's home.

If the RHC provider is driving home and comes upon an accident and renders a service to the accident victim, he/she can bill Medicare as a RHC visit, using revenue code 522.

Can you charge a relative for Medicare services under the RHC program?

Publication 27, Section 441: Payment may not be made under Part A or Part B for expenses which constitute charges by immediate relatives of the beneficiary or by members of his/her household.

Who are relatives? Spouse, children, in-laws, parents, and adopted children.

How are flu and pneumococcal shots billed in RHCs?

A log or roster of Medicare patients is maintained and submitted with the cost report at year-end. Medicare pays the cost of the shots.

No bill is submitted to Medicare.

What does Medicare require regarding documentation in the flu and pneumococcal logs?

Patient Name, HIC Number (Medicare Number), and Date of service (shot).

Do I have to log every flu and pneumococcal shot including non-Medicare patients?

No. There is no requirement to log other payer types: but in order to complete the cost report correctly you need total flu and total pneumococcal shots provided.

Can RHC bill for both a rural health clinic visit and an inpatient admission on the same day?

No. Medicare considers this double dipping.

If you perform a surgery in the hospital using a global fee and the patient has a pre-op and a post-op visit in the RHC, can I bill Medicare Part A for the RHC visits?

No. Medicare would consider this double dipping.

Can an RHC utilize a treatment room and bill Part B for those services?

Minor surgeries performed during the hours of the RHC is open must be billed to the RHC and cannot be billed to Part B.

If the procedure is performed in hours when the RHC is not open or if specific hours have been set aside for this purpose and no RHC patients are seen at that time: the Part B may be billed (i.e., during lunch hours or one hour before the clinic opens).

If you do bill Medicare Part B for the minor surgeries it will be necessary to carve out all expenses associated with the procedure.

Can you bill Medicare Part B for laboratory services including the required six waived tests?

Yes, however, you must disclose all expenses related to providing the laboratory tests on the cost report. Disclosure of these expenses will slightly reduce your all-inclusive rate.

Can an RHC lab take specimens from patients who are not patients at the clinic?

Yes, as long as you do not accept more than 100 in any category during any calendar year.

According to R041160, "If a RHCs laboratory accepts specimens (at least 100 in any category during an calendar year) or referral from physicians who are not part of the clinic staff, it must be certified as an independent laboratory.

If the service is performed by the RHC lab without an encounter, a claim cannot be filed to either the Carrier or Intermediary. Instead, the RHC includes the cost of providing that service in its RHC cost report. CMS has acknowledged that in this situation the patient is not responsible for any so-payments since a claim is not filed. CMS has acknowledged that in this situation the patient is not responsible for any co-payments since a claim is not filed.

What are guidelines for billing technical the carrier and professional charges to trailblazers as RHC services?

CMS has published that the technical components of an X-ray, EKG or other diagnostic test are not services or supplies covered under the RHC benefit. In general, diagnostic services are not covered as RHC services. Technical components must be billed to the Part B Carrier on the CMS 1500 claim form. Any professional component associated with these services can be billed to TrailBlazers as an RHC charge on the UB-92 form, assuming there is also a clinic visit being billed.

What is Abuse?

Abuse is the action of providers, physicians, or suppliers that is questionable in nature and may result in improper payments, unnecessary costs or over utilization of services.

What is Fraud?

Fraud is the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, made knowing that the deception could result in some unauthorized benefits to himself/herself or some other person.

The most frequent kind of fraud arises from a false statement or is representation made which results in incorrect payments made by the Medicare Program.

Fraud may take forms such as:

  • Billing for services not rendered
  • Upcoding on inpatient bills (changing the diagnosis tone with a higher payment) Billing for duplicate services
  • Falsifying the date of service, the individual who performs the services, or the beneficiary who receives the service
  • Misrepresenting non-covered items as covered services on claims.
  • Emergency Room Abuser: A beneficiary who travels to multiple ERs, usually seeking narcotic drugs either to support his/her drug habit or obtain drugs for resale. These beneficiaries are usually under 65 years of age and are on Medicare because of disability.

What is an FQHC?

Federally Qualified Health Centers (FQHC) are non-profit or public organizations that receive federal grants from the Health Resources and Services Administration (HRSA) Bureau of Primary Health Care (BPHC) through Section 330 of the Public Health Service Act.

To qualify for federal funding, among other things each health center must:

  • Serve all the residents in their service area without regard to income or insurance status.
  • Provide services on a sliding fee scale basis (i.e., charges are assessed based on family income).
  • Be located in a designated medically under served area or serve a medically under served population. (MUA/P)
  • Maximize all sources of patient and third party payment and limit use of the 330 grant funds to cover any operating deficit.
  • Ensure that the board of directors reflects the demographics of the service area and that a majority of the board is consumers of services provided by the center.

For more information on FQHCs, please visit the Oregon Primary Care Association.

CMS's Federally Qualified Health Center Fact Sheet provides information about Federally Qualified Health Center (FQHC) designation; covered FQHC services; FQHC preventive primary services that are not covered; FQHC payments; and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Don't see your question here?

E-mail questions about Rural Health Clinics to Meredith Guardino, , or at (503) 494-4450.