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TRANSCRIPT
NARHC Fall Institute
Wednesday, October 24, 2018Lake Tahoe Conference
Making RHCs More Competitive with Retail Clinics
Jeff HarperPrincipal, Consultant, Coach
InQuiseek
National Association of Rural Health Clinics
10/24/18
If we don’t wake up and compete, theBig Boys are going to get Our Cheese
By Jeff Harper
• Written in 1998
• Small Change
Management Fable
• Sold 26 Million
copies
• Translated into 37
languages
• And its about
Cheese
“Cheese” – a metaphor fo r what we
want to have in life, whether i t is a
cushy job, a practice, money, a big
house, f reedom, health, recognit ion,
spiritual peace, or a panel o f
patients.
THERE ARE FOUR CHARACTERS IN THIS STORY
Who does not wantto change. (He could be a seasoned physician.)
Who is startledby change but changes and moves on to new cheese
Who cansmell change in the air
Who goes into action immediately
HEM HAW SNIFF SCURRY
Mice
▪ Simplistic Thinkers
▪ Used Instincts
▪ Was Aware of Changes
In Surrounding
(Watchful)
▪ When The Environment
Changed, They
Changed With It.
Little People
▪ Complex Thinkers
▪ Used Reason
▪ Ignorant to Changes
In Surrounding
(Familiar)
▪ Not Prepared For Change
and Did Not Change With
Environment.
Differences In The Characters
Every morning, the mice & the little people dressed in their running gear & headed over to Cheese Station C where they found their own kind of cheese. It was a large store of Cheese that Hem & Haw eventually moved their homes to be closer to it & built a social life around it.
One morning, Sniff & Scurry arrived at Cheese Station C & discovered there was no cheese.
They weren’t surprised. Since they had noticed the supply of cheese had been getting smaller every day, they were prepared for the inevitable & knew instinctively what to do. They were quickly off in search of New Cheese.
Later that same day, Hem & Haw arrived. “What! No Cheese? Whomoved my Cheese? It’s not fair!”, Hem yelled. They went home thatnight hungry & discouraged.
The next day Hem & Haw left their homes, & returned to CheeseStation C. But situation hadn’t changed. Haw asked, “Where are Sniff & Scurry? Do you think they know something we don’t?” Hem scoffed, “What would they know? They’re just simple mice. They just respond to what happens. We’re the trained providers. We’re smarter.”
Haw and Hem didn’t know but the mice had already found new and better cheese. Hem and Haw were late to respond because for years, their cheese was always waiting on them in the clinic waiting room.
A majority of RHCs are seeing their encounter numbers shrink.
Investment in retail clinics is growing every year.
If we are trying to find new cheese we need to know something about the new cheese.
Who are the patients that we need?
With Productivity Standards we need patients more than patients need us.
KNOW YOUR CHEESE
What kind of Cheese is out there?
Is it the medicare patient with multiple comorbidities?NO! We either have them or we can’t move them.
Cheese = Patients & New Cheese = New patients
Is it those who can’t travel very far due to either lack of $ or lack of capacity?
NO!
We probably have them due to our location or they are not going to come due to their limitations.
Is it the loyal baby boomer?
NO!
We already have them and if we don’t they are too loyal to change.
Well, Who is our target market?
The younger and more mobile patients…oh no! They don’t exist. The younger and more mobile crowd are not patient therefore
they are not PATIENTS…they are CONSUMERS.
What are the characteristics of these consumers/patients?
1. They have grown up with a smart phone at their disposal.
2. Face to Face engagement is not a driving issue with them.
3. Texting is their preferred means of communication.
4. They have grown accustom to longer commutes for work, for entertainment, and for a better variety of goods and services.
What are the characteristics of these consumers/patients? (Continued)
5. They want things on their timetable, the news, shows, playlists. They want to speak things into existence (“Alexa, turn on the lights and give me the weather.”)
6. References and resumes are not as important as Reviews. Social media lets them know who to choose.
7. They don’t look at a TV schedule and adjust their E-schedule to watch a certain show. They watch what they want and when they want it.
What are the characteristics of these consumers/patients? (Continued)8. Like their handheld GPS, they have options and they are always considering how to overcome delays.
9. They do not tolerate bad processes, they expect to key in their name once.
10.Due to dwindling commerce in rural America, they are probably commuting to work in a larger community.
11.Wages aren’t rising as fast as costs, so their time is at least as valuable as anyone at the clinic.
Who is our competition? Who wants our cheese?
• It’s probably not someone local
• It’s someone in the neighboring larger town or
• It’s a telemed provider far far away
What do we know about competition?
Let’s leave our small town and go to Wall Street and get some clues…Wall Street has been called the
BIG CHEESE.
WHY is Walmart biding for Humana?
A neighborhood drug store buying Aetna
Why?
UnitedHealth, Walgreens Partner To Put Urgent Care Next To PharmaciesFeb. 28, 2018 Forbes
Article from McKinsey Group from October 2018
In 2012 there were 225 P.E. deals in HealthcareIn 2017 there were 510 P.E. deals in Healthcare
What is happening in the healthcare marketplace?
16
Many of you have seen this slide before.
Let’s examine just on of the big boys’ strategy: Walmart’s strategy:
• They focus on rural areas• They start with low prices, then convenience Open 24/7• They compete with small locals until they win • They become the only commerce in town • They expand their market and do it again.
1. Dry Goods2. Automotive Svs3. Groceries4. Pharmacy5. Now Primary Care
Guess how many Walmart stores are in the US?Guess how many RHCs are in the US?
4,761
4,177
Should we just keep eating cheese until we have no patients?
NO!
We have to understand our society.Let’s eavesdrop on some of our patients…..
I wish they took appts after 5. I can’t afford to lose another shift.
I have been waiting over an hour. Isn’t my time valuable,
too?Didn’t I fillout this samepaperwork last
month?
What your patients are really thinking?
I would be in and out if I had gone to the CVS
20
Seeing Your Clinic from your Patient’s Point of View
• Ease of Scheduling• Paperwork or Process Burden• Redundancy• Staff Attitude• Wait Times (front & back)• Convenience• Do I feel welcomed and
appreciated?• Did I receive quality of care?
Who comes 1st?
This is closer to the sign we need
Patients come First and everyone else
is second!
THE C.A.R.E. MODEL©
21
Courtesy
Accommodate Respect
Excellence
Customer Service Model – C.A.R.E.
© InQuiseek Consulting
What can we do to compete?
Use our strengthsWe know them and their family. Use the history.Know our patientsKnow how many and who turns 65 this month.Fight fire with fireBe convenient. Give them no good reason to leave the zip code.Get the right Providers for the changeIf your providers can’t adjust then you must adjust.CCM has to play a partCCM was developed to be a safety net & it can for you too.TelemedicineUse it or Lose it – either compete with it or compete against it
Serve morePatients always notice a servant heart! Who’s first?
.
Are the Big Boys really our enemy?No, not really, they are only going to a market sector that is stuck in the past. They know that primary care + convenience is a sure fire way to get patients.
Change hurts but not changing will hurt more. And once the cheese is gone, we can’t get it back.
I think Walt Kelly in 1971 said it best:
THANK YOU
• Meet with your staff• Challenge them with the facts• Meet weekly to develop a customer service model.• And make sure every patient leaves thinking they are
No.1
Questions?
Breakout Sessions
Stay for
EmergencyPreparedness
Julie Quinn
Go to Martis Peak for
Social Media& Marketing
Sarah Badahman
OR
Emergency PreparednessJulie Quinn
CPA, MBAVP of Cost Reporting & Provider Education
Health Services Associates
OBJECTIVE
Discuss the four components of Emergency Preparedness
Emergency Plan
Policies and Procedures
Communication Plan
Training and Testing
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EMERGENCY PLAN
Promoting Access to Health Care
EMERGENCY PLAN
491.12(a) Emergency Plan. The RHC must
develop and maintain an emergency
preparedness plan that must be reviewed and
updated at least annually.
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EMERGENCY PLAN
Why do we need a plan?
What does that plan look like?
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EMERGENCY PLAN
Table of Contents Policy – Program Description
Document Cover Page
Document Table of Contents
Emergency Operation Plan
Attachment A: Facility Map
Attachment B: Facility Floor Plan
Attachment C: Risk Assessment
Attachment D: Organizational Chart
Attachment E: External Contact List
Attachment F: Notification Call Tree
Attachment G: Vendor Contact List
Attachment H: Facility Profile
Attachment I: Exercise Documentation
Hazard 1
Hazard 2
Hazard 3
Hazard 4
Hazard 5
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EMERGENCY PLAN
Risk Assessment
Items to consider: Proximity to a school
Proximity to a major highway
Proximity to a major water source
Proximity to a railroad
Proximity to a military base
Proximity to a chemical or nuclear plant
Proximity to a fault line
Strategies to address the top 5 risks
The top five risks need to have a specific policy and procedure the clinic will follow during that emergency.
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EMERGENCY PLAN
Clinic demographics:
Patient population
Services provided What can you provide to the community in an emergency?
Continuity of operations Delegations of authority
Succession plan
List of receiving facilities
A process for how you will cooperate with local, tribal, state, and federal officials
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POLICIES AND PROCEDURES
Promoting Access to Health Care
POLICIES AND PROCEDURES
491.12(b) Policies and Procedures. The RHC
must develop and implement emergency
preparedness policies and procedures, based
on the emergency plan set forth in paragraph
(a) of this section, and the communication
plan at paragraph (c) of this section. The
policies and procedures must be reviewed
and updated at least annually.
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POLICIES AND PROCEDURES
Safe evacuation
Where is your meeting place outside the clinic?
Exit signs posted throughout clinic
Receiving facilities
Notification to local authorities
Patient safety
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POLICIES AND PROCEDURES
Shelter in place
Where is your meeting place within the clinic?
Close windows and doors securely.
If necessary; turn off fans, ventilators and air
conditioners and stuff clothes in gaps around doors and
windows
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POLICIES AND PROCEDURES
Patient records
All rules pertaining to the protection of and access to
patient information (HIPAA) remain in effect during
an emergency
A system of care documentation that does the
following:
Preserves patient information
Protects confidentiality of patient information.
Secures and maintains the records
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POLICIES AND PROCEDURES
Volunteers
Does the clinic utilize volunteers?
Have a job description in place
Address in your plan that the clinic will allow for
authorized volunteers from local, regional, tribal, state
and federal agencies to serve in their fields of skill.
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POLICIES AND PROCEDURES -
RECOMMENDED
Facility lock down
All windows and doors need to be secured and no one is
permitted to enter or leave the facility until the all
clear is given
Ensure all doors and windows are strong enough to
fend off the person trying to gain access to the facility
Recommended that all staff and patients be secured
behind at least two locked doors
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POLICIES AND PROCEDURES -
RECOMMENDED
Suspension of services
If the facility is unable to operate then the clinic would
close for the duration of the emergency
Notification to patients and staff
Receiving facilities to offer continuation of care
Rescheduling when the suspension has been rectified
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POLICIES AND PROCEDURES -
RECOMMENDED
Medications
Power outage procedure
How do you monitor temps during and after business hours
Where can you move medications
How do you maintain viability of medications
Properly dispose medications that go out of temperature
range
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COMMUNICATION PLAN
Promoting Access to Health Care
COMMUNICATION PLAN
491.12(c) Communication plan. The RHC
must develop and maintain an emergency
preparedness communication plan that
complies with Federal, State, and local laws
and must be reviewed and updated at least
annually.
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COMMUNICATION PLAN
Names and contact information for all
Staff
Entities providing services under arrangement
Physicians
Other RHC’s
Volunteers
Recommend an electronic and printed clinic call tree
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COMMUNICATION PLAN
Names and contact information for all
Federal, state, tribal, regional, and local emergency preparedness staff
Other sources of assistance
Recommend an external contact list
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COMMUNICATION PLAN
Alternate forms of communication
Ham radios
Walkie talkies
Radio
Pagers
Cell phone –CAUTION
Recommend that you contact local authorities or hospital to determine
what form of communication they utilize in an emergency
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COMMUNICATION PLAN
Patient information
HIPAA laws are still in effect
The clinic must have a means of providing information about the location
and condition of patients
Important information needs to be sent with the patient in a timely
manner to help expedite continuation of care
Saving patient information to a cloud or a removable storage medium
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COMMUNICATION PLAN
Surge capacity and resources
List of services
What can the clinic do for the community in an emergency?
Asking for help
Reaching out to local, state and federal resources to aid patients that may be
sheltered in place.
External contact list
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TRAINING AND TESTING
Promoting Access to Health Care
TRAINING AND TESTING
491.12(d) Training and Testing. The RHC must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing must be reviewed and updated at least annually.
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TRAINING
Initial training on the emergency plan for all new and existing staff
Training must be conducted annually on the plan
The staff must demonstrate knowledge of the plan
Can they locate the plan?
Do they know their role during an emergency?
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TESTING
Full-scale exercises
The clinic must participate in at least one full-scale exercise.
Actual event
Any man-made or natural disaster that requires the clinic to activate the plan
Examples of community or facility based full-scale exercise
Contacting the fire department to participate in a fire drill
Contacting the local police to participate in an active shooter exercise
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TESTING
The clinic must also complete a second exercise
Either another full-scale exercise or
A table-top drill
This is a group based discussion
Led by a facilitator
Must be clinically relevant (one of the top 5 hazards)
Includes problem statements, directed messages or prepared questions
Should challenge the emergency plan
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TESTING
After action reports
Documentation must be kept for every event, exercise or drill
Analyze clinic’s response
Revise the emergency plan based on findings
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INTEGRATED HEALTHCARE
SYSTEMS
Promoting Access to Health Care
INTEGRATED HEALTHCARE SYSTEMS
491.12(d) Integrated healthcare systems. If an RHC is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the RHC may choose to participate in the healthcare system’s coordinated emergency preparedness program.
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INTEGRATED HEALTHCARE SYSTEMS
Document every clinic’s participation in the creation of the plan
A clinic specific risk assessment must be included
The clinic’s patient population and services offered need to be
addressed
The plan must be usable in every location
Policies and procedures, communication plan and training and
testing programs must include every location
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EMERGENCY PREPAREDNESS
PROCESS
Promoting Access to Health Care
EMERGENCY PREPAREDNESS PROCESS
Create an emergency plan for your clinic
Train all staff on the emergency plan
Test the plan by conducting exercises
Evaluate and revise the plan based on the outcome of the exercises
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EMERGENCY PREPAREDNESS PROCESS
Annual Review
Emergency plan
A new risk assessment needs to be completed each year
Policies and procedures
Communication plan
Testing and training program
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EMERGENCY PREPAREDNESS PROCESS
Document everything!
Efforts to contact officials
Call your local officials, hospitals, emergency services to become a part of the
community emergency response team
Patient information
Training
Current and new staff
Testing of the plan
Actual events
Full-scale exercises
Table-top drills
Integrated health systems
Show involvement in the plan
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QUESTIONS?
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Julie Quinn, CPA
VP, Compliance & Cost
Reporting
Health Services Associates
Southeast Regional Office
Health Services Associates, Inc.2 East Main Street 54 Pheasant Ln
Fremont, MI 49412 Ringgold, GA
Ph: 231.924.0244 231.250.0244
Fx: 231.924.4882 888.200.4788
Promoting Access to Health Care
Breakout Sessions
Return for
RHC AdvancedBillingJanet Lytton
Go to Martis Peak for
Patient Quality& Engagement
Shannon Chambers
OR
PREMIERSPONSOR
PLATINUMSPONSOR
GOLD SPONSORS SILVERSPONSORS
Networking BreakRefreshments are available in Regency DEF with the Exhibitors
RHC Advanced BillingJanet Lytton
RHIT, NHADirector of ReimbursementRural Health Development
✓ Learn how to bill preventive care, nonRHC &
Incident to services & what Revenue code to use
✓ Learn how to handle Pt D drugs
✓ Learn how to bill for TCM, CCM, ACP
97
98
▪ Allowed Medicare Preventive Services are billed through the Rural
Health Clinic on the UB04
▪ Technical Components, labs, EKG tracing are
▪ billed on the nonRHC side
▪ PBRHC through the Hospital OP provider number
▪ IRHC to MCR Pt B
▪ Each preventive service MUST be on a separate line on the UB
▪ G-code on main preventive service when all services are preventive
▪ARE NOT bundled
▪ Some claims may have more than one G-code
99
100
Medicare Does not pay for physicals
Exception for the Introduction to Medicare Physical (IPPE)
If visit is for a physical, not ailments = bill the patient
Does not require an Advance Beneficiary Notice (ABN)
If patient requested by patient, RHC required to send a “no-pay”
claim to Medicare for denial
710 TOB with all charges noncovered and CC 21
101
➢ How does a RHC bill for a "Well Woman Exam"?
➢ Medicare does not have a "Well Woman Exam" as a covered preventive
service, CPT codes 99381-99387.
➢ Each component of the "Well Woman Exam" billed on separate line
items i.e.:
➢ G0438 - initial Annual Wellness Visit (covered once in a lifetime)
➢ G0439 - subsequent Annual Wellness Visit (covered annually).
➢ Screening Pap Tests Q0091 and Screening Breast and Pelvic Examinations
G0101 covered every 24 months for low risk.
➢ Each Code billed separately, if the beneficiary is eligible, with 052x rev code
➢ If ailments are addressed, then appropriate to assign E&M
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103
▪ Injections with Office Visit
▪ Charge All CPT codes in system
▪ Bundle all charges with the QVC; list the RC 0250 w/no CPT code, or RC 0636 with the J-code & submit claim to RHC MCR
▪ If it is a Pt D drug, it must be sent to Pt D plan or Patient
▪ Injections only—nurse service (Incident to service)
▪ Charge in system
▪ Either DO NOT bill (write off) as there is no f-t-f visit
▪ OR can be bundled with a visit within “a medically appropriate time” generally 30 days pre or post nursing service and submitted with the f-t-f visit
▪ If injectable is a Part D drug it MUST not be on RHC claim; only billable to the patient or to Part D
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▪ Injectable/Vaccine as a Part D drug – 1/1/08
▪ The injectable/vaccine is payable only through Pt D
▪ Exception is flu and pneumonia is payable through the RHC cost report; Hepatitis B is Pt B covered if indicated Pt high risk
▪ If injectable/vaccine is obtained at the clinic level, then the patient is to pay for the injectable/vaccine and the administration privately and then they have to submit that claim to their Part D company to be reimbursed for the services.
Clinics can link to: www.mytransactrx.com and bill the Pt D drug and get payment to include administration of the drug and the system will let you know the copay amount. (an electronic system for the clinic to bill is suggested by CMS)
105
➢ MCR excluded services, i.e. dental, hearing & eye tests = Patient payable
➢ Lab Services; Technical components of an RHC service = Billable to Pt B for
IRHCs; PBRHC billed by parent hospital
➢ DME, Prosthetic devices, Braces = Must have DME provider # to bill items
➢ Ambulance Services = Ambulance company bills
➢ Hospital Services ER, OP, IP, ASC, MCORF = Billed to Pt B; if CAH Method
II, ER, OP, ASC billed by CAH
➢ Telehealth distant-site services = Billed on the RHC claim with 780 RC with
Q3014 and charge
➢ Hospice Services (if for DX of hospice); Auxiliary Services, i.e. language
interpretation, transportation, security = not billable to anyone
• All coded with the accurate CPT code
• Don’t forget to charge the venipuncture with OV
• Part of the office RHC services (0300 RC)
• IRHCs—All Labs, to include the required basic 6 tests, are payable through Medicare Part B (1500 form)
• PBRHCs—All labs, to include the required basic 6 tests, are payable through the Hospital OP provider number
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• All coded with CPT code for each the technical component and the professional component if provider interprets
• Chest x-ray = 71020-TC; 71020-26 x-ray interpretation
• Interpretation billed with office visit and bundled
• Submitted on RHC claim a separate line item with 0521 RC & charge
• Technical Component
• Billed to Medicare Pt B for IRHC
• Billed using the hospital OP provider number for PBRHC
Medicare reg on nonRHC service billing, TCs & EKG tracing: CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.
107
• RHC must “split” bill for EKGs
• EKG Tracing only = Technical Component = nonRHC service = 93005
• EKG Interpretation and report = RHC service = 93010
• Interp, 93010, is billed with OV (if performed in the RHC)
• Included in bundled line item of RHC claim
• And listed on separate line w/0521 RC, CPT and charge
• Tracing, 93005, is the nonRHC portion
• IRHC bills to Medicare Pt B under Provider NPI
• PBRHC billed through the hospital OP provider number
Medicare reg on nonRHC service billing, TCs & EKG tracing: CMS Internet-Only Manual, Publication 100-04, Ch 9, Sec 90.
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Telehealth Site Service with Office Visit Same Day
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance/
Deductible
Applied
52X 99213CG 1 1/25/2018 $XX.XX AIR Yes
780 Q3014 1 1/25/2018 $XX.XX
80% of $26
Approx Yes
Any service date after 10/1/16
Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line)
Telehealth Site Service only
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance/
Deductible
Applied
780 Q3014 1 1/25/2018 $XX.XX
80% of $26
Approx Yes
Any service date after 10/1/16
Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line)
110
Hospice Claim for ailment other than hospice diagnosis
111
▪ Direct supervision by a provider is required▪ Must be in clinic, not in same room
▪ being in the hospital when attached to clinic is NOT “incident to”
▪ Part of provider’s services previously ordered▪ integral, though incidental
▪ covered as part of an otherwise billable encounter▪ I.e. BP check, dressing change, injection, suture removal, etc.
CMS Internet Manual 100-02, Ch 13, Sec 120, 140, 160
RHC claims should reflect the Provider of services, not the supervising Phys for
the PA, NP or CNM
112
• Can be combined on claim with a visit within “a medically appropriate” timeframe (30 days pre/post)
• NEVER considered a separate visit or sent to Part B
• List only the date of the FTF visit as date-of-service
• Charges should reflect all services bundled (CG line)• Added charges will be on subsequent lines of UB04
• When added, additional reimb is the 20% copay
• Adjustments OK—717 Type of Bill; CC=D1; remarks “changes in charges”
• Otherwise, the costs are included on the cost report and claimed indirectly
CMS Internet Manual 100-02, Ch 13, Sec 120
113
• TOB 717
• Claim must be in finalized status
• Adjustment will appear as a debit or credit on future
remittance advice
• Encourage submitting electronically• exceptions—denied charges & claims rejected as MSP
• Do not send another 711 claim as will error as a
duplicate
• Examples of Adjustments:• Revenue code changes, Service unit decrease or increase,
Total charges changed, Primary payer incorrect
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• Transitional Care Management (TCM)
• General Chronic Care Management (CCM)
• General Behavioral Health Integration (BHI)
• Psychiatric Collaborative Care Model (CoCM)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/
Downloads/FQHC-RHC-FAQs.pdf
116
• 30-day transitional period of next 29 days after discharge from:
• Inpatient Acute Care Hospital• Inpatient Psychiatric Hospital• Long Term Care Hospital• Skilled Nursing Facility• Inpatient Rehabilitation Facility• Hospital outpatient observation or partial hospitalization• Partial hospitalization at a Community Mental Health Center
• Discharge to:• His or her home• His or her domiciliary• A rest home• Assisted living
MLN ICN 908628
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• Face-to-face visit• 99495 – moderate medical decision complexity w/I 14 days
• 99496 – high medical decision complexity w/I 7 days
• Only 1 health care professional may report TCM
• Report once per beneficiary during TCM
• For RHC, Date of service used is the F-T-F visit day
• RHC paid their RHC all-inclusive rate
• TCM cannot be billed during a global period
• Documentation required:• Date of discharge
• Date of interactive contact with bene and/or caregiver
• Date of face-to-face visit
• Complexity of Medical Decision making
MLN ICN 908628
118
• Reimbursed as nonRHC service
• G0511 General Care Management = $62.28• Services for primary care conditions
• G0511 Behavioral Health Integration = $62.28• Services for primary care and/or mental or behavior health conditions
• Patient must have been seen in the last year or initiate CCM at an
AWV or a physician visit
• Billed under: Physicians, NPs, PA s, CNMs, and CNMs
• General supervision allowed; allows for offsite management
MM10175
119
• At least 20 minutes of clinical staff time per calendar month to address ailments that include:
• Option A – General Care Management – Pt with multiple (2 or more) chronic conditions to last at least 12 mo with significant risk of death, acute exacerbation/ decompensation, or functional decline
• Option B – BHI – Pt with any behavioral health or psychiatric condition being treated by an RHC provider that is determined to warrant BHI services
• Must have Pt verbal or written consent with method to opt out• Must develop a comprehensive care plan with patient receiving a copy• 24/7 Access to Care – “access to physicians or other qualified health care
professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week” (Can use secure email or phone calls)
• Must use EHR;• Allows transmission of the care plan by fax
MM10175
120
• Billed on the RHC/FQHC UB-04 to Medicare Part A
• Revenue code – 521
• Can be billed with other services or billed alone
• Will receive the payment alone or in addition to your visit rate
• Payment allowance• Made under the Physician Fee Schedule Non-Facility Rate
• No geographic adjustment
• Average of the comparable CPT codes (99490, 99487 & 99484)
• 2018 allowance: $62.28
• Coinsurance/deductible are applicable
121
CCM Furnished as a Stand-alone Billable Visit
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance
/Deductible
Applied
52X G0511 1 1/31/2018 $XX.XX
80% of
$62.28 Yes
Any service date after 1/1/18
Enter your charge (coinsurance will be based upon your charge)
CCM Billed with another Face-to-face Visit
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance
/Deductible
Applied
52X 99213CG 1 1/25/2018 $XX.XX AIR Yes
52X G0511 1 1/25/2018 $XX.XX
80% of
$62.28 Yes
Any service date after 1/1/18
Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line)
122
• G0512 CoCM = $145.08 – Paid at national non-facility avg 99492 & 99493
• Patient must have been seen in the last year or initiate CCM at an AWV
or a physician visit
• Billed under: Physicians, NPs, PA s, CNMs, and CNMs
• General supervision allowed; allows for offsite management
• Must have Pt verbal or written consent with method to opt out
• 70 minutes or more of initial psychiatric CoCM services; 60 minutes or
more of subsequent psychiatric CoCM services• Initial assessment by a behavioral health manager
• Primary care practitioner determines if the patient is eligible for psychiatric CoCM
• Psychiatric consultant• Participates in regular reviews of the clinical status of the patient
• Advises the medical care provider
MM 10175
123
CoCM Furnished as a Stand-alone Billable Visit
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance
/Deductible
Applied
52X G0512 1 1/31/2018 $XX.XX
80% of
$145.08 Yes
Any service date after 1/1/18
Enter your charge (coinsurance will be based upon your charge)
CoCM Billed with another Face-to-face Visit
Revenue
Code HCPCS
Service
Units
Service
Date
Total
Charges Payment
Coinsurance
/Deductible
Applied
52X 99213CG 1 1/25/2018 $XX.XX AIR Yes
52X G0512 1 1/25/2018 $XX.XX
80% of
$145.08 Yes
Any service date after 1/1/18
Enter your charge (coinsurance will be based upon your charge) (this amount is not included in the CG line)
124
• Advance care planning including the explanation and discussion of advance directives such as standard forms – first 30 minutes (but does not have to have forms completed)
• Can be a “stand alone” service and paid as a visit• Or, is an add-on element of the AWV• No frequency limits, but if performed again there should be a change
in status or change in end-of-life wishes documented• FTF with patient, family member(s), and/or surrogate• No deductible or copay when with the AWV• Deductible and copay applies when billed otherwise• 99498 can be billed for each additional 30 minutes • No specific diagnosis required
ICN 909289 June 2018
125
126
▪ Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 220
issued 1/09/18
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/bp102c13.pdf
▪ RHC CMS Claims Manual Ch 9 Rev 3434 issues 12/31/15
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/
Downloads/clm104c09.pdf
▪ CMS clarification of stand-alone preventive services 8/10/16
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf
▪ CMS Rural Health Clinics Center
https://www.cms.gov/center/provider-type/rural-health-clinics-center.html
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html (interactive preventive service web tool)
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf
https://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_g_rhc.pdf (CMS State Operations Manual updated 1/26/18)
www.narhc.org (National Association of RHCs)
Make sure you are subscribed to your MAC listserve for updated info!
Rural Health Development Website & my e-mail: www.rhdconsult.com [email protected]
127
128
Any ?’s
After Lunch Breakout Sessions
Return for
Policy ManualFor Provider Based
Patty Harper
Go to Martis Peak for
Policy ManualFor Independents
Julie Quinn
OR
LUNCHBoxed Lunch Provided in
Regency DEF (Exhibitor Room)Grab & Go…. Enjoy lunch in one of the many beautiful settings
Hyatt & Lake Tahoe have to offer. The hospitality room is also available.
Sessions resume at 1:30 p.m.
Policy Manual for PBsPatty Harper
RHIA, AHIMA-AppICD-10CM/PCS Trainer,
CHTS-IM, CHTS-PW, CEOInQuiseek
WHY DO WE NEED POLICIES?
WHAT IS THE PURPOSE OF POLICIES?
HOW WE MISS THE POINT?
132
Was your Clinic Building Constructed
Without a Blueprint?133
Your Compliance Plan should also
be constructed. Your written
policies and procedures are your
tools and materials for building
your compliance playbook!
So, why aren’t you using a blueprint for building your
compliance framework?
134
Policies are more than binders on your shelf! They
are the backbone of your compliance program!135
The PBRHC must be able to identify one body of policies. Those policies can include
hospital policies but should also have RHC-specific policies that address the
certification standards and provider-based regulations.
RHC Compliance42 CFR 491
42 CFR 413.65
Other CMS Guidelines
Federal and State Laws
Written Policies and
ProceduresHospital
RHC Specific
PBRHC Specific
Education and
Training
Hospital
Policies
• OCR
• CMS
• Labor Laws
• OSHA
• Other Laws
• HR/Admin
136
1. Start with policies that are required for RHCs.• 42 CFR 491
• Appendix G
• Policy Benefit Manual, Chapter 13
• Claims Processing Manual, Chapter 9
• AO’s Standards
2. Add in provider-based policies (42 CFR 413.65)
3. Add in hospital-wide policies needed for common areas of compliance and administration.
Note that hospital compliance and RHC compliance may differ. Your policies should not
include anything that doesn’t apply to RHCs. If hospital policies conflict with RHC
regulations, they should not be in your policies.
4. Add in procedures and processes as needed for the RHC. Do not manage by policy.
5. Have all policies in a similar format and cross-referenced to either the citation or the
survey J tag.
6. Refrain from having frivolous policies. Address issues in employee handbook instead.
Steps for Developing PBRHC Policies and Procedures
137
WHY DO WE NEED POLICIES?Sometimes Hospital Compliance Officers,
Physician Group Managers and
Hospital Quality Directors already have their plates full
and are wearing too many hats to be
able to champion Rural Health Clinics. RHCs end up
being managed as either “regular” physician practices or as “departments” of the
hospital. Neither situation is optimal for RHC compliance. Neither is optimal for
the development of written policies and procedures. Neither is optimal for
operational efficiency.
You need at least one RHC Champion who can be the point person and liaison
between the clinic(s) and the parent organization if the hospital leadership is
unable to become RHC subject matter experts. This is particularly a problem with
systems that have different provider types under the same leadership or with
either very small or very large hospitals.138
Policies are broad statements or
mandates which rarely change.
“We will comply with the
Conditions of Certification for
RHCs.”
“All providers will maintain
current licensure with the state
medical board.”
Policies:
139
Policy vs Procedure vs Process vs Plan
Procedures:Procedures are the specific steps that
are taken to ensure that the policies
are maintained.
Processes:Processes are even more specific
steps within a procedure.
Plan or Program:A collection of policies, procedures and
processes related to a specific targeted
area. These may include other facility-
wide initiatives.
→ Policy: Cross Roads RHC will include hand hygiene as part of our infection control plan.
→Procedures: 1)We will train our employees and staffon proper methods of hand hygiene and 2)provide soap/water or alcohol-based sanitizer in all areas of the clinic.
→Processes: Employees will wash hands before and after entering a patient room, before and after eating, and before and after toileting. 140
Examples of Plans or Programs:
• Infection Control Plan
• Emergency Preparedness Plan
• QAPI Program
141
Suggested Policies and Procedure Categories:
WHAT TYPES OF POLICIES DO YOU NEED?
142
▪ Organizational and Administrative
▪ Physical Plant and Environment
▪ Provision of Services: Patient Care
▪ HR/Employment
▪ Quality/Risk
▪ Financial
▪ Other
Or organize by J tag, citation or standard. Organize your policies and any
supporting evidence documents in a way that is logical and is easily located
and retrieved.
UNDERSTANDING WHAT THE REGS SAY ABOUT
RHC POLICIES AND PROCEDURES
143
42 CFR §491.7
Organizational structure.
(a) Basic requirements. (1) The clinic
or center is under the medical
direction of a physician, and has a
healthcare staff that meets the
requirements
of § 491.8.
(2) The organization’s policies and its
lines of authority and responsibilities
are clearly set forth in writing.
144
Organizational Structure
Examples of Evidence
Documents that support
this policy:
• Type of Ownership
• Leadership Disclosure
• In Good Standing
Certificate
• Organizational Chart
• Medical Director
Disclosure
• Clinic Roster
• Chain of Command
42 CFR 491.8
(b) Physician responsibilities.
(1) The
physician:
(ii) In conjunction with the physician’s assistant and/or
nurse practitioner member(s), participates in
developing, executing, and periodically reviewing the
clinic’s or center’s written policies and the services
provided to Federal program patients;
How involved are your medical director and physicians in
policy development and review?
145
Is your policy development truly a
collaborative process?
§491.9 Provision of services.
(2) The policies are developed with the advice of a group
of professional personnel that includes one or more
physicians and one or more physician assistants or
nurse practitioners. At least one member is not a
member of the clinic or center staff.
146
Our policies dictate how we provide services:
42 CFR §491.8
(2) The physician assistant or nurse practitioner
performs the following functions, to the extent they
are not being performed by a physician:
(i) Provides services in accordance with the
clinic’s or center’s policies;
147
§491.9 Provision of services.
3) The policies include:
Description of Services
▪ Drug Storage & Handling
▪ Direct services
▪ How and Where
▪ Lab services
▪ Services Under Arrangement
▪ Emergency Care
▪ Inpatient Care
▪ Annual Review of Policies
What do you do in your
clinic?
How do you provide the
six required tests?
What services do you
contract out?
Emergency Kit, EMS
Transfer Policy,
Hospitalist Agreement?
148
Provision of Services
§491.9 Provision of services.
3) The policies include:
▪ Guidelines for Medical
Management
▪ Clinical Documentation
▪ Patient Referrals
▪ Medical Management Policy
Review
Clinical protocols?
Clinical
Documentation?
Chart Review?
Referral Tracking?
Annual Evaluation?
Policy Review?
MORE POLICIES ABOUT HOW WE PROVIDE
SERVICES:
149
Appendix G now instructs surveyors to verify that all
providers have been trained on the RHC medical
management policies and other-related policies
upon hire. Does everyone just do their own thing?
§491.10 Patient Health Records
For PBRHCs- Medical records must be
retrievable between the hospital and
the RHC both ways.
42 CFR 413.65
(v) Medical records for patients treated
in the facility or organization are
integrated into a unified retrieval
system (or cross reference) of the main
provider.
Content of Medical
Record?
Designated Staff?
Retention of Records?
Privacy & Security?
Consent to Treat?
POLICIES ABOUT MEDICAL RECORD CONTENT, CONSENTS,
AND RELEASE OF INFORMATION
150
§491.11 Program Evaluation
(a) The clinic or center carries out, or or arranges for,
an annual evaluation of its total program.
(b) The evaluation includes review of:
(1) The utilization of clinic or center services,
including at least the number of patients served
and the volume of
services;
(2) A representative sample of both active and
closed clinical records; and
(3) The clinic’s or center’s health
care policies.
(c) The purpose of the evaluation is to determine
whether:
(1) The utilization of services was appropriate;
(2) The established policies were followed; and
(3) Any changes are needed.
(d) The clinic or center staff considers the findings of
the evaluation and takes corrective action if necessary
Who is the policy
review going to be
conducted?
Periodically?
All at Once ?
How documented?
How is the program
evaluation going to be
conducted?
How will changes be
made?
Annual Meeting?
151
§491.12 Emergency Preparedness
For PBRHCs- You must have your own
risk assessment, plan and
training/testing for emergencies which
can occur uniquely within the walls of
your RHC.
See Appendix Z for more details.
▪ Hazard Risk
Assessment
▪ Plan for each
potential risk
▪ Testing
▪ Training
▪ Annual Update
152
Labor Laws
OCR
OSHA
CDC
Other HHS/CMS Regs
State & Local Laws
Licenses
Inspections
§491.4 Compliance with Federal, State
and local laws.
The rural health clinic and its staff are in
compliance with applicable Federal,
State and local laws and regulations.
For PBRHCs, some of these policies can
overlap with the parent hospital’s policies
IF or WHEN, the regulations and the
compliance looks exactly the same for
each.
WHAT OTHER POLICIES DO YOU NEED TO MAKE SURE
YOU HAVE PROCESSES IN PLACE FOR OTHER
FEDERAL AND STATE LAWS?
153
OTHER SPECIFIC PBRHC POLICIESPlease refer to 42 CFR §413.65 for the criteria of provider-based status for
RHCs. Add policies when they are needed to demonstrate compliance.
Some areas which might require policy development or modification include:
Medical Staff Privileging for RHC professional staff
Integrated Financial Reporting & Financial Policies
Medical Director Oversight
Advertising and Signage
Ownership Disclosure
Managerial Oversight
Medical Record Retrieval
If you filed a Provider-based attestation, you attested that this criteria
had been met. Make sure you have the policies and procedures in place
to insure compliance. 154
Employment Agreements, Job Descriptions,
Competency Check-offs, and Performance Evaluations
Make sure that if you follow your hospital’s HR policies or if the hospital
manages your clinic HR issues that the job descriptions are specific to your
RHC. Don’t use standard job descriptions from the hospital if the title,
qualifications, or duties are different in the RHC. If you have a RHC policy
that says a specific employee will be responsible for something, have that
task in job description and evaluations.
A floor nurse at the hospital may have very different tasks than a RHC nurse.
A RHC nurse may have different tasks from another physician office.
Most hospital HR departments are clueless about RHCs. One size does not
fit all.155
156
Oh, my aching head!
ORGANIZING AND FORMATTING POLICIES
157
Written Policy and Procedures may be
maintained in a binder or retrievable on-line.
It is helpful to compile one set of policies
and procedures that can serve as your
Administrative or Survey Evidence Binder.
In this binder, you would also include any
necessary supporting documents which help
establish compliance.
If you store evidence documents on-line,
restrict access to proprietary information.158
POLICY FORMAT
▪ Well-Organized
▪ Standard Format
▪ Customized to your
RHC
▪ One copy available
to staff
▪ One administrative
copy
159
SAMPLE POLICY HEADER
160
SAMPLE POLICY BODY
161
162
163
SAMPLE POLICY ADOPTED FOR MORE THAN ONE
FACILITY
POLICY # 210 APPROVED ON 05/16/2018 FOR THESE FACILITIES:1. CROSS ROADS MEDICAL CENTER
2. CRMC SURGERY CENTER
3. CROSS ROADS RURAL HEALTH CLINIC
4. CRMC SPECIALTY CLINIC
USING POLICIES EFFECTIVELY
164
Enough!
You need enough
policies to establish and
maintain compliance
and give operational
and managerial
guidance.
165
HOW MANY POLICIES DO YOU NEED?
Too Many?
Don’t confuse the need
for a written policy or
procedure with a minor
operational issue that can
be handled through
improved relationships,
better communication or
improved processes.
Reminder: Policies are broad and typically static. Processes are
more dynamic. Don’t overly restrict yourself with policy terms.
166
Avoid creating
written policies over
“people” issues!
Don’t hide behind policies
as a passive-aggressive or
authoritarian way to
address problems.
Patty Harper
318-243-2687
www.inquiseek.com
167
Questions, Comments, or Suggestions?
Breakout Sessions
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Management Services
Presentation Topics
✓ Provider-Based Requirements
✓ Provider-Based Enrollment Issues
✓ PBRHC – Department of the Hospital?
✓ Provider Numbers
✓ Employment Considerations
✓ RHC Providers, RHC Services, and Incident-To Services
✓ Non-RHC Services Billing/Enrollment
✓ Locum Tenens
Provider-Based RHC Compliance Components
✓ Licensure
✓ Clinical Services
✓ Financial Integration
✓ Public Awareness
✓ Obligations of hospital outpatient departments
✓ Joint Ventures
Operation, Supervision, and Control
✓ 100% ownership by parent entity.
✓ Same governance as parent entity.
✓ Same by-laws/organizing documents.
✓ Parent entity has full responsibility and final authority.
✓ Organizational structure and reporting requirements are the same as other departments of parent entity.
Provider-Based RHCs – NOT a Department
42 eCFR 413.65 (a)(2):
For purposes of this part, the term “department of a provider” does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC.
Outpatient PPS 2017
A key interpretation in 2017 implemented Section 603 of the Bipartisan Budget Act of 2015, which affected how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider (hereinafter referenced as off-campus “provider-based departments” (PBDs)).
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html
Places of Service Codes – Danger!!
Rural Health Clinics are NOT Hospital Outpatient Departments (PBD). Place of Service Codes 72 or 11 are only ones relevant for RHC claims.
Outpatient Hospital Places of Service are hereby “those which shall not be named”!
Place of Service Codes
72 – Rural Health Clinic (Yay – Money!)
19 – Satellite Outpatient Department (Boo! Shall Not Be Named)
11 - Office (Better than those which shall not be named)
22 – Outpatient Hospital (Hiss!Shall Not Be Named)
Distance Requirement
An RHC that is otherwise qualified as a provider-based entity of a hospital that is located in a rural area, as defined in §412.62(f)(1)(iii) of chapter IV of Title 42, and has fewer than 50 beds, as determined under §412.105(b) of chapter IV of Title 42, is not subject to the [location requirements]…of this PM.
Payment Window Provisions
(f) In the case of a patient admitted to the hospital as an inpatient after receivingtreatment in the hospital outpatient department or hospital-based entity, payments forservices in the hospital outpatient department or hospital-based entity are subject tothe payment window provisions applicable to PPS hospitals and to hospitals and unitsexcluded from PPS set forth at §412.2(c)(5) of this chapter and at §413.40(c)(2),respectively.
NOTE: The payment window provisions do not apply to critical access hospitals (CAHs).
Provider-Based RHC Enrollment
✓ All RHC Enrollment begins with the Medicare 855A.
✓ All Provider-Based RHCs must be enrolled under their parent hospital EIN number.
✓ Advise getting RHC NPI (261QR1300X Taxonomy).
✓ Enroll RHC as additional service site under the Hospital PTAN.
Provider Numbers
Provider Number
Description
RHC PTAN Six Digit (XX-XXXX) P-Tan – RHC Site/AddressEnrolled using Medicare 855A Application
Hospital PTAN Hospital Provider Number (Hospital NPI/EIN)
Medicare Part B Group
Fee-For-Service (1500) Medicare Group
Medicare Part B Individual
Fee-for-Service (1500) Individual Medicare 855I and reassigned to Medicare Group via (855R)
NPI Number National Provider Identifier“Universal” Number for individual providers and facilitiesOne or more “taxonomy codes” is attached to NPI numbers indicating specialty or facility type.
Commercial Payers
✓ Only ONE EIN can be billed out of a Provider-based RHC during RHC hours.
✓ All commercial claims during RHC hours must be billed under the hospital EIN…NOTunder a separate medical group EIN.
✓ All commercial payers should be approached to add “outpatient professionalservices” to provider contracts to enable compliant billing.
RHC Claims - Medicare Part A
✓ RHC Services are submitted on a CMS-UB04 claim form.
✓ The formal electronic format is ANSI837-Institutional.
✓ Rural Health Clinic claims are administered by Medicare Part A.
✓ It is a Part B (Physician Service) benefit, using the structure of Medicare Part A.
✓ This is why we deal with UB04, Cost Reports, Revenue Codes, etc.
Providers and support staff
Main providers are not required to employ other support staff, such as maintenance or security personnel, who are not directly involved in providing patient care, nor are licensed professional caregivers such as physicians, physician assistants, or certified registered nurse anesthetists required to become provider employees.
Qualified RHC Providers
An RHC encounter can be billed for the following providers:
✓ Physicians (MD, or DO)
✓ Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives
✓ Clinical Psychologists (PhD)
✓ Clinical Social Workers (CSW or LCSW)
Leased Employees
The main provider (or an organization that also employs the staff of the main provider and that is not the management company) employs the staff of the facility or organization who are directly involved in the delivery of patient care, except for management staff and staff who furnish patient care services of a type that would be paid for by Medicare under a fee schedule established by regulations at part 414 of chapter IV of Title 42.
(CMS A03-030 Transmittal)
No “Leased” Patient Care Staff
“Other than staff that may be paid under such a Medicare fee schedule, the main provider may not utilize the services of “leased” employees (that is, personnel who are actually employed by the management company but provide services for the provider under a staff leasing or similar agreement) that are directly involved in the delivery of patient care.”
(CMS A03-030 Transmittal)
RHC Services include:
✓ Physicians' services, as described in section 100;
✓ Services and supplies incident to a physician’s services, as described in section 110;
✓ Services of NPs, PAs, and CNMs, as described in section 120;
✓ Services and supplies incident to the services of NPs, PAs, and CNMs, as described in section 130;
✓ CP and CSW services, as described in section 140;
✓ Services and supplies incident to the services of CPs and CSWs, as described in section 150; and
✓ Visiting nurse services to the homebound as described in section 180.
The RHC Encounter is:
“A RHC or FQHC visit is defined as a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more RHC or FQHC services are rendered. A Transitional Care Management (TCM) service can also be a RHC or FQHC visit.”
(Medicare Benefit Policy Manual. Chapter 13. Section 40.)
Incident-to Services Defined
✓ Incident-to services are considered covered and paid under the RHC.
✓ They must be bundled with the RHC encounter. They are not separately billable or payable.
✓ Services that do not occur on the same date as the encounter can be bundled if they occur 30 days before or after.
✓ The effect on payment is an increase in the charge, and therefore in the co-insurance.
✓ The cost for these services are included in the cost report, but are not separately payable on claims.
Provision of Incident-to Services
✓ Services and supplies furnished incident to physician’s services are limited to situations in which there is direct physician supervision of the person performing the service.
✓ Direct supervision does not mean that the physician must be present in the same room…the physician must be in the RHC or FQHC and immediately available.
(Medicare Benefit Policy Manual. Chapter 13. Section 110.1)
Locums, RHCs, Provider Enrollment
✓ There is no such thing as a Locum Tenen Nurse Practitioner or Physician Assistant.
✓ Reciprocal billing is for physicians and physical therapists (effective June 13, 2017)
✓ Nurse practitioners receive 100% reimbursement for RHC encounters.
✓ There is no 15% discount for billing under the NP/PA.
✓ MOST commercial payers enroll Nurse Practitioners.
Locum Tenens and RHCs
Medicare Claims Processing Manual
Chapter 1 - General Billing Requirements
30.2.10 Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACS Part B(Rev.3774, 05-12-17, Effective: 06-13-17, Implementation: 06-13-17)
The patient’s regular physician or physical therapist may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services which the regular physician or physical therapist arranges to be provided by a substitute physician or physical therapist on an occasional reciprocal basis, if:
✓ The regular physician or physical therapist is unavailable to provide the services;
✓ The Medicare patient has arranged or seeks to receive the services from the regular physician or physical therapist;
✓ The substitute physician or physical therapist does not provide the services to Medicare patients over a continuous period of longer than 60 days…
Locum Tenens and NPs
✓ There is NO additional Medicare enrollment process, for approved providers (MD/DO/NP/PA) in an RHC.
✓ NPs and PAs are paid at 100% of the RHC Encounter Rate.
✓ NPs and PAs individual NPIs normally have to be ‘attached’ to an RHC Medicaid Provider number.
✓ There is a separate enrollment process and set of requirements for each commercial plan.
Non-Rural Health Services
Non-Rural Health Services can be billed to the fee-for-service carrier (or hospital FI).
These services include:
✓Diagnostic testing - X-Ray, EKG, etc.
✓Laboratory services – except Venipuncture!
✓Professional services rendered in the hospital
Diagnostic Testing and Lab: Provider-Based
The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter.
The technical components for X-Ray, EKG, ultrasounds, etc. are billed to the FI using the parent entity’s billing number.
Lab services are also billed to the MAC using the parent entity’s CCN.
Provider-based Diagnostic Claims
PBRHC owned by CAH:
✓Billed using parent’s CCN.
✓ LAB: TOB 851/Rev Code 300/UB04
✓RAD-TC:TOB 851/Rev Code 320/UB04
✓EKG-TC: TOB 851/Rev Code 730/UB04
✓Payment is cost-based.
PBRHC owned by PPS
Billed using parent’s CCN.
✓ Lab: TOB 141/Rev Code 300/UB04
✓Rad-TC: TOB 131/Rev Code 320/UB04
✓EKG-TC: TOB 131/Rev Code 730/UB04
✓Payment is on Medicare Fee Schedule.
Provider-Based RHC Enrollment: Conclusion
✓ Two Tax IDs cannot be billed out of the Provider-based entity at once.
✓ Physicians and NPs may be contracted or directly employed.
✓ If the providers remain employed by an outside medical group, a service agreement back to the Provider-based parent is acceptable.
✓ No patient care staff may be directly employed by a third-party.
✓ Commercial contracts must be changed so that claims can be submitted using the parent entity’s EIN.
✓ Contracting under the parent EIN, should begin long before the RHC survey/approval date.
CMS Resources
Medicare Claims Processing Manual – UB04 Completion
www.cms.gov/manuals/downloads/clm104c25.pdf
Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues
www.cms.gov/manuals/downloads/clm104c09.pdf
Medicare Benefit Policy Manual – Chapter 13 RHC/FQHC
www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c13.pdf
Contact Information
Charles A. James, Jr.
North American Healthcare Management Services
President and CEO
888.968.0076
www.northamericanhms.com
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Patty Harper
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Melissa Ryan
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Coding & Clinical DocumentationPatty Harper
RHIA, AHIMA-AppICD-10CM/PCS Trainer,
CHTS-IM, CHTS-PW, CEOInQuiseek
The encounter, the clinical documentation and the claim all should represent the same picture. Subtle differences can create big issues!
Elements of a Typical Clinic
Note
Element Part of Note
Nature SOAP
Chief Compliant History Subjective S
HPI History Subjective S
Review of Systems History Subjective S
Problem List History Objective --------
PFSH History Subjective S
Examination Exam Objective O
Lab Results/Diagnostics Exam Objective O
Diagnosis Assignment MDM Professional Judgement
A
Treatment MDM Professional Judgement
P
Medication Reconciliation
History Objective or Subjective --------
Chief Complain
The Chief Complaint is the reason that the patient gives for coming into the clinic. However, this may not be the “real” reason for the visit. The provider may change or reword the chief complaint upon determining the true nature of the presenting problem(s).
▪ Be careful of systems which populate the chief complaint from the appointment reason.
▪Educate providers that they can change the chief complaint.
▪The CC is the beginning of the story. We don’t want a chief complaint and a primary diagnosis that aren’t logically connected.
Other Problems with Chief Complaints
The Chief Complaint also helps establish medical necessity and if an RHC encounter occurred.
Avoid or Clarify
▪Follow-up: Use the condition requiring follow-up or “follow-up for hypertension” (condition).
▪Annual exam or check-up: Medicare never covers a routine examination. Wellness visits are different. List conditions being followed.
▪Lab Results: If lab results are abnormal and require an additional service, report the condition.
▪Status of Chronic Conditions not documented as part of History. An auditor may not look all the way down to the Plan section of the note.
History of Present Illness
History of Present Illness is obtained by interviewing the patient about the onset, severity, duration, timing, associated signs and symptoms, context, and modifying conditions related to the Chief Complaint.
Although this information is often obtained by nursing staff, it is the provider’s responsibility to verify the HPI and to interview the patient further. The provider should be collecting HPI.
▪Often the provider interviews the patient but doesn’t validate or document the additional HPI.
▪If the Chief Compliant changes, so does the HPI. More interviewing is necessary.
Review of Systems
The ROS is the only part of the History section that can be recorded by nursing or collected directly by from the patient. It is subjective from the patient’s perspective.
Many clinics are using intake forms or tablets to collect CC, HPI and ROS from the patient. Many collect it but providers don’t review it.
Patients may list symptoms which are never addressed or added into the clinical documentation as being pertinent to the problem or indicative of another problem.
No ROS at all is a common audit finding.
Personal, Family and Social History
All of the History section of the note should be PERTINENT to the chief complaint/reason for the visit.
It is not necessary to obtain personal medical history/surgical history from the patient for conditions that happened years ago which have been resolved and are unrelated to today’s problem.
It is not necessarily pertinent that I had my tonsils out when I was 5 if the reason for my visit is a sprained ankle. The fact that I had knee surgery last year might be pertinent.
Be efficient in workflow by making data collection relative to the visit.
Physical Examination
▪Body systems identified in the HPI or ROS are marked as “wnl” or negative in the note.
▪Exam components are cloned from patient to patient or from encounter to encounter. The exam documentation looks the same for all patients or for all of a patient’s visits.
▪System marked as remarkable but no detail given about abnormal finding.
▪ 4 x 4 system documentation is missing from higher level E & M visits.
▪Discrepancies in laterality, gender, location of pain, presence of pain, site, etc.
▪Body systems and Body areas mixed-up.
▪Exam not documented at all. Free text is better than nothing.
Point-of-care Test Results
not documented
▪Point-of-care lab tests performed but not documented in EHR or Charge Capture.
▪Confusion over who is will document when CLIA labs are performed by nursing based on protocols. Nursing sometime cannot do this based on EHR settings.
▪Tests performed &used in assessment but not documented.
▪Diagnosis not supported by test results.
Procedure Coding and
Documentation
▪ A common audit finding is the absence of a procedure note when an in-office procedure is performed. Example: destruction of skin lesion, laceration repair, joint injection, IUD insertion, I & D, etc.
▪No details of procedure in note at all, but charge drops. Free text is better than nothing.
▪Make sure EHR can capture a procedure note.
▪Obtain procedural consent for any invasive procedure.
▪Nursing documentation for injections, immunizations, bandage change even if not a billable encounter.
Diagnosis Assignment
and Sequencing
▪ The primary diagnosis is the one most related to the Chief Complaint.
▪Diagnosis not logical in respect to clinical documentation.
▪Acute conditions are sequenced before chronic conditions.
▪ If multiple problems are equally addressed, either may be the primary diagnosis.
▪Symptoms which are integral to the definitive diagnosis should not be listed; some EHRs require this if the treatment includes separate plans by symptom. Doing this can artificially the MDM and E & M level.
▪Diagnoses on the problem list should not be pulled into assessment unless they are addressed during this visit or were considered in the treatment options. Some EHRs pull over the problem list automatically.
Diagnosis Assignment
and Sequencing
▪Symptoms are coded when there is not definitive outpatient diagnosis.
▪Outpatient coding guidelines do not support differential diagnoses or rule-out diagnoses. Inpatient coding guidelines do.
▪For risk adjusted/HCC coding, only report the diagnoses addressed during the visit or considered this visit. Do not report all unless all are addressed. All chronic should be addressed sometime in the calendar year.
▪Diagnosis assignment should be as specific as the clinical documentation. The use of unspecified codes is only permitted when the clinical documentation does not support a more specific code assignment. Provider often see truncate descriptions or have memorized general codes.
Wellness Visits and Preventive Services
Medicare, Medicaid and other Payers have specific components of wellness visits and preventive services. Providers need to be aware of these. Customize templates to help guide documentation. Do not report a service unless all elements were performed.
This includes Medicare IPPE and AWV services.
Do not report an annual check-up or follow visit for chronic conditions as an AWV.
CPT® and HCPCS® are different between payers.
Preventive service may be restricted by frequency, age, or gender.
Nursing Home and SNF Visits
Documentation for RHC encounters billed for nursing home, SNF, and other location visits should fully support the level of service provided.
Clinical documentation should be in the RHC EHR and not just in the nursing home chart.
Use tablets for documentation or have note templates available at the facility for the providers to use.
Do not use “gang” billing. Every service should not occur on the same day of the month.
Providers are doing the work but not getting it down on “paper”
▪Providers are usually doing the work—mentally, physically. The medical decision-making is being performed.
▪It is not, however, being documented for one reason or the other.
▪RHC providers are keenly familiar with their patients and they often connect the dots and formulate assessments and treatments without documenting their “work”. It’s automatic.
▪We need to be reminded that an auditor who neither knows your patient or your provider will try to make heads and tails out of a note years after it was written. That is the concern.
Remember that Providers are not Coders and Coders are not providers.
Providers are trained to assess and treat patients. The process of making a diagnosis is very different than the process of assigning a diagnosis or procedure code. Code assignment is not intuitive to providers. Making a diagnosis or developing a treatment plan is.
EHR Implementation has given the provider more direct responsibility in the coding function.
Providers must be given some help in learning coding guidelines.
High volume clinics are employing coders as revenue-cycle team members.
Charges Dropped but
not documented or vice versa
For clinics on paper or hybrid systems, sometimes we see charges drop on the claim that are not supported by clinical documentation. Labs, in-office procedures, other diagnostics.
Sometimes services are documented and not charged.
Clinical workflow, administrative checks and balances and correct bill formatting within the system are essential.
Signatures & Open Notes
▪Open, unsigned notes
▪Delay in signing charts leads to documentation discrepancies and lack of detail. 40-60 days?
▪For PBRHCs, medical staff rules and regs should govern completion of notes. PBRHC providers are required to be governed by the hospital medical staff. (42 cfr 413.65)
▪Independent clinics should have clearly understood expectations for timely signatures.
▪With optimal EHR use, notes should be signed within 48 hours unless waiting for reference lab results.
EHR Implementation
We still have a love/hate relationship.
The pros out weight the cons.
Handwritten notes and hybrid notes are hard to audit.
Involve providers in product selection, implementation and training.
Don’t succumb to hiring scribes unless absolutely necessary.
Compensation should be tied to EHR/HIT adoption.
EHR Training &
Optimization
EHR design and set-up is necessary for good documentation and provider buy-in.
Staff and Provider training is absolutely necessary.
EHR adoption should be part of the provider’s employment or compensation agreement.
Customization is worth the added cost.
Be prudent when selecting which fields and screens are mandatory to complete. Optimize workflow as well as ease of documentation.
Focus on what can be done and not what cannot be done in your system.
Discourage work-arounds if they compromise the quality of documentation or quality reporting.
Patients Over Paperwork
CMS has launched a “Patients Over Paperwork” initiative which seeks to unburden providers with unnecessary paperwork.
Provider should not respond to this initiative by reducing the quality of clinical documentation. Patient care is important. And other reporting requirements depend on good documentation.
Audit and Retrain as part
of your Compliance
Plan
Perform internal audits for overall quality of documentation and record completeness.
Perform focused audits on new providers or for specific problem areas or suspected problem areas.
Benchmark providers E & M levels by MGMA or CMS standards. Identify trends which are outside the bell curve.
Provide provider-specific education to improve quality of documentation and code assignments.
Get outside help if needed.
Have checks and balances in place. Do not pay wRVU bonuses without chart auditing. Reconsider wRVU models for RHCs.
The encounter, the clinical documentation and the claim all should represent the same picture. Subtle differences can create big issues!
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Patty Harper, RHIA, CHTS-IM, CHTS-PW
www.inquiseek.com
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