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In the wake of meaningful use, the adoption of ICD-10, and other healthcare system mandates comes yet another requirement. With a Centers for Medicare & Medicaid Services (CMS) implementation date of April 1 and an effective date of April 4, rural health clinics (RHCs) will be required to report the appropriate HCPCS code for each service line, along with the revenue code and other required billing codes.

This new ruling affects all RHCs submitting claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries. More specifically, RHCs, including those exempt from electronic reporting under Section 424.32(d)(3), are required to report the appropriate HCPCS code for each service line, along with the revenue code and all other required billing codes. Payment for RHC services will continue to be made under the all-inclusive rate (AIR) system when all of the program requirements are met.

There is no change to the AIR system and payment, per information shared by the MLN Matters – Medicare Learning Network. A closer look reveals that beginning April 1, only RHC claims that include one of the billable visits listed on the RHC Qualifying Visit List (found on the CMS and National Association of Rural Health Clinics websites) will be paid. To understand this, one must understand that “billable visits” are medically necessary, face-to-face medical or mental health visits with a RHC practitioner or qualified preventive health provider. 

Here comes the devil in the details – “the aforementioned RHC lists (are) 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.”

Additionally, “services furnished through March 31, 2016 should be billed without a HCPCS code,” under the previous guidelines.

While this communication is meant to be a primer, with more information from the March 29, CMS Open Door Webinar to be shared on Open Mike Monday, April 4 at 10 a.m. EST, rural health stakeholders must see that beyond the mandate, there is the bigger picture of the necessary activity. 

To better understand this, let’s briefly assess past activities. Dating back to April 1, 2005 through Dec. 31, 2010, RHCs billing under the AIR system were not mandated to report any HCPCS coding when billing for any RHC services, with a couple of exceptions. Because the AIR system was originally designed to provide payment for all costs associated with a patient encounter for a single day, it wasn’t necessary to require any reporting of the HCPCS.

With the passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010 came further modifications for RHC billing, and beginning Jan. 1, 2011, the PPACA waived the co-insurance and deductible for the initial preventive physical examination (IPPE), the annual wellness exam (AWE), as well any other Medicare preventive services covered or recommended by the USPSTF (the United States Preventive Services Task Force). This affected services rendered with a grade A or B. So since Jan. 1, 2011, due to this provision, RHCs have been required to report HCPCS codes for preventive services.     

Additionally, CMS required a standard set of medical code sets to be used for electronic patient healthcare transactions (defined as Level I & Level II of the HCPCS). Using the 2016 Physician Fee Schedule, CMS also proposed that all RHCs, including those exempt from electronic reporting, would be required to submit for HCPCS and other codes as required for claims on any other services provided to patients. The RHC requirements to submit HCPCS codes were finalized in what is known as the 2016 PFS final rule, with comment period.

In summary, let’s refer to the “heart” of the matter – the CR9269 changes that act as basic guidelines for RHC visits. The RHC visit is generally defined as a “necessary” medical or mental health visit, a qualified preventive health visit, or a transitional care management (TCM) service that is provided as a face-to-face patient encounter with a RHC provider in which one or more RHC services are provided (please note that there are shades of gray requiring one to refer to Chapter 13 of the Medicare Policy Manual for additional acceptable provisions). 

It appears that this new RHC billing regulation is another action to help recalibrate our healthcare delivery model, in spite of the fact that exorbitant healthcare costs historically haven’t equated to healthier patients or better patient outcomes.

Now, the following areas could be one step closer in the post-PPACA world:

  1. Precision coding = precision care= healthier individual patient outcomes.
  2. More coding and billing reference points would deter fraud and waste in the healthcare system.    
  3. Greater patient satisfaction.
  4. Increased patient-provider engagement.
  5. RHC mission, margin, and value drivers of individual Medicare beneficiary care and services necessary to create healthier individuals and populations.

Whatever the case or cause, we will continue to track and monitor both the CMS and RHC sides of this story. 

About the Author

Janelle Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow. 

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