Billing & Coding - Section 1: Billing & Coding

Question 1

RHC services are defined by ____ and ____ (payers)

Answer 1

Medicare and Medicaid

Question 2

True or False:

Some RHCs have negotiated contracts with commercial payers to reimburse them at the RHC rate

Answer 2

True

Question 3

Other payers, such as BCBS, most commonly consider RHCs as ____ providers, although some will contract with an RHC as a facility type

Answer 3

Fee for service

Question 4

A medically necessary face-to-face visit with a provider in the allowed “places of service”

Answer 4

RHC encounter

Question 5

True or False:

Without a face-to-face visit with a provider, there is no billable professional service

Answer 5

True

Question 6

Is the below a billable service?

A nurse visit (99211)

Answer 6

No, not a billable professional service

Question 7

Items provided during a nurse visit (99211) can be added an encounter ____ days before or after the visit

Answer 7

30

Question 8

An RHC or FQHC visit is a medically-necessary medical or ____ health visit, or qualified ____ health visit

Answer 8

Mental

Preventive

Question 9

The medically necessary medical or mental health visit or qualified preventive health visit must be ____-to-____ encounter between a patient and a physician, NP, PA, CNM, CP, or CSW during which time one or more RHC or FQHC services are rendered

Answer 9

Face-to-face

Question 10

A ____ care management service can be an RHC or FQHC visit

Answer 10

Transitional

Question 11

Services furnished must be within the practitioner’s state ____ of practice, and only services that require the skill level of the RHC or FQHC practitioner are considered RHC or FQHC visits

Answer 11

Scope

Question 12

An RHC visit can also be a visit between a home-bound patient and an ____ or ____ under certain conditions

Answer 12

RN or LPN

Question 13

____ to ____ encounter + medically ____ + level ____ or higher = RHC encounter (billable)

Answer 13

Face-to-face encounter + medically necessary + level 2 or higher

Question 14

The term “____” includes a doctor of medicine, osteopathy, dental surgery, dental medicine, podiatry, optomerty, or chiropractic who is licensed and practicing within the licensee’s scope of practice, and meets other requirements as specific

Answer 14

Physician

Question 15

Physician services are professional services furnished by a physician to an RHC and include ____, ____, ____, and ____

Answer 15

Diagnosis, surgery, therpy, and consultation

Question 16

True or False:

A physician does not need to examine the patient in person or be able to directly visualize

Answer 16

False

Question 17

Direct visualization includes ____ of the patient’s x-ray, EKGs, tissue sample, etc

Answer 17

Review

Question 18

Except for services that meet the critera for authorized care management or virtual communication services, telephone or electronic communication between a physician and a patient, or between a physician and someone on behalf of a patient, ARE or ARE NOT considered physicians’ services and ARE or ARE NOT included in an otherwise billable visit

Answer 18

Are

Are

Question 19

Except for services that meet the critera for authorized care management or virtual communication services, telephone or electronic communication between a physician and a patient, or between a physician and someone on behalf of a patient, are considered physicians’ services and are included in an otherwise billable visit. They DO or DO NOT constitute a separately billable visit

Answer 19

Do not

Question 20

Qualified services furnished at an RHC, FQHC, or other authorized site by an RHC or FQHC physician are ____ only to the RHC or FQHC

Answer 20

Payable

Question 21

RHC and FQHC physicians are paid according to their ____ ____ or ____

Answer 21

Employment agreement or contract

Question 22

Other than physicians, who qualifies as additional clinicans?

Answer 22

NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinic social worker (CSW)

Question 23

A clinical psychologist (CP) must have their ____ degree and be ____ in the state where services are provided

Answer 23

PhD

Licensed

Question 24

A clinical social worker (CSW) must have a minimum of a ____ degree, worked a minimum of ____ years of supervised clinical social work, and ____ in the state providing services

Answer 24

Masters
2
Licensed

Question 25

True or False:

Providers may not be eligible for other payers even though they are RHC eligible

Answer 25

True

Question 26

True or False:

Dentists, podiatrists, optometrists, and chriopractors are not defined as physicians in Medicare statute

Answer 26

False; are defined as physicians

Question 27

True or False:

Dentists, podiatrists, optometrists, and chiropractors are defined as physicians in Medicare statute, and qualified services furnished by these physicians are billable visits in an RHC

Answer 27

True

Question 28

Dentists, podiatrists, optometrists, and chriopractors can provide RHC services that are within their ____ of practice and not excluded from ____

Answer 28

Practice

Coverage

Question 29

Patient care hours must be posted where?

Answer 29

Outside of the RHC

Question 30

A qualified RHC provider must be available to provide service during what time frame?

Answer 30

All posted patient care hours

Question 31

A NP or PA must be staffed ____% of the time

Answer 31

50%

Question 32

An RHC must have posted ____ hours

Answer 32

Administrative

Question 33

What can happen during administrative hours?

Answer 33

Patients may pay their bills and make appointments

Question 34

True or False:

No patient services (including lab draws, blood pressure checks, injections, bandage changes, etc) can be performed without a provider in the four walls of the RHC

Answer 34

True

Question 35

No patient services (including lab draws, blood pressure checks, injections, bandage changes, etc) can be performed without a provider in the four walls of the RHC. This includes ____ patients in advance of a provider’s arrival.

Answer 35

Rooming

Question 36

If the patient is in a treatment area, it is assumed that a provider is ____

Answer 36

On-site

Question 37

A ____ or ____ doees not qualify as the only qualified provider on site

Answer 37

Chiropractor, podiatrist

Question 38

An RHC provider is a physician, NP, PA, CNM, CP, or CSW. At least one of these practitioners must be present in the RHC and available to furnish patient care at what timeframe?

Answer 38

At all times the RHC is in operation

Question 39

True or False:

A clinic that is open solely to address administrative matters or to provide shelter from inclement weather is considered to be in operation during this period and is subject to the staffing requirements (i.e., an RHC provider must be present in the RHC at all times)

Answer 39

False; is not considered to be in operation and is not subject to the staffing requirements

Question 40

Your state ____ plan might recognize other provider types as RHC providers. Follow your RHC state regulations

Answer 40

Medicaid

Question 41

All RHC providers must be ____ to practice in your state and provide services within the state’s ____ of practice requirements

Answer 41

Licensed

Scope

Question 42

What does RHC revenue code 0521 stand for?

Answer 42

Office visit in-clinic

Question 43

What does RHC revenue code 0522 stand for?

Answer 43

Home visit

Question 44

What does RHC revenue code 0525 stand for?

Answer 44

Visit to a patient in a SNF, NF, ICR MR, AL

Question 45

What does RHC revenue code 0524 stand for?

Answer 45

Visit to a part A SNF or swing bed patient

Question 46

What does RHC revenue code 0527 stand for?

Answer 46

Visiting nurse service in a designated HHA shortage

Question 47

What does RHC revenue code 0528 stand for?

Answer 47

Visit at other site (i.e., scene of accident)

Question 48

What does RHC revenue code 0780 stand for?

Answer 48

Telehealth service

Question 49

What does RHC revenue code 0900 stand for?

Answer 49

Mental health services

Question 50

What 2 places can RHC visits not take place?

Answer 50

1) An inpatient or outpatient department of a hospital, including a CAH
2) A facility which has specific requirements that preclude RHC or FQHC visits (e.g., a Medicare comprehensive outpatient rehabilitation facility, a hospice facility, etc)

Question 51

Telehealth visits are billed under which revenue code during a public health emergency?

Answer 51

0521

Question 52

Rural health clinics place of service code is ____

Answer 52

72

Question 53

Where might you need to file the place of service?

Answer 53

On commercial payer claims

Question 54

Place of service only applies to the ____ ____ claim form type

Answer 54

HCFA 1500

Question 55

What billing form should be used for an independent RHC billing encounter professional services?

Answer 55

Part A UB-04

Question 56

What billing form should be used for a provider-based RHC billing encounter professional services?

Answer 56

Part A UB-04

Question 57

What billing form should be used for an independent RHC billing CLIA lab performed in RHC?

Answer 57

Part B Form 1500

Question 58

What billing form should be used for a provider-based RHC billing CLIA lab performed in RHC?

Answer 58

Billed to MAC by parent hospital

Question 59

What billing form should be used for an independent RHC billing other technical components (non-RHC)?

Answer 59

Part B Form 1500

Question 60

What billing form should be used for an independent RHC billing professional services outside of RHC hours?

Answer 60

Part B Form 1500

Question 61

What billing form should be used for a provider-based RHC billing professional services outside of RHC hours?

Answer 61

Billed to MAC as professional service or CAH Method II Billing

Question 62

What billing form should be used for a provider-based RHC billing other technical components (non-RHC)?

Answer 62

Billed to MAC by parent hospital

Question 63

All RHC claims must have a CG modifier to receive payment with the exception of what types of visits?

Answer 63

CCM and initial preventative visit (IPPE)

Question 64

True or False:

All HCPCS codes must match revenue codes used

Answer 64

True

Question 65

Patient responsibility is ____% of charge

Answer 65

20%

Question 66

MAC pays up to ____% of the rate minus the deductible or coinsurance that patient owes

Answer 66

80%

Question 67

Provider performed an injection, tendon ($150) during an in-office encounter. No other services were provided. The supplies and local anesthesia would be integral to the procedure. The patient would be responsible for a $____ co-insurance payment.

Answer 67

$30

Question 68

Provider performed an E&M service ($100) and an in-office procedure ($150) during the same visit. The supplies and local anesthesia would be integral to the procedure. The patient would be responsible for a $____ co-insurance payment.

Answer 68

$50

Question 69

Provider performed an E&M service ($100) and an in-office procedure ($150) during the same visit. The supplies and local anesthesia would be integral to the procedure. Additional service items are reported as less than or equal to ____. The patient would be responsible for a $____ co-insurance payment.

Answer 69

0.01

$50

Question 70

Provider performed an E&M service ($125) and an ABX injection ($15 + $50) during the same visit, Also, a UA and an x-ray were performed in the RHC. Total RHC services would be $190. The patient would be responsible for a $____ co-insurance payment

Answer 70

$38

Question 71

Total bundled charges of all service lines except preventive codes; separate line for each bundled service with charge > $____

Answer 71

$0.01

Question 72

Lab and x-ray services would be billed ____ under the appropriate method for the type of RHC

Answer 72

Separately

Question 73

Professional services furnished by an NP, PA, or CNM to an RHC or FQHC patient are services that would be considered ____ ____ services under Medicare

Answer 73

Covered physician

Question 74

The NP, PA, or CNM must ____ examine the patient, or directly ____ the patient’s medical information, such as x-rays, EKGs, and tissue samples

Answer 74

Directly

Review

Question 75

Except for services that meet the criteria for authorized care management or virtual communication services, telephone, or electronic communication between an NP, PA, or CNM and patient, or between such practitioner and someone on behalf of a patient, are considered NP, PA, or CNM services, and are included in an otherwise ____ visit

Answer 75

Billable

Question 76

Refers to services and supplies that are integral, though incidental, part of the physician’s professional service

Answer 76

Incident to

Question 77

Incident to services are commonly rendered without ____ and included in the RHC payment

Answer 77

Charge

Question 78

Incident to services are commonly furnished in what type of setting?

Answer 78

Outpatient clinic setting

Question 79

Incident to services are furnished under the physician’s ____ supervision, except for authorized care management services which may be furnished under ____ supervision

Answer 79

Direct

General

Question 80

Incident to services are furnished by RHC or FQHC ____ personnel

Answer 80

Auxiliary

Question 81

Incident to services include drugs and biologicals that are not unusually ____-____

Answer 81

Self-administered

Question 82

Incident to services and supplies include Medicare-covered ____ injectible drugs (e.g., influenza, pneumococcal)

Answer 82

Preventive

Question 83

Payment for Medicare-covered part B drugs that are not usually self-administered and are furnished by an RHC practitioner to a Medicare patient are included the RHC ____

Answer 83

All-inclusive rate

Question 84

True or False:

During the public health emergency, RHCs are not allowed to be the “distant site” for telehealth

Answer 84

False; are allowed

Question 85

RHCs may serve as an originating site for telehealth services, which is what type of location?

Answer 85

The location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs

Question 86

RHCs and FQHCs that serve as an originating site for telehealth services are paid what?

Answer 86

An originating site facility fee

Question 87

RHCs and FQHCs are not authorized to serve as a ____ site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished

Answer 87

Distant

Question 88

What is a distant site for telehealth consultations?

Answer 88

The location of the practitioner at the time the telehealth service is furnished

Question 89

True or False:

RHCs cannot bill or include the cost of a telehealth visit on a cost report if they are serving as the distant site

Answer 89

True

Question 90

What is the below describing?

A patient sitting at their home and talking to an RHC provider

Answer 90

A distant site for telehealth

Question 91

True or False:

A provider cannot treat a hospice patient, even if the condition is not related to hospice diagnosis

Answer 91

False; can treat a hospice patient but only for a condition not related to hospice diagnosis

Question 92

A provider cannot ____ for hospice ailments, even if medically necessary

Answer 92

Bill

Question 93

Can a provider bill Part B for hospital-related ailments?

Answer 93

No

Question 94

For hospice-related ailments, who should the providers coordinate care with?

Answer 94

The hospice company

Question 95

When would a hospice service be billable?

Answer 95

If providers provides service during non-RHC hours

Question 96

____ from other providers are considered your RHC services or non-RHC services (ex: face-to-face visit with the provider is an RHC service even if the patient was referred to the clinic by another provider)

Answer 96

Referrals

Question 97

Many referrals will be ____ services from another provider

Answer 97

Incident to

Question 98

Allowed Medicare preventive services are billed through the rural health clinic on the ____

Answer 98

UB04

Question 99

Technical components, labs, EKG tracing are billed on the ____ side

Answer 99

Non-RHC

Question 100

Each preventive service must be on a ____ line on the UB with ____-code

Answer 100

Separate

G

Question 101

True or False:

There are generally copys or deductible applied to preventive services

Answer 101

False; generally, there is no copy or deductible applied to preventive services

Question 102

When preventive services are billed with other RHC services, the RHC will receive their ____ as payment

Answer 102

All-inclusive rate

Question 103

Claims with only preventive services billed must have the ____ preventive service billed with the ____ modifier

Answer 103

Primary

CG

Question 104

For preventive services, why will the RHC receive additional settlement dollars on the cost report?

Answer 104

Because the RHC received no copay amounts at the time of service

Question 105

The physician performed IPPE (Welcome to Medicare) service on a DOS.

1) Is a CG modifier required?
2) Will there be a cost share for the patient? Explain why or why not.

Answer 105

1) No

2) No, deductible and co-insurance is waived

Question 106

The physician received a subsequent AWV along with other preventive services (breast/pelvic exam, Pap Smear) on the same date of services,

1) Is the CG modifier required? If yes, where?
2) Will there be a cost share for the patient?

Answer 106

1) Yes - appended to the AWV

2) No

Question 107

For transitional care management, a face-to-face is required within ____ days of discharge

Answer 107

14 days

Question 108

How many health care professional can report TCM?

Answer 108

1

Question 109

Transitional care management can only be reported ____ per beneficiary

Answer 109

Once

Question 110

For RHC, the ____ used is the face-to-face visit day for transitional care management

Answer 110

DOS

Question 111

Can TCM be billed during a global period?

Answer 111

No

Question 112

Documentation required for TCM:
Date of ____
Date of interactive contract with ____ and/or caregiver
Date of ____-to-____ visit
____ of medical decision making (will determine what code is billed)

Answer 112

Discharge
Beneficiary
Face-to-face visit
Complexity

Question 113

CCM requires ____ or more chronic conditions

Answer 113

2

Question 114

Effective January 1, 2018, RHCs can receive payment for CCM or general behavioral health integration services when ____ minutes or more of CCM or general BHI services are furnished

Answer 114

20 minutes

Question 115

Effective January 1, 2018, RHCs can receive payment for CCM or general behavioral health integration services when 20 minutes or more of CCM or general BHI services are furnished and ____ is billed either alone or with other payable services on an RHC claim

Answer 115

G0511

Question 116

Effective January 1, 2018, RHCs can receive payment for psychiatric collaborative care model services when ____ minutes or more of initial psychiatric CoCM services or ____ minutes or more of subsequent psychiatric CoCM services are furnished and ____ is billed either along or with other payable services on an RHC claim

Answer 116

70
60
G0512

Question 117

Principle care management codes are intended to cover services for patients with only one ____ ____ condition that requires management by a specialist

Answer 117

Complex chronic

Question 118

The principle care management codes are intended to reimburse physicians for the additional work they do caring for what type of patients?

Answer 118

Complex, high risk

Question 119

New RHC principal care management services requires ____ minutes of provider time each calendar month to care for the patient

Answer 119

30 minutes

Question 120

At what frequency can the principal care management code be billed?

Answer 120

Monthly

Question 121

New RHC principal care management services requires 30 minutes of provider time each calendar ____ to care for the patient

Answer 121

Month

Question 122

New RHC principal care management services requires ____ minutes of clinical staff time directed by a provider each calendar month for patient care

Answer 122

30

Question 123

For principal care management services, provider supervision DOES or DOES NOT require the provider to be onsite while the clinical staff performs PCM services

Answer 123

Does not

Question 124

How will RHCs bill PCM?

Answer 124

Using G0511

Question 125

For PCM, does the patient need to agree to participate?

Answer 125

Yes

Question 126

For PCM, does a care plan specific to the chronic complex condition need to be in place?

Answer 126

Yes

Question 127

If CCM is billed alone, is the CG modifier required? Explain your answer.

Answer 127

No, because the service is paid under fee-for-service reimbursement

Question 128

If CCM is billed alone, do deductibles and co-insurance apply?

Answer 128

Yes, the patient will have a cost share

Question 129

If CCM is billed with another RHC service, is the charge for CCM added to the first line (the office visit line)?

Answer 129

No

Question 130

If CCM is billed with another RHC service, the charge for CCM is not added to the first line (the office visit line). Where is the CG modifier added?

Answer 130

On the first line

Question 131

If CCM is billed with another RHC service, how will the clinic be paid?

Answer 131

Will receive the AIR for the office visit/enounter and the rate for the CCM

Question 132

Can advance care planning (ACP) be a stand alone service?

Answer 132

Yes

Question 133

How is advance care planning paid?

Answer 133

As a visit at the AIR

Question 134

Are there frequency limits with advanced care planning?

Answer 134

No

Question 135

What should happen if advance care planning services are performed again?

Answer 135

Should be a change in status or in end-of-life wishes

Question 136

Is there a deductible or copay with advance care planning?

Answer 136

No, when with the AWV

Question 137

When would the deductible and copay apply for advance care planning?

Answer 137

When billed without the AWV

Question 138

Is a specific diagnosis required for advance care planning?

Answer 138

No

Question 139

True or False:

All lab services are non-RHC services

Answer 139

True

Question 140

Venipuncture is an RHC service and billed with the ____ visit or other standalone services provided

Answer 140

Office

Question 141

How will independent RHCs bill lab services?

Answer 141

To Medicare part B on the 1500 form

Question 142

How will provider based RHCs bill lab services?

Answer 142

Through their parent provider on the UB04 (just like if the patient walked into the hospital to have these services done)

Question 143

What will payment for lab services be based on?

Answer 143

Medicare Part B fee schedule amounts

Question 144

How will labs that are sent out be billed?

Answer 144

By the provider performing the test

Question 145

What are the 6 basic required labs?

Answer 145

UA dipstick
Hemoglobin or hematocrit
Hemoccult test
Blood sugar test
Pregnancy test
Transfer of cultures to a certified lab

Question 146

The 6 basic required labs are CLIA ____ tests

Answer 146

Waived

Question 147

True or False:

You can perform more than the 6 basic required labs, but you must be within the scope of the CLIA certificate

Answer 147

True

Question 148

Any ____ component (EKG tracing, x-ray, etc) is a non-RHC service

Answer 148

Technical

Question 149

How would independent RHCs bill technical components (EKG tracing, x-ray, etc.)?

Answer 149

To Medicare part B under the clinic’s part B provider #

Question 150

How would provider based RHCs bill technical components (EKG tracing, x-ray, etc.)?

Answer 150

Through the parent provider

Question 151

Medicare influenza and pneumonia injections are NEVER or are ALWAYS billed in the RHC

Answer 151

Never

Question 152

How are influenza and pneumonia injections paid?

Answer 152

Through the cost report

Question 153

To be paid for influenza and pneumonia injections through the cost report, it is required to report ____ injections given and how many of those were ____

Answer 153

Total

Medicare

Question 154

Effective January 1, 2019, RHCs can receive payment for virtual communication services when at least ____ minutes of communication technology based or remote evaluation services are furnished by an RHC practitioner to a patient who has had an RHC billable visit within the previous year

Answer 154

5 minutes

Question 155

Effective January 1, 2019, RHCs can receive payment for virtual communication services when at least 5 minutes of communication technology based or remote evaluation services are furnished by an RHC practitioner to a patient who has had an RHC billable visit within the previous ____

Answer 155

Year

Question 156

Effective January 1, 2019, RHCs can receive payment for virtual communication services when at least 5 minutes of communication technology based or remote evaluation services are furnished by an RHC practitioner to a patient who has had an RHC billable visit within the previous year AND what 2 requirements are met?

Answer 156

1) The medical discussion or remote evaluation is for a condition not related to an RHC service provided within the previous 7 days
2) The medical discussion or remove evaluation does not lead to an RHC visit within the next 24 hours or at the soonest available appointment

Question 157

To receive payment for virtual communication services, RHCs must submit an RHC claim with
HCPCS code ____ (virtual communication services) either alone or with other payable
services.

Answer 157

G0071

Question 158

True or False:

RHC face-to-face requirements are waived when virtual communication services are furnished to an RHC patient

Answer 158

True

Question 159

For virtual communication services, do coinsurance and deductibles apply?

Answer 159

Yes

Question 160

Do Medicare excluded services require an Advance Beneficiary Notice?

Answer 160

No

Question 161

Durable medical equipment (prosthetic devices, braces) must have what to bill services to Medicare?

Answer 161

DME provider number