Billing & Coding - Section 1: Billing & Coding Flashcards
RHC services are defined by ____ and ____ (payers)
Medicare and Medicaid
True or False:
Some RHCs have negotiated contracts with commercial payers to reimburse them at the RHC rate
True
Other payers, such as BCBS, most commonly consider RHCs as ____ providers, although some will contract with an RHC as a facility type
Fee for service
A medically necessary face-to-face visit with a provider in the allowed “places of service”
RHC encounter
True or False:
Without a face-to-face visit with a provider, there is no billable professional service
True
Is the below a billable service?
A nurse visit (99211)
No, not a billable professional service
Items provided during a nurse visit (99211) can be added an encounter ____ days before or after the visit
30
An RHC or FQHC visit is a medically-necessary medical or ____ health visit, or qualified ____ health visit
Mental
Preventive
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
Face-to-face
A ____ care management service can be an RHC or FQHC visit
Transitional
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
Scope
An RHC visit can also be a visit between a home-bound patient and an ____ or ____ under certain conditions
RN or LPN
____ to ____ encounter + medically ____ + level ____ or higher = RHC encounter (billable)
Face-to-face encounter + medically necessary + level 2 or higher
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
Physician
Physician services are professional services furnished by a physician to an RHC and include ____, ____, ____, and ____
Diagnosis, surgery, therpy, and consultation
True or False:
A physician does not need to examine the patient in person or be able to directly visualize
False
Direct visualization includes ____ of the patient’s x-ray, EKGs, tissue sample, etc
Review
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
Are
Are
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
Do not
Qualified services furnished at an RHC, FQHC, or other authorized site by an RHC or FQHC physician are ____ only to the RHC or FQHC
Payable
RHC and FQHC physicians are paid according to their ____ ____ or ____
Employment agreement or contract
Other than physicians, who qualifies as additional clinicans?
NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinic social worker (CSW)
A clinical psychologist (CP) must have their ____ degree and be ____ in the state where services are provided
PhD
Licensed
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
Masters
2
Licensed
True or False:
Providers may not be eligible for other payers even though they are RHC eligible
True
True or False:
Dentists, podiatrists, optometrists, and chriopractors are not defined as physicians in Medicare statute
False; are defined as physicians
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
True
Dentists, podiatrists, optometrists, and chriopractors can provide RHC services that are within their ____ of practice and not excluded from ____
Practice
Coverage
Patient care hours must be posted where?
Outside of the RHC
A qualified RHC provider must be available to provide service during what time frame?
All posted patient care hours
A NP or PA must be staffed ____% of the time
50%
An RHC must have posted ____ hours
Administrative
What can happen during administrative hours?
Patients may pay their bills and make appointments
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
True
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.
Rooming
If the patient is in a treatment area, it is assumed that a provider is ____
On-site
A ____ or ____ doees not qualify as the only qualified provider on site
Chiropractor, podiatrist
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?
At all times the RHC is in operation
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)
False; is not considered to be in operation and is not subject to the staffing requirements
Your state ____ plan might recognize other provider types as RHC providers. Follow your RHC state regulations
Medicaid
All RHC providers must be ____ to practice in your state and provide services within the state’s ____ of practice requirements
Licensed
Scope
What does RHC revenue code 0521 stand for?
Office visit in-clinic
What does RHC revenue code 0522 stand for?
Home visit
What does RHC revenue code 0525 stand for?
Visit to a patient in a SNF, NF, ICR MR, AL
What does RHC revenue code 0524 stand for?
Visit to a part A SNF or swing bed patient
What does RHC revenue code 0527 stand for?
Visiting nurse service in a designated HHA shortage
What does RHC revenue code 0528 stand for?
Visit at other site (i.e., scene of accident)
What does RHC revenue code 0780 stand for?
Telehealth service
What does RHC revenue code 0900 stand for?
Mental health services
What 2 places can RHC visits not take place?
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)
Telehealth visits are billed under which revenue code during a public health emergency?
0521
Rural health clinics place of service code is ____
72
Where might you need to file the place of service?
On commercial payer claims
Place of service only applies to the ____ ____ claim form type
HCFA 1500
What billing form should be used for an independent RHC billing encounter professional services?
Part A UB-04
What billing form should be used for a provider-based RHC billing encounter professional services?
Part A UB-04
What billing form should be used for an independent RHC billing CLIA lab performed in RHC?
Part B Form 1500
What billing form should be used for a provider-based RHC billing CLIA lab performed in RHC?
Billed to MAC by parent hospital
What billing form should be used for an independent RHC billing other technical components (non-RHC)?
Part B Form 1500
What billing form should be used for an independent RHC billing professional services outside of RHC hours?
Part B Form 1500
What billing form should be used for a provider-based RHC billing professional services outside of RHC hours?
Billed to MAC as professional service or CAH Method II Billing
What billing form should be used for a provider-based RHC billing other technical components (non-RHC)?
Billed to MAC by parent hospital
All RHC claims must have a CG modifier to receive payment with the exception of what types of visits?
CCM and initial preventative visit (IPPE)
True or False:
All HCPCS codes must match revenue codes used
True
Patient responsibility is ____% of charge
20%
MAC pays up to ____% of the rate minus the deductible or coinsurance that patient owes
80%
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.
$30
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.
$50
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.
0.01
$50
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
$38
Total bundled charges of all service lines except preventive codes; separate line for each bundled service with charge > $____
$0.01
Lab and x-ray services would be billed ____ under the appropriate method for the type of RHC
Separately
Professional services furnished by an NP, PA, or CNM to an RHC or FQHC patient are services that would be considered ____ ____ services under Medicare
Covered physician
The NP, PA, or CNM must ____ examine the patient, or directly ____ the patient’s medical information, such as x-rays, EKGs, and tissue samples
Directly
Review
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
Billable
Refers to services and supplies that are integral, though incidental, part of the physician’s professional service
Incident to
Incident to services are commonly rendered without ____ and included in the RHC payment
Charge
Incident to services are commonly furnished in what type of setting?
Outpatient clinic setting
Incident to services are furnished under the physician’s ____ supervision, except for authorized care management services which may be furnished under ____ supervision
Direct
General
Incident to services are furnished by RHC or FQHC ____ personnel
Auxiliary
Incident to services include drugs and biologicals that are not unusually ____-____
Self-administered
Incident to services and supplies include Medicare-covered ____ injectible drugs (e.g., influenza, pneumococcal)
Preventive
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 ____
All-inclusive rate
True or False:
During the public health emergency, RHCs are not allowed to be the “distant site” for telehealth
False; are allowed
RHCs may serve as an originating site for telehealth services, which is what type of location?
The location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs
RHCs and FQHCs that serve as an originating site for telehealth services are paid what?
An originating site facility fee
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
Distant
What is a distant site for telehealth consultations?
The location of the practitioner at the time the telehealth service is furnished
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
True
What is the below describing?
A patient sitting at their home and talking to an RHC provider
A distant site for telehealth
True or False:
A provider cannot treat a hospice patient, even if the condition is not related to hospice diagnosis
False; can treat a hospice patient but only for a condition not related to hospice diagnosis
A provider cannot ____ for hospice ailments, even if medically necessary
Bill
Can a provider bill Part B for hospital-related ailments?
No
For hospice-related ailments, who should the providers coordinate care with?
The hospice company
When would a hospice service be billable?
If providers provides service during non-RHC hours
____ 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)
Referrals
Many referrals will be ____ services from another provider
Incident to
Allowed Medicare preventive services are billed through the rural health clinic on the ____
UB04
Technical components, labs, EKG tracing are billed on the ____ side
Non-RHC
Each preventive service must be on a ____ line on the UB with ____-code
Separate
G
True or False:
There are generally copys or deductible applied to preventive services
False; generally, there is no copy or deductible applied to preventive services
When preventive services are billed with other RHC services, the RHC will receive their ____ as payment
All-inclusive rate
Claims with only preventive services billed must have the ____ preventive service billed with the ____ modifier
Primary
CG
For preventive services, why will the RHC receive additional settlement dollars on the cost report?
Because the RHC received no copay amounts at the time of service
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.
1) No
2) No, deductible and co-insurance is waived
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?
1) Yes - appended to the AWV
2) No
For transitional care management, a face-to-face is required within ____ days of discharge
14 days
How many health care professional can report TCM?
1
Transitional care management can only be reported ____ per beneficiary
Once
For RHC, the ____ used is the face-to-face visit day for transitional care management
DOS
Can TCM be billed during a global period?
No
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)
Discharge
Beneficiary
Face-to-face visit
Complexity
CCM requires ____ or more chronic conditions
2
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
20 minutes
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
G0511
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
70
60
G0512
Principle care management codes are intended to cover services for patients with only one ____ ____ condition that requires management by a specialist
Complex chronic
The principle care management codes are intended to reimburse physicians for the additional work they do caring for what type of patients?
Complex, high risk
New RHC principal care management services requires ____ minutes of provider time each calendar month to care for the patient
30 minutes
At what frequency can the principal care management code be billed?
Monthly
New RHC principal care management services requires 30 minutes of provider time each calendar ____ to care for the patient
Month
New RHC principal care management services requires ____ minutes of clinical staff time directed by a provider each calendar month for patient care
30
For principal care management services, provider supervision DOES or DOES NOT require the provider to be onsite while the clinical staff performs PCM services
Does not
How will RHCs bill PCM?
Using G0511
For PCM, does the patient need to agree to participate?
Yes
For PCM, does a care plan specific to the chronic complex condition need to be in place?
Yes
If CCM is billed alone, is the CG modifier required? Explain your answer.
No, because the service is paid under fee-for-service reimbursement
If CCM is billed alone, do deductibles and co-insurance apply?
Yes, the patient will have a cost share
If CCM is billed with another RHC service, is the charge for CCM added to the first line (the office visit line)?
No
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?
On the first line
If CCM is billed with another RHC service, how will the clinic be paid?
Will receive the AIR for the office visit/enounter and the rate for the CCM
Can advance care planning (ACP) be a stand alone service?
Yes
How is advance care planning paid?
As a visit at the AIR
Are there frequency limits with advanced care planning?
No
What should happen if advance care planning services are performed again?
Should be a change in status or in end-of-life wishes
Is there a deductible or copay with advance care planning?
No, when with the AWV
When would the deductible and copay apply for advance care planning?
When billed without the AWV
Is a specific diagnosis required for advance care planning?
No
True or False:
All lab services are non-RHC services
True
Venipuncture is an RHC service and billed with the ____ visit or other standalone services provided
Office
How will independent RHCs bill lab services?
To Medicare part B on the 1500 form
How will provider based RHCs bill lab services?
Through their parent provider on the UB04 (just like if the patient walked into the hospital to have these services done)
What will payment for lab services be based on?
Medicare Part B fee schedule amounts
How will labs that are sent out be billed?
By the provider performing the test
What are the 6 basic required labs?
UA dipstick Hemoglobin or hematocrit Hemoccult test Blood sugar test Pregnancy test Transfer of cultures to a certified lab
The 6 basic required labs are CLIA ____ tests
Waived
True or False:
You can perform more than the 6 basic required labs, but you must be within the scope of the CLIA certificate
True
Any ____ component (EKG tracing, x-ray, etc) is a non-RHC service
Technical
How would independent RHCs bill technical components (EKG tracing, x-ray, etc.)?
To Medicare part B under the clinic’s part B provider #
How would provider based RHCs bill technical components (EKG tracing, x-ray, etc.)?
Through the parent provider
Medicare influenza and pneumonia injections are NEVER or are ALWAYS billed in the RHC
Never
How are influenza and pneumonia injections paid?
Through the cost report
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 ____
Total
Medicare
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
5 minutes
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
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?
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
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.
G0071
True or False:
RHC face-to-face requirements are waived when virtual communication services are furnished to an RHC patient
True
For virtual communication services, do coinsurance and deductibles apply?
Yes
Do Medicare excluded services require an Advance Beneficiary Notice?
No
Durable medical equipment (prosthetic devices, braces) must have what to bill services to Medicare?
DME provider number
