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Providers are already seeing the impacts of CMS’s billing changes that expand the level of coding detail and changes the format of charge reporting.


Rural Health Clinics Must Adapt to New Billing Requirements

  • 5/24/2016

The Centers for Medicare and Medicaid Services (CMS) have made changes to the billing requirements for Rural Health Clinics (RHC) that will have significant impacts on their current operations. CMS Change Request CR 9269, (which stems from the recently finalized 2016 Physician Fee Schedule final rule found at 80 FR 71088 ), expands the level of coding detail required on RHC claims and also changes the format of charge reporting on these claims. Facilities will have to adapt their systems, and, in the short term, may have to adjust patient flow and business office operations. Providers are already seeing impacts of these changes. 

See detailed examples of the required billing formats in a CMS Medlearn Matters article. Learn more

System impacts 

Historically, RHCs were not required to report Health Care Common Procedure Coding System (HCPCS) detail on Medicare claim forms. Recent changes required these codes to be added for certain preventative services that were exempt from coinsurance and deductibles. Now RHCs are required to report line item HCPCS codes for all services provided in the RHC setting. These specific change requirements include the need to summarize total charges on the first line of each bill, with a HCPCS code that is included in the RHC Qualifying Visit Listing (RHCQVL). 

Unfortunately, the format of the billing doesn’t follow the detailed billing that is required on a hospital billing claim form. RHC claims will require line item detail with prices on each, and will also have to summarize and include the total charges on the first line of the claim. This may cause confusion when Medicare beneficiaries receive their explanation of benefit forms. This may require RHCs to educate beneficiaries about the changes in order to reduce office calls when an unfamiliar bill is received. 

Operational consequences 

The requirement that each claim needs to have an initial billable service that is included on the RHCQVL will have operational consequences for cases where patients return for follow up procedures. When it was initially released, the RHCQVL contained predominantly Evaluation and Management (E&M) service HCPCS codes. As a result, when a patient returned for follow up procedures that did not involve E&M services, there was not a clear mechanism for billing these services as a qualifying RHC visit. The RHCQVL has since been updated to contain a number of procedure codes, but does not include all procedures that may be performed. Additionally, the codes that were added to the RHCQVL are not allowed to be billed until October 1, 2016. 

From a cost report perspective, an RHC visit is counted as a face-to-face visit with a provider. Since these follow-up procedures include a face-to-face encounter with a provider, if a procedure is performed that is not on the RHCQVL listing, it would still need to be counted as a visit for cost reporting purposes. Currently, those procedures not included on the RHCQVL are still not separately billable. 

Because all procedure codes added to the RHCQVL after its initial release are not billable by CMS until October 1, 2016, payments for these services will be delayed. Without additional fixes from CMS, this would result in a lower Medicare utilization on the Medicare cost report, delays in payments for some procedural visits, and a loss in reimbursement for most providers. 

Operational adjustments 

Some operational changes to clinical patient flow could help prevent a loss or delay in reimbursement. 

For example, if the provider has already determined that a procedure is necessary, rather than scheduling the patient to return for it, the procedure could be done at the time of the visit. For billing and cost report purposes, these would be counted as one claim/encounter. This could help eliminate a reduction in the Medicare percentage of visits, but reducing the overall visits could also push some RHCs below the provider utilization limitations. 

A second option would be to refer the patient to return for further evaluation so that an E&M service and the potential procedure could be provided at that time. This could potentially include the referral to another physician for a consult on the procedure. 

In any case, correct coding initiatives need to be complied with to ensure appropriate billing occurs. 

How we can help 

These new regulations will require RHCs to make some changes. CLA can help your organization adapt from a reimbursement and operational perspective. Our experienced health care team has a long history of helping organizations adjust to major changes in the industry.