Summary of CMS Rural Health Clinic Open Door Forum

March 03, 2016

On March 3, 2016 CMS held a Rural Health Clinic Open Door Forum to review upcoming guideline changes.

Effective April 1, 2016, CMS will require that Rural Health claims report revenue codes and HCPCS codes for each service line. Services provided through March 31, 2016 should be billed without a HCPCS code per previous guidelines.

What Hasn't Changed

  • The All-Inclusive Rate (AIR) system and payment methodology.
  • The scenarios where multiple RHC encounters may be paid for the same DOS:
    • Patient Suffers an illness/injury requiring treatment, after an RHC encounter on the same day.
    • Patient has a qualifying medical visit on the same day as a qualifying mental health visit.
    • Patient has an IPPE on the same day as a separate qualifying medical and/or qualifying mental health visit.

The Changes

  • An RHC visit must include one of the services listed on the CMS RHC Qualifying Visit List
  • The qualifying services should be the first listed charge with the total charges of the RCH encounter (minus any charge for an approved preventative service) as the billed amount. Payment will be made under the All-Inclusive Rate (AIR) based on this line.
    • Qualifying medical services billed with the revenue code 052X.
    • Qualifying mental health services are billed with revenue code 0900.
    • Telehealth originating site facility fees are billed with revenue code 0780.
  • Other RHC services performed in the encounter are billed on separate lines with appropriate revenue and HCPCS codes. Charge amounts should also be billed for each line.

The Challenges

  • No procedure codes are listed on the RHC Qualifying Visit List. Without a qualifying service, the RHC claim will not pay the AIR. The CMS presenter mentioned that quarterly updates to the RHC Qualifying Visit List will be posted on the CMS website. At this point, procedure-only RHC encounters will not receive AIR payment.
  • Because the total charges in line one (used for AIR payment) will differ from the total amount billed, some beneficiaries may question the veracity of the RHC clinic's billing. Customer service staff may need additional training and support to better explain the required billing changes to patients.
  • Billing systems should be checked to assure that RHC charges will total properly in line one, while excluding charges related to approved preventative services (carve-out).

Read the complete CMS bulletin with examples.

Edited March 24, 2016:

CMS announced that additional codes for commonly performed minor procedures have been added to the Qualifying Visit List. However, these additional codes will not be paid until 10/1/2016.

The RHC Qualifying Visit List is updated to include additional medically-necessary billable visits, effective April 1, 2016, but not payable until October 1, 2016. RHC's should hold claims for these billable visits added to the RHC Qualifying Visit List until October 1, when RHC's can bill these claims for payment.

View the updated list