part ii policies and procedures for rural health clinic services

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Rev 01/09Payments specified as the PPS rates are all inclusive of professional,technical and facility charges including evaluation and management,routine surgical and therapeutic procedures and diagnostic testing(including laboratory, pathology and radiology) capable of beingperformed on site at the RHC and billed by the facilities‟ provider ID andTIN.a. Laboratory, pathology, radiology and medications administered arenot separately reimbursable. To the extent that the provider has thecapabilities to provide these services and historically provided theseservices, the RHC shall continue to provide such services.b. The bundling of therapeutic and diagnostic testing services in thePPS rate is not meant to imply that the RHC shall vend or refer outsuch ancillary services to other providers merely for the purpose ofmaximizing reimbursement.c. Health Check visits are reimbursable at the PPS rate only to thoseRHCs and their practitioners who are enrolled as Health CheckScreening providers. Abnormal Health Check Visits may be paid as asecond PPS rate on the same member for the same date of service.Services listed in Appendix J are separately reimbursed according toa fee schedule or Vaccine for Children applicable rules.901.2 Services and Supplies Incident to a Service VisitRev 01/09Services and supplies incident to a Service visit include those servicescommonly furnished in a physician‟s office and ordinarily renderedwithout charge or are included in the practice‟s bill, such aslaboratory/pathology services, radiology services, ordinary medications,supplies used in a patient service visit. Services provided incident to aservice visit must be furnished by an employee and must be furnishedunder the direct supervision of an RHC health care practitioner, meaningthe health care practitioner must be immediately available whennecessary even by telephone.The reasonable costs associated with these services were reported on theRHC cost report and were considered as part of the RHC PPS baselinerate calculation. (See Chapter 1000 for more information).Rev 01/09901.3 Location Where RHC Services Can Be ProvidedRHC “Core” Services can be provided at the Clinic, a hospital an (eitherin-patient or outpatient setting), at the patient‟s place of residenceJanuary 2012 Rural Health Clinic Services IX-2
(including nursing homes), or other medical facility. (See Section 906 fordetails). All care provided at these locations by staff employed by anRHC are considered RHC “core” services and are all reimbursed on anall-inclusive Prospective Payment System reimbursement rate per visitbased on the PPS rate assigned to the specific clinic. (See Chapter 1000for more details). Refer to the NCCI guidelines on billing for servicesrendered in a hospital setting. An RHC visit is defined in Appendix C.Rev. 04/03Rev 7/04Rev 01/09901.4 Other Ambulatory ServicesIn addition to “core” services, an RHC provider may provide otherambulatory services as defined in Section 904 of this manual. Theseservices are billed separately by category of service under a separateprovider number. Certain procedure codes of these services listed inAppendix F are reimbursable at all inclusive PPS rate per visit.902. Coding of ClaimsThe claim forms required by the Department for billing Rural HealthClinic (Facility-Based and Free-Standing) services are the NationalUniform Billing form (UB-04) and the CMS-1500 form respectively. SeeAppendix F of this manual for the required information to file both claimforms for RHC services.Provider coding of both diagnosis and procedures is required for allclaims. The coding schemes acceptable by the Department are theICD-9-CM (International Classification of Diseases - 9th Edition - ClinicalModification) for diagnosis and the CPT (Current Procedural Terminology- 4th Edition) for procedures. Copies of the CPT and ICD-9-CM codebooks are available for purchase from the following organizations:CPT-4 and ICD-9-CMAmerican Medical AssociationOrder DepartmentP. O. Box 7046Dover, DE 19903-7046Or call: 1 (800) 621-8335Certain codes from these coding schemes are not accepted by theDepartment and certain modifications to the CPT coding scheme have beenmade. These are discussed in the following sections.January 2012 Rural Health Clinic Services IX-3
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Page 4 and 5: Rev. 01/09APPENDIX AAPPENDIX BAPPEN
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Page 10 and 11: PART II - CHAPTER 800PRIOR APPROVAL
Page 14 and 15: 902.1 ICD-9-CMCodes deleted from pr
Page 16 and 17: 903.3 Laboratory ServicesRev 01/09R
Page 18 and 19: COS 600 ID. The procedure codes for
Page 20 and 21: 904 Other Ambulatory Clinics Servic
Page 22 and 23: 4. ResidentialRev 01/09Clinics may
Page 24 and 25: 1001. Reimbursement MethodologyPART
Page 26 and 27: health clinics, and the UB-04 claim
Page 28 and 29: APPENDIX BSTATEMENT OF PARTICIPATIO
Page 30 and 31: Rev 01/09Rev 01/09Rev 01/09Example
Page 32 and 33: APPENDIX EBILLING INSTRUCTIONS AND
Page 34 and 35: PLACE OF SERVICE CODES11 - Office12
Page 36 and 37: Completion of the Health Insurance
Page 38 and 39: OrEnter the Prior Authorization Num
Page 40 and 41: enter the date.Unsigned invoice for
Page 42 and 43: Completion of the National Uniform
Page 44 and 45: FL 42FL 43FL 44FL 46FL 47Revenue Co
Page 46 and 47: FL 68thru 75Codes prefixed in „E
Page 48 and 49: Established Patient 99391 - 99395Ne
Page 50 and 51: APPENDIX HVACCINE FOR CHILDREN PROG
Page 52 and 53: (5) A request for review of a chang

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