part ii policies and procedures for rural health clinic services

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903.3 Laboratory ServicesRev 01/09Rev 01/09(A) Laboratory procedures are defined and listed in the CPT and fallwithin the procedure code range of 80002 through 89399. Laboratoryservices furnished by RHC staff are not separately reimbursable but mustbe listed on the claim form in conjunction with an RHC visit. Clinicsreferring members to laboratory facilities independent of the clinic maynot bill the Department for such services. Laboratory services completedindependent of the clinic must be billed by the laboratory facility thatcompletes them.Clinics collecting specimens and forwarding them to an independent orpublic health laboratory may not bill for the collection and handling, normay clinics bill for the test procedure.With the appropriate CLIA certification, the clinic must provide to allRHC members any laboratory procedure that falls within the aboveprocedure code range that the RHC is capable of providing and which isavailable at the clinic to its private paying patients.There are six of the above wide ranges of laboratory services that aremandatory for RHC provider status. They are essential to immediatediagnosis and treatment and are as follows:1. chemical examination of urine, by stick or tablet method or both(including urine ketones)2. hemoglobin or hematocrit3. blood sugar4. examination of stool specimens for occult blood5. pregnancy tests (only by visual comparison method) and6. primary culturing for transmittal to a certified laboratory.Note:To perform gram stains, microscopic examination of urinesediments or tests for pinworm, the clinic is required to have theappropriate CLIA certification.Laboratory procedures required to be sent to the state laboratories, arenot separately reimbursable and must be performed by the statelaboratories.January 2012 Rural Health Clinic Services IX-6
e/09903.4 Obstetrical ServicesRural Health Clinics may be reimbursed for antepartum and postpartumservices if and when these services are available at the clinic. Theappropriate CPT codes must be used on the claim form if antepartum andpostpartum care services are provided by the RHC for which they will bereimbursed at the PPS rate for the RHC per visit. (Refer to Appendix F ofthis manual for the valid CPT codes)The delivery however, is not considered an RHC “core” service. Thephysician or nurse-midwife managing and providing the delivery servicemust bill the Department directly for that service only; using his/herindividual provider number and the RHC TIN. The RHC will bereimbursed at the Fee for Service rate for the applicable delivery only CPTcode. Global OB codes should not be billed by the RHC.It is strongly suggested by the American Academy of Pediatrics (AAP) andthe American College of Obstetricians and Gynecologists (ACOG) that allpregnant women receive HIV education and counseling as part of theirregular prenatal care. HIV testing of consenting pregnant women is alsorecommended in light of the availability of treatment that significantlyreduces HIV transmission from mother to infant, and protects the health ofthe newborn.The Centers for Disease Control (CDC) has further stated that knowledgeof HIV infection during pregnancy can permit treatment before the onsetof opportunistic infections and disease progression, as well as earlyidentification and treatment of HIV-exposed infants.903.5 Pediatric Preventive Health Screening/Newborn MetabolicScreening ProcedureRev 01/0902/0902/09Preventive health screenings performed on eligible children after theinitial newborn examination are governed by the policies and proceduresspecific to the Health Check Program and billing is according to thePolicies and Procedures specific to the Health Check Program. However,Health Check visits are reimbursable at the PPS rate to those clinics thatare enrolled as Health Check screening providers. RHC`s may enroll inthe Health Check Program by contacting the Department‟s ProviderEnrollment Unit. If a practitioner is a RHC employee or contractor, he orshe does not need to enroll into Health Check Program (COS 600).Health Check services should be billed and reimbursed under the RHCJanuary 2012 Rural Health Clinic Services IX-7
Page 2 and 3: PART II - POLICIES AND PROCEDURESFO
Page 4 and 5: Rev. 01/09APPENDIX AAPPENDIX BAPPEN
Page 6: . 01/09Rev. 01/09Rev. 01/09Rev. 07/
Page 10 and 11: PART II - CHAPTER 800PRIOR APPROVAL
Page 12 and 13: Rev 01/09Payments specified as the
Page 14 and 15: 902.1 ICD-9-CMCodes deleted from pr
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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