part ii policies and procedures for rural health clinic services

906. Alternate Places of ServiceRural health clinic services are reimbursable when furnished to a patient at theclinic, hospital, other medical facility, or at the member‟s home. The followingrestrictions apply to alternate place(s) of service.1. HospitalsIn order for the RHC per visit rate to be paid as a PPS visit, one of theCPT procedure codes listed in Appendix F must be recorded on a claim. Ifa procedure is also billed in conjunction with the E/M or PPS visit code,NCCI guidelines will apply. Based on NCCI Coding Manual and CPTguidelines, some services/procedures performed in conjunction with anE/M code will bundle into the procedure when performed by samephysician and separate reimbursement should not be allowed if the solepurpose for the visit was to perform the procedures.Services may be provided on either an outpatient or inpatient basis andmay be rendered by an RHC physician or physician extender.Preadmission certification is required according to procedures outlined inSection 803 of this manual.2. Nursing HomesClinics may be reimbursed for services rendered in nursing homes when suchservices are included in the procedure codes listed in Appendix F and renderedby a RHC physician. Such primary care services must be prescribed by theattending and prescribing physician managing the member‟s tertiary care at thenursing home. If the clinic staff physician is also the attending and prescribingphysician at the nursing home, the member‟s primary care should be renderedwithin the scope of the physician‟s individual practice. Prescribed visits madeby physician assistants, nurse practitioners, and nurse midwives are notreimbursable for nursing home services.3. Other ClinicsThere are no primary care delivery restrictions on the provision of services at aclinic other than those of the managing clinic facility if the member andmanaging clinic facility agree to the services for reasons of their own.January 2012 Rural Health Clinic Services IX-11