Q&A: Rural health clinic HCPCS billing

April 5, 2016
Medicare Web

Q: Rural health clinics (RHC) have to start to bill all services on individual lines with HCPCS codes and charges. Is there a way to report these services on a separate line without the appearance of inflating our charges?

A: As of April 1, RHCs must report HCPCS codes and charges for all services on separate lines outside of the qualifying visit line. The visit line will already include all of the charges for the services provided during the visit (i.e., E/M, injection, medication) except for those preventive services that already must be billed separately. During a recent Rural Health Open Door Forum call, many providers voiced similar concerns that it may appear to the patient that the RHC is overcharging or double-billing. In addition, this will cause major accounting problems for any RHC when balancing claims and revenue, as well as what will look like write-offs even though the RHC was already paid in the AIR. The CMS representative on the call said that asking providers to report HCPCS codes on individual lines with a separate charge was not a new concept and referenced other payment systems. That statement is only partially true. In most cases when CMS requires this type of reporting, the billed amount for the individual line can be reported as $1 or less to prevent that line from being included as part of a payment calculation and to bypass any system edits where billed charges cannot be equal to $0.00. 

Although an MLN Matters Article 9269 uses the actual charge for the additional lines in the examples, CMS has since confirmed in a recent presentation that an RHC can bill any amount ≥ $0.01 for the additional lines separate from the qualifying visit line. This makes the most sense for all involved because the new charge reporting structure could be driven through a chargemaster or charge code process which would simplify the process. In addition, the charges would not appear to be inflated to the patients. In looking ahead, I hope that CMS clarifies this point either in their Frequently Asked Question document that is supposed to be published soon on the CMS RHC website or consider a revision to the examples in MLN Matters Article 9269 using the $0.01 charge as reporting option. RHCs should also carefully review One Time Notification Transmittal 1596 and the most recent RHC Qualifying Visit List on the CMS Rural Health Clinics Center.

Debbie Mackaman, RHIA, CPCO, CCDS, an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and lead instructor for the Critical Access Hospital Version and Rural Health Clinic Version, answered this question. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.