Industry Insights

CMS Releases Updated RHC ‘Qualifying Visit’ List

April 2016
Author:  Marla Dumm

Marla Dumm

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

Rural health clinics (RHC) are now facing the challenge of new UB-04 claims processing requirements specific to primary Medicare encounter services. The Centers for Medicare & Medicaid Services (CMS) expects to see service detail on the UB-04 claim form with the appropriate Healthcare Common Procedure Coding System (HCPCS) code listed for each service furnished during the encounter.

A “qualifying visit” code typically has been defined as a medical evaluation and management service, mental health service or covered Medicare preventive service (IPPE, AWV or G0101) tied to revenue codes 052x or 0900 to prompt the all-inclusive rate (AIR) payment. The original draft of the new CMS detailed billing instructions omitted HCPCS codes for procedural services (CPT code ranges 1XXXXX - 6XXXXX) from the list of qualifying visits. Under these instructions, a “procedure-only,” face-to-face encounter with the physician or nonphysician practitioner wouldn’t have prompted encounter payment; instead, it would’ve had to be captured as an allowable cost at the end of the year. This lack of AIR reimbursement for procedure-only encounters could have resulted in significant lost revenue for many RHCs.

In response to the first draft of CMS billing instructions, the National Association of Rural Health Clinics, National Rural Health Association and various state hospital associations requested that CMS reconsider the issue. On March 24, 2016, CMS released an updated list of qualifying visit HCPCS codes, which included “additional medically necessary billable visits, effective April 1, 2016, but not payable until October 1, 2016, when RHCs can bill these claims for payment.” Under the updated instructions that became effective April 1, 2016, if one of the HCPCS codes on the qualifying visit list is performed solely on a date of service, the claim can be processed for AIR payment. CMS has recommended that all RHCs hold procedure-only claims until October 1, 2016, to allow time to update their internal claims processing systems.

The updated qualifying visit list isn’t all-inclusive and leaves out some common procedures provided in the RHC setting. However, CMS has indicated it will update the list as appropriate on a quarterly basis.

If you have questions or need assistance transitioning to the new detailed billing requirements, contact your BKD advisor.

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