Rural Health Clinic Billing and Reimbursement

RHCs are paid on the basis of an encounter. An encounter is defined as “a face-to-face encounter between the patient and a practitioner (physician, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, clinical psychologist or clinical social worker) during which an RHC service is rendered. 

Encounters with more than one practitioner and multiple encounters with the same practitioner, which take place on the same day and at a single location, constitute a single visit. An exception would be when a patient, who was already seen in the RHC, suffers an illness or injury later that same day requiring additional diagnosis or treatment. In that instance, multiple visits may be billed.

For Dates of Service on or After April 1, 2016

All charges for a visit must be reported on the service line with the qualifying visit HCPCS code, minus any charges for preventive services using revenue code 052x for medical services and/or revenue code 0900 for mental health services. RHCs are allowed to report additional 052x or 0900 revenue code lines 

All other services furnished during the encounter are also reported with the charge associated. Payment for these lines is included in the AIR.

Beginning October 1, 2016, the Medicare Administrative Contractors will accept modifier CG (policy criteria applied) on RHC claims and adjustments. RHCs report modifier CG on one revenue code 052x and/or 0900 service line, which includes all charges subject to coinsurance and deductible for the visit. 

Modifier CG should only be used to indicate which revenue code 052x and/or 0900 service line should receive the AIR, and be subject to coinsurance and deductible. 

Preventive Services

If an approved preventive service is furnished with a medical visit, report the preventive service on another 052X revenue code line with the associated charges. 

The qualifying medical visit line should include the total charge for the visit minus the charge for the approved preventive services; payment and coinsurance is based on this line.

References

• Centers for Medicare & Medicaid Services Internet Only Manual, Publication 100-04, Claims Processing Manual, Chapter 9
• MLN Matters® Article, MM9269 - Required Billing Updates for Rural Health Clinics
• RHC Qualifying Visit List
• RHC Reporting Requirement - Modifier CG