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Monday, 8 August 2016
Important RHC and FQHC Billing Change
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Effective October 1, 2016, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are permitted to bill for nursing visits, provided certain criteria are met.  Section 1861(aa)(1)(C) of the Social Security Act authorizes RHCs and FQHCs located in areas with a shortage of home health agencies to furnish part-time or intermittent nursing care and related medical supplies (other than drugs and biologicals) by a Registered Professional Nurse (RN) or Licensed Practical Nurse (LPN) to a homebound individual under a written plan of treatment.

Definitions:

The patient is considered homebound as defined at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf.

An area with a shortage of home health agencies exists if the RHC or FQHC is located in a county, parish or similar geographic area in which the Secretary has determined that:

  • There is no participating HHA under Medicare, or adequate home health services are not available to RHC or FQHC patients even though a participating HHA is in the area; or
  • There are patients whose homes are not within the area serviced by a participating HHA; or considering the area's climate and terrain, whose homes are not within a reasonable traveling distance to a participating HHA.

If your RHC or FQHC is located in an area that has not been determined to have a HHA shortage, you must make a written request to the CMS RO along with justification that the area you serve meets the required conditions in order to seek reimbursement for visiting nurse services.

Billing:

The current evaluation and management codes for home health visits are not billable by RNs or LPNs furnishing RHC or FQHC home health visits. However, effective October 1, 2016, Healthcare Common Procedure Coding System (HCPCS) code G0490 has been added as a stand-alone billable visit for RHCs and FQHCs.  For dates of service on or after October 1, 2016, HCPCS code G0490 will be paid as a visit: 

  • Under the RHC all-inclusive rate payment system when reported on a RHC claim with revenue code 052X and modifier CG,' or
  • Under the FQHC Prospective Payment System when reported on a FQHC claim with revenue code 052X and HCPCS code G0466 or G0467.

Links:

https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html

https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf

Unfortunately, lack of proper medical care is a common problem among the elderly.  This could be due to a number of factors, including lack of transportation, physical limitations, or a shortage of home health services in the patient's area.  Each of these barriers could be mitigated with this change, which would allow more patients to receive the care they need and deserve.

If you have questions or need further information, feel free to contact Bill Matheney (bmatheney@matheneystees.com), Martha Calfee (mcalfee@matheneystees.com), or Meredith Cate (mcate@matheneystees.com).  You may also reach us by phone at 800-556-1076.

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Posted on 08/08/2016 1:42 PM by Meredith P. Cate
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