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Rural Health Clinics Center

Spotlights
  • RHC Preventive Services

    RHCs are paid an all-inclusive rate (AIR) per visit for qualified primary and preventive health services. Except for IPPE, all preventive services furnished on the same day as another medical visit constitute a single billable visit.  If an IPPE visit occurs on the same day as another billable visit, two visits may be billed.  Except for DSMT/MNT, all of the preventive services listed below may be billed as a stand-alone visit if no other service is furnished on the same day.

    Additional information on payment and claims processing for RHC preventive services is available in the Medicare Claims Processing Manual, Pub 100-04, Chapters 9 and 18.  Additional information on RHC policy for preventive services is available in the Medicare Benefit Policy Manual, Pub 100-02, Chapter 13. These manuals are available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

    The chart below lists preventive services with their associated HCPCS code and descriptor, whether they are eligible to be paid based on the RHC’s AIR when billed without another covered visit, which preventive services can be billed separately when another visit is billed on the same day, and which preventive services have the co-insurance and deductible waived.

    Service

    HCPCS Code

    Long Descriptor

    Paid at the AIR

    Eligible for Same Day Billing

    Coinsurance/Deductible

    CMS Pub 100-04

    Initial Preventive Physical Examination (IPPE)

    G0402

    Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment

    Yes

    Yes

    Waived

    Ch 9 §150

    Ch 18 §80

    Diabetes Self-Management Training (DSMT)

    G0108

    Diabetes outpatient self-management training services, individual, per 30 minutes

    No

    No

    Not Waived

    Ch 9 §181

    Ch 18 §120

    Medical Nutrition Therapy (MNT)

    97802

    Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes

    No

    No

    Waived

    Ch 9 §182

    97803

    Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

    No

    No

    Waived

    G0270

    Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes

    No

    No

    Waived

    Annual Wellness Visit

    G0438

    Annual wellness visit, including PPPS, first visit

    Yes

    No

    Waived

    Ch 18 §140

    G0439

    Annual wellness visit, including PPPS, subsequent visit

    Yes

    No

    Waived

    Screening Pelvic Exam

    G0101

    Cervical or vaginal cancer screening; pelvic and clinical breast examination

    Yes

    No

    Waived

    Ch 18 §40

    Prostate Cancer Screening

    G0102

    Prostate cancer screening; digital rectal examination

    Yes

    No

    Not Waived

    Ch 18 §50

    Glaucoma Screening

    G0117

    Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist

    Yes

    No

    Not Waived

    Ch 18 §70

    G0118

    Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

    Yes

    No

    Not Waived

    Sample Billing for Screening Pelvic and Clinical Breast Examination (HCPCS Code G0101)

    Until further notice, claims for which G0101 is the only service furnished shall be paid based on a RHC’s AIR when submitted as shown in the following example on a 71X TOB with revenue code 052X:

    42 Rev Code 44 HCPCS/RATES 45 SERV DATE 46 SERV UNITS 47 Total Charges
    0521 Blank or Valid HCPCS code 10/01 1 $00.01
    0521 G0101 10/01 1 $XX.XX

 (Updated 9/10/14)

  • The Medicare Benefit Policy Manual, Chapter 13 - Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) has been updated to include new information on Transitional Care Management, Hospice payment exceptions, and RHC employment, and provides clarification of existing information and is effective January 1, 2014.
  • Vaccination is the Best Protection Against the Flu [PDF, 414KB]
  • SE1039Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide
  • Medicare Rural Health Clinics Waiver of Coinsurance and Deductible Claim Processing Issue:  The Centers for Medicare & Medicaid Services (CMS) has identified an issue when Healthcare Common Procedure Coding System (HCPCS) codes are reported for preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B on Rural Health Clinic claims (71X) for dates of service on or after January 1, 2011. Since the additional revenue line(s) are not separately payable, the contractors have been instructed to move the charges associated with these revenue lines to the non covered field and to override reason code 31577. This will allow the claim to continue processing and not delay payments. After the changes for CR 7208, transmittal 2122, are implemented on April 4, 2011, contractors will mass adjust these claims to ensure the charges are reflected as covered. Providers should not attempt to resubmit affected claims as their FI or MAC will be initiating adjustments for the sole purpose of correcting the charges. Providers should anticipate the initiation of these adjustments within 30 calendar days after the implementation of CR 7208.

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