IME Responses to Medicaid Questions

SUBJECT:
FROM:
TO:
CC:
SENT:
EXPIRES:
Reply
FW: RHC ?s
[email protected]
[email protected]
[email protected]
Mon 21 Apr 2014 18:45:42 CDT
Wed 21 May 2014 18:45:42 CDT
Reply to All
Janet,
I have been asked to respond to the 2 questions in your e-mail below, which I've pasted in immediately below for
convenience. At the outset, my apologies for the delay in getting back to you, which is on me.
1. When a Medicaid patient (either managed care medicaid, hawk-i or regular medicaid) patients are in the RHC,
does it require that the patient see a "provider" in order to have a billable visit? In the past, RHCs were told that
if a medicaid patient came in for a flu shot or any injectable, that would be considered a visit and billable as such
even if it was the nurse that had performed the injection only. Can you please also give me where I can find this
information as many RHCs want to "see it in writing" so they have on file.
IME Response:
Iowa Medicaid does not have a rule that specifies which practitioner(s) in an RHC must render services or
specifies the nature of the service in order for such to be considered a "billable encounter". Given the absence of
such specific policy, Iowa Medicaid follows Medicare. This is specified under 441 Iowa Administrative Code
79.9(1) that states the following: "Medicare definitions and policies shall apply to services provided unless
specifically defined differently." The Medicare Claims Processing Manual Chapter 9 - Rural Health
Clinics/Federally Qualified Health Centers, Section 20.1 - Payment Rate for Independent and Provider Based
RHCs and FQHCs (page 5): "The term 'visit' is defined as a face-to-face encounter between the patient and a
physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, clinical psychologist, or clinical
social worker during which an RHC/FQHC service is rendered."
Therefore, to answer the first part of your question... yes, in order for an RHC to bill Iowa Medicaid for an
encounter, the Medicaid patient must see a provider, as defined in the above excerpt from the Medicare Claims
Processing Manual (i.e., physician, physician assistant, nurse practitioner, nurse midwife, visiting nurse, clinical
psychologist, or clinical social worker). An RHC may not bill an encounter if the Medicaid patient is only seen by
a nurse and to only receive an injection, where there was not also a face-to-face encounter with one of the
provider types listed above. This was clarified in August, 2013, at which time it was noted that there was prior
incorrect communication to the contrary in 2011.
2. RHCs were given a "draft" that listed the places of services for an RHC to bill for Medicaid encounters through
the RHC provider number. I have the sheet attached. And then in July 2013, I received an email from you that
stated that those were indeed "places of service" that RHCs could bill encounters for as an RHC encounter. I also
have the email conversations attached. If this is the regulation that these are valid "places of service" could you
either send me that verification of the regulation or give me a link on where I can obtain it. I have many clinics
that want to "see it in writing" that this is the case.
IME Response: The valid places of service (POSs) where an RHC practitioner renders services and for which an
RHC can bill a valid encounter are listed in first attached document. For convenience, those valid POSs are the
following:
* Office (POS 11)
* Patient's home (POS 12)
* Inpatient hospital (POS 21)
* Outpatient hospital (POS 22)
* Hospital emergency room (POS 23)
* Ambulatory surgery center (POS 24)
* Skilled nursing facility (POS 31)
* Nursing home (POS 32)
* Rural health clinic (POS 72)
As to the second part of your question, Iowa Medicaid rules under Iowa Administrative Code (IAC) chapters 78
or 79 do not specifically list these valid POSs for RCHs, or the limitations pertaining thereto. That
notwithstanding, you can consider the foregoing list as "verification" from IME Policy that these are indeed valid
POSs for RHCs. As reflected in the first attachment, the following limitations would apply in determining
whether an RHC can bill an encounter in POSs other than the RHC (which is also per IME Policy guidance, not
reflected in rules):
o Two key questions to determine whether services rendered in a setting other than the FQHC/RHC are billable
by the FQHC/RHC (see POS listing below):
1. Does the FQHC/RHC compensate the physician for the service being rendered?
a. If yes, then the service can be billed by the FQHC/RHC as an FQHC/RHC service, using the T1015 encounter
code.
b. If not, then the service should not be billed as an FQHC/RHC service by the FQHC/RHC. In this case, the
claim should be billed under the rendering physician's NPI/taxonomy.
2. Is the service being rendered/billed one that is otherwise normally rendered at the FQHC/RHC or one that
could be rendered at the FQHC/RHC?
a. If yes, then the service can be billed by the FQHC/RHC as an FQHC/RHC service, using the T1015 encounter
code.
b. If not, then the service should not be billed as an FQHC/RHC service by the FQHC/RHC. In this case, the
claim should be billed under the rendering physician's NPI/taxonomy.
Hope this is helpful.
Marty
Marty Swartz
Medicaid Policy Specialist/Program Manager
Iowa Department of Human Services
Iowa Medicaid Enterprise - Bureau of Adult and Children's Medical Services
100 Army Post Road
Des Moines, Iowa 50315
phone: 515-256-4651
fax: 515-725-1360
e-mail: [email protected]<mailto:[email protected]>

Download Report