Just-In Preventive Service Fee Waivers for Medicare Patients

If you code for a rural health clinic (RHC), be extra careful in assuring proper reimbursement for Medicare preventive services. The CMS has identified a claims processing issue that impacts rural health clinics (RHCs) submitting claims for preventive health care services on or after January 1 this year.

PPACA waives the coinsurance and deductible for the initial preventive physical examination (IPPE), the Annual Wellness Visit (AWV), and other Medicare-covered preventive services recommended by the US Preventive Services Task Force (USPSTF) with a grade of “A" or “B," with effect from January 1, 2011. However, Medicare contractors will not implement the system changes required to correctly process claims for these RHC services until April 4 this year.

According to a National Institutes of Health (NIH) listserv and the Rural Health Clinics Center on the CMS website, as additional revenue lines are not payable separately, contractors have been instructed to move the associated charges to the non-covered field and to override reason code 31577. This'll allow claims to continue processing and not delay payments.

Providers who submit claims between January 1, 2011 and April 3, 2011 shouldn't resubmit affected claims.

You do not need to resubmit as the contractors will mass adjust the claims in any case. Resubmission would be unnecessary work on the RHC's part.

Process: In order to ensure the charges are reflected as covered, contractors will mass adjust the affected claims within 30 days post the claims processing instruction in Transmittal 2122, Change Request (CR) 7208 are implemented on April 4 this year. Comprehensive HCPCS Level II coding is required; but in order to ensure that coinsurance and deductibles aren't applied to these preventive services when submitted by RHCs on a 71X type of claim with dates of service on or after January 1, 2011.

When the physician provides one more preventive services that meets the specified criteria (say for instance a USPSTF grade A or B) as part of an RHC visit, charges for these services must be deducted from the total charge for purposes of calculating beneficiary copayments and deductibles. For instance, if the total charge for the visit is $150, and $50 of that is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the total charge. If no other RHC service takes place along with the preventive service, no copayment or deductible apply.

Information: Take a look at Transmittal 2122 for the official instruction. Attachment A covers a list of CPT codes that are termed as preventive services under Medicare as well as Level II HCPCS codes for the IPPE and AWV. One can even visit the RHC Center on CMS's Website.