Watchfulness is the Key to Proper Reimbursements

The CMS has identified a claims processing issue that impacts rural health clinics (RHCs) submitting claims for preventive health care services on or post January 1, 2011. Watchfulness will help you assure rightful reimbursement if your practice is an RHC.

PPACA of 2010 waive 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," starting from January 1 this year. But then Medicare contractors will not implement the systems changes required to process claims correctly for these RHC services until April 4 this year.

Since additional revenue lines are not separately payable, contractors have been taught to move the associated charges to the non-covered field and to override reason code 31577 more than one unit is reported with revenue code 052X. This will allow claims to continue processing and not holdup payments.

Providers who submit claims between January 1 and April 3, 2011 should not resubmit affected claims. You do not need to resubmit since the contractors will mass adjust the claims in any case. Resubmission would be unnecessary work on the part of RHC.

Process: To make certain the charges are shown as covered, contractors will mass adjust the affected claims within 30 days post the claims processing instructions in Transmittal 2122, Change Request (CR) 7208, are implemented April 4, 2011. Detailed HCPCS Level II coding is called for; but then to ensure that coinsurance and deductibles are not applied to these preventive services when submitted by RHCs on a 71X type of claim with DOS on or post January 1 this year.

When the doctor provides one or more preventive service that meets the specified criteria as part of an RHC visit, charges for these services must be subtracted from the total charge for purposes of calculating beneficiary copayments and deductibles. For instance, if the total charge for the visit is $150, of which $50 is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the entire charge. If no other rural health clinics service takes place along with the preventive service, no copayment or deductible applies.