May 23, 2017
NARHC Addresses Senate Press Conference
WASHINGTON, D.C.–The National Association of Rural Health Clinics (NARHC) was invited to speak at a Senate press conference on rural health hosted by Senator Martin Heinrich (D-NM). NARHC President John Gill stressed the important role Medicaid plays in allowing RHCs to provide care in rural communities. John emphasized that the average RHC sees a much greater percentage of Medicaid patients than the average fee-for-service clinic and therefore RHCs are particularly concerned about any potential cuts or changes to the Medicaid program that could reduce Medicaid payments to RHCs. Senator Martin Heinrich (D-NM) opened the press conference and was followed by Senator Bob Casey (D-PA), Senator Tom Udall (D-NM), and Senator Al Franken (D-MN) who all made comments on health care reform and its imact on rural health.
From left to right Senator Tom Udall, Senator Martin Heinrich, NARHC President John Gill, Senator Al Franken and Dr. Robert Rosenberg speak at a Senate Rural Health Press Conference.
April 26, 2017
Raising the RHC Cap?
A question was posed about the prospects for raising the RHC cap and when this might occur. Raising the RHC cap requires an Act of Congress as the cap is set by law. The current cap is an extension of the RHC cap established in 1988 ($46.00 per visit) adjusted for medical inflation over the intervening 29 years. Obviously it is very out-of-date.
We do not anticipate that Congress will begin to look at Medicare reforms until the Fall at the earliest. We anticipate that much of the Congressional Calendar over the next few months will be devoted to efforts aimed at repealing/replacing the Affordable Care Act and tax reform.
We believe there is strong bi-partisan support in Congress for raising the RHC cap; however, that optimism is tempered by the realization that to do so would result in a significant increase in Medicare expenditures. Under current rules, any change in the Medicare law that results in higher expenditures must typically be offset by savings elsewhere in the Medicare program. So the challenge in raising the RHC cap is not convincing Members of Congress of the need to raise the Cap, it is identifying cuts in the Medicare program that would offset the higher expenditures associated with raising the cap.
Let’s presume that Congress agreed to raise the RHC Medicare cap to $110 per visit as proposed by the Senate Rural Caucus (a bi-partisan coalition of Senators representing largely rural states). Estimates are that this would increase total Medicare spending on RHCs by approximately $150 Million per year or more than $1.5 Billion over ten years. This means that concurrent with raising the cap, Congress would have to cut $150 Million per year or more than $1.5 Billion over 10 years somewhere else in the Medicare program. Finding spending cuts of that magnitude – while not impossible – would be a challenge.
Now, as large as that number – $150 Million – seems to most of us, it is also important to point out that Medicare spending on RHCs constitute less than 1% of Medicare spending. So $150 Million is – in budget terms – a rounding error in Medicare spending.
So I cannot say when the RHC cap might be raised by Congress. We’ve been pushing this for several years.
Finally, I would mention that the NARHC staff is also looking at options and ideas for improving the financial viability of RHCs subject to the cap. Some of these alternatives would not require a change in the RHC statute and could provide financial relief comparable to what would be accomplished by raising the RHC cap. We will have more on this as these ideas evolve. Hope this lengthy explanation is helpful in understanding the opportunity and challenge we face in raising the RHC cap.
April 18, 2017
Policy & Procedure Manual Template
Below are some options. I would strongly recommend that you use these as templates. Also, please note that the P/P manual in the “How To” publication is getting old and likely needs to be updated but it will still give you a sense of how you may want to proceed. It is extremely important that the P/P manual be a reflection of how YOUR RHC intends to practice and see/treat patients.
Keep in mind that the manual must also reflect the unique laws and regulations governing medical practices in your state. So a manual developed from one state may not cover of the things that would be necessary in your state due to practice nuances or state regulatory requirements (not necessarily RHC but general state medical/nursing laws) in your state.
Several RHC consultants have also developed RHC Policy and Procedures manuals that they sell or otherwise make available. You may want to consider contacting an RHC consultant if you don’t find that either of the documents linked below meet your needs. I would discourage use of a cookie cutter approach. That having been said, here are some options for you to consider:
RHC How To Manual produced by NARHC a few years ago. A sample P/P is included in this document.
And this from the Oregon Health Sciences University. Although specific to provider-based clinics, much of what is in this would be relevant to independent RHCs as well. Hope this helps.
March 27, 2017
Are Visits to an SNF by an RHC Provider an RHC visit?
Recently, an NARHC News listserve participant posted a question/concern regarding a comment she heard during a webinar conducted by the Medicare MAC – Noridian. The commenter stated that the representative from Noridian stated that visits to a SNF by an RHC provider were not RHC visits and should be billed on the 1500 claim form and not billed on the UB-04. If correct, this would constitute a significant change in CMS policy (as well as the Medicare statute).
NARHC contacted the Noridian representative to whom the above comments were attributed and sought clarification. Here is what we asked and the responses to our inquiry:
NARHC News Commenter stated:
“In that Webinar she stated that Providers that go to a SNF to render services are outside of the rural health clinic and should be billed as a non-RHC encounter and on a 1500 form. I asked again during the Q&A and she reiterated this as fact according to the IOM.”
In response, the Noridian representative said that she was specifically referencing a situation in which the RHC provider was NOT being compensated by the RHC during the time the visit occurred. Specifically:
If the RHC physician is not compensated for services provided in the SNF the physician may bill on the 1500 form.
We also sought additional clarification by writing: First, did you say that SNF visits were not billable as RHC visits on the UB-04 claim form and if so, why?
No RHC visits can take place in a SNF. I was listing non-RHC services which the IOM states that a NON-RHC service is a service where the RHC does not compensate a physician service (RHC Part One slide 64).
The Noridian answer is correct but it is important that you pick up the specific context. “… the RHC physician is not compensated for services provided in the SNF” by the RHC.
SNF visits by RHC providers are RHC visits and billable as an RHC encounter on the UB-04 Claim form. We hope this helps to clear up any misunderstanding and we appreciate that Noridian staff responded to our inquiry in an effort to ensure that there was no lingering confusion.
Updates from Cahaba on RHC Claims
Nov. 29, 2016
ALL RHC Medicare claims – whether “single line” or “multi-line” MUST have the CG modifier on the “pay” line. If a single line, the CG modifier goes on the single line with the HCPCS code for that RHC visit.
If multi-line, then the CG modifier goes on the line (typically the line that is the principle reason for the visit) on which you have rolled up all of the charges for the encounter. This lets CMS know that this is the line on which they should base the beneficiary co-insurance.
If you had claims rejected because the claim did not have the CG modifier, then you will need to re-file the claim. Here is a link to the instructions for re-filing a Cahaba claim: http://www.cahabagba.com/documents/2012/02/part-a-fiss_correct.pdf
CG Modifier & Cahaba
Nov. 23, 2016
As many of us know, beginning October 1, most RHC Medicare claims (with a few exceptions) were required to have modifier CG on the claim. While we (the NARHC) communicate billing updates through this listserv as soon as we learn about them, this is ultimately a responsibility of each MAC to communicate these updates to their jurisdiction.
NARHC staff has discovered that Cahaba did a very poor job of communicating the Oct. 1 CG changes to their providers. A significant number of RHCs in Cahaba’s jurisdiction were completely unaware of the CG modifier changes. Making matters worse, Cahaba’s customer service department was also not aware of these billing changes, even though their IT department had updated their system per the Oct. 1 guidelines.
As a result, RHCs that were oblivious to the CG modifier changes started calling Cahaba and inquiring why their claims were being denied. Unable to accurately diagnose the problem (that there was no CG modifier on the claims), Cahaba’s customer service department began telling people that it was a “system” problem on Cahaba’s end and that they were working on a fix.
NARHC staff has confirmed with CMS central staff that this is not a problem with the FISS or some other Cahaba system, but rather a severe lack of communication within Cahaba, and to Cahaba providers, around the CG modifier changes.
The good news is that CMS and Cahaba realize the true nature of the problem now, and we have been told that Cahaba is actively working on getting all their departments on the same page here. We have made it clear that Cahaba needs to detail specific instructions on how RHCs should refile the claims that were rejected for not following the CG rules. We anticipate that Cahaba will issue a correction soon that explains their oversight and properly educates their RHC providers on the CG changes.
NARHC Director of Government Affairs
Election First Take Analysis
November 10, 2016
The following is our quick analysis of the election for your reading pleasure. NARHC will also be creating a more RHC-centric analysis and sending that out sometime next week via List Serve.
Two days ago, Republican candidate Donald Trump was elected as the 45th President of the United States. Trump defeated his Democratic opponent, Hillary Clinton, despite an overwhelming sense by almost everyone going into Election Day that Clinton would win.
Trump’s 276 electoral votes, which is only six more than are required to win the election, does not speak for the decisiveness of his victory. Those who paid close attention to polling data and projections on reputable websites, such as 538 and Real Clear Politics, expected a very close race with Clinton edging out a win. Not only did Trump outperform projections in most of the up for grab “swing” states such as Pennsylvania, North Carolina and Florida, he was also able to win several states that historically vote Democrat that he was not expected to have a chance of winning. The most notable of these states include Wisconsin and Michigan.
Most pundits and pollsters dismissed the possibility of a “Trump effect” in which Trump outperformed polls due to the people being surveyed not wanting to go on record that they were supporting Trump. The Trump effect played a significant role in the primary elections. Trump had also narrowed a lead that Clinton held over the past two weeks. In fact, Trump was polling within the margin of error in many of the states he won.
This was, by any measure, a transformational election. It was an “insiders” vs. “outsiders” election more than a “liberals” v. “conservative” election at the Presidential level. It was also an economic election. Places like Pennsylvania, Ohio, Wisconsin and Michigan voted red. While the national economic numbers are improving, general confidence in the economy has yet to make a full recovery after the great recession. Many Americans felt that they have been passed over. This was middle class America’s “I will not be ignored” moment.
Looking down the ticket, the House of Representatives will remain in Republican control. This was always expected. The Senate will also remain in Republican control despite a much less certain outlook going into Election Day. However, Republicans will not have a “super majority” of 60 seats needed to override a Senate filibuster. The results of the House and Senate elections will be covered in greater detail later in this document.
But now the work begins.
It is worth noting that this will be the first time the GOP has controlled the House, Senate and White House since 1928 so this is something none of us have ever experienced. The Republicans will also now be able to nominate a ninth Supreme Court Justice, which could swing the political balance of the court towards conservative ideology.
The GOP victories down ticket (House and Senate) suggest that there are opportunities to get things done in the legislative arena that may not have been possible under divided government. We still have the filibuster in the Senate but it is possible that we will see, particularly in the first 100 days, legislation enacted that makes some significant changes in policy. The GOP had the odds against them relative to the number of seats they were defending relative to the Democrats. But those tables are turned in 2018 when more than 20 Democratic Senate seats will be up and only a handful of GOP seats. Trump is a negotiator, not an ideologue, so he will likely be open to deals that wouldn’t be possible under a more ideologically driven politician. Democrats up for re-election in 2018 may be inclined to “work with” the new President, particularly if they are in a “red” state.
With regards to health policy, this may result in some down-the-road changes to MACRA but the core will remain. MACRA enjoyed strong bi-partisan support and will likely continue to enjoy bi-partisan support. However, changes could be made that might have been unrealistic just a few weeks ago.
Additionally, key provisions of the Affordable Care Act (ACA) are in jeopardy (individual mandate, employer mandate). It may also accelerate Health Plan departure from the ACA Exchanges because they want more in the way of protections from risk and those are not likely to occur under a GOP Congress. Lack of a filibuster-proof Senate means a full repeal of the ACA is unlikely but dramatic changes will likely occur.
Trump and the GOP Congress can, despite the filibuster, use Budget Reconciliation – the same legislative process President Obama used to pass some of the key provisions of the ACA – to repeal and or replace key provisions of the ACA with only a simple majority. Some provisions of the ACA, such as protections for patients with preexisting conditions and allowing consumers to remain on their parent’s insurance plan until they are 26, remain popular and could exist in some form under a Republican alternative.
Reconciliation could also be the likely process for enacting a tax reform
Nov. 4, 2016
2017 Physician Fee Schedule Final Rule – RHC Provisions
While many of you were probably watching the Chicago Cubs win their first world series since 1908, we at the NARHC, were diligently reviewing the 2017 Physician Fee Schedule Final Rule for RHC related provisions.
These provisions are effective as of January 1, 2017. You can find the final rule here:
1-Supervision Requirement for RHCs Furnishing CCM Services (page 760-764)
CMS has finalized their change to the supervision requirement for CCM (Chronic Care Management) services furnished by RHCs. Effective January 1, 2017 RHCs may provide CCM and TCM services under the general supervision of a RHC practitioner.
2-Other CCM Changes (page 327)
There were numerous tweaks to the CCM scope of service. For those interested in the specific language of these changes, we have included a chart below which details the CY 2016 and CY 2017 scope of service requirements.
We should note that CMS is not allowing RHCs to bill for either one of the more complex CCM service CPT codes (99487 and 99489) or the separately billable CCM assessment and care planning code (G0506). NARHC will be reaching out to CMS to understand CMS’ rationale for prohibiting RHC CCM billing for the more complex CCM codes. Once we have a better understanding of their thinking, we will determine how best to respond to this restriction.
3-Diabetes Prevention Program (page 1074)
The Diabetes Prevention Program (DPP) is a new benefit that CMS is expanding to the entire Medicare program beginning in 2018. We requested that CMS design the benefit in such a way that RHCs could bill for DPP services on a UB-04 form and not have to carve out costs of furnishing DPP from their cost report (a system similar to the CCM benefit).
Unfortunately, while CMS acknowledges that RHCs may enroll as MDPP suppliers, CMS clarified that they do not believe DPP services qualify as an RHC service. As currently structured, RHCs that chose to furnish DPP services would have to carve out all costs related to furnishing DPP services. This is a policy that makes adoption of DPP services in rural and RHC settings unnecessarily difficult.
The NARHC will be advocating that CMS reconsider this structure as they refine the DPP benefit for 2018 implementation.
|CCM Scope of Service Requirements|
|CY 2016||CY 2017|
|Initiating Visit- Initiation during an AWV, IPPE, or face-to-face E/M visit for all patients (Level 4 or 5 visit not required).||Initiating Visit- Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required) for new patients or patients not seen within 1 year|
|Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.||Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications and medication allergies using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.|
|24/7 Access to Care- Access to care management services 24/7 (providing the beneficiary with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs regardless of the time of day or day of the week).||24/7 Access to Care- Provide 24/7 access to physicians or other qualified health professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week.|
|Continuity of Care- Continuity of care with a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments||Continuity of Care- Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.|
|Comprehensive Care Management– Care management for chronic conditions including systematic assessment of the beneficiary’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications.||Retained|
|Electronic Comprehensive Care Plan- Creation of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues||Retained|
|Electronic Sharing of Care Plan- Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (by fax in extenuating circumstance) as appropriate with other practitioners and providers.||Electronic Sharing of Care Plan- Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary’s care.|
|Beneficiary Receipt of Care Plan– Provide the beneficiary
with a written or electronic copy of the care plan.
|Beneficiary Receipt of Care Plan– A copy of the plan of care must be given to the patient or caregiver.|
|Documentation of care plan provision to beneficiary- Document provision of the care plan as required to the beneficiary using certified EHR technology||Removed|
|Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Format clinical summaries according to certified EHR technology (content standard).
-Not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (by fax in extenuating circumstance).
|Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers.
|Home- and Community-Based Care Coordination- Coordination with home and community based clinical service providers.||Retained|
|Documentation of Home- and Community-Based Care Coordination- Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record using certified EHR technology.||Documentation of Home- and Community-Based Care Coordination- Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record.|
|Enhanced Communication Opportunities-Enhanced opportunities for the beneficiary and any caregiver to
communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods.
|Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Document the beneficiary’s written consent and authorization using certified EHR technology
|Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month).
-Document in the beneficiary’s medical record that the required information was explained and whether the beneficiary accepted or declined the services.
NARHC, Director of Government Affairs
October 28, 2016
RHC Guide to the MACRA Final Rule
We understand that there are a lot of questions and interest around MACRA (Medicare Access and CHIP Reauthorization Act) especially around the specifics of how it does and does not affect RHCs. We have put together the following Q&A to address many of the relevant aspects of the final rule for RHCs.
It is important that we make a distinction at the outset between RHC claims – those submitted for RHC services using a UB-04 claim form and traditional Medicare Part B claims submitted by Physicians, PAs and NPs using an individual or group NPI using a 1500 claim form.
Q: Will my RHC All-Inclusive Rate be affected by the new Medicare Incentive Payment system (MIPS)?
A: No. The final rule states that because RHC services furnished by eligible clinicians (Physician, PAs and NPs) are not reimbursed under the Medicare PFS (Physician Fee Schedule), RHC services are not covered by the MIPS program. Reimbursement for RHC UB-04 claims will be unaffected by this new program. The RHC Cap will continue to adjust each year to reflect medical inflation and productivity improvements.
However, non-RHC claims submitted by RHC Physicians, PAs and NPs to Medicare Part B (i.e. items billed on a 1500-form) may be affected (see below).
Q: Will non-RHC services (billed on a 1500) using the individual/group NPI be affected by MACRA?
A: Potentially. We believe MOST RHC physicians, PAs and NPs will fall under a low-volume exemption threshold (see below), which will exempt these clinicians and their 1500 claims from MIPS reporting and payment adjustments.
Q: What is the low-volume threshold?
A: CMS has determined that Physicians, PAs and NPs who do not submit sufficient Medicare Physician Fee Schedule (1500) claims will be exempt from the MIPS program. These are classified as “low-volume” providers. A low-volume provider is defined as a Physician, PA or NP who, during the low-volume threshold period,
- Has billed Medicare Part B allowed charges of $30,000 or less during the billing cycle; OR
- Provided care to 100 or fewer Medicare Part B-enrolled beneficiaries during the billing cycle.
RHC claims are NOT counted when determining whether or not a clinician meets the threshold.
- What billing cycle will CMS use to do the claim or patient count?
CMS will review Physician, PA and NP Medicare Physician Fee Schedule billing for the 24 months preceding the reporting year broken into two, separate 12 month calculations or “billing years”. These will not be calendar years but rather so-called “billing year”. For 2017 (2019 payment adjustment year), the “billing year” reviewed by Medicare will be claims submitted between September 1, 2015 through August 31, 2016. CMS will conduct a second “billing year” calculation based on claims submitted between September 1, 2016 through August 31, 2017 to determine additional eligible clinicians and groups.
If the individual Physician, PA or NP claim submissions are $30,000 or less during EITHER of these billing years, the clinician will be considered exempt from MIPS for the associated Payment Adjustment Year. Each year after 2017, CMS will conduct a similar review with the older year dropping from the calculation and the most recent September – August “billing year” being added to the calculation. Again, as long as the Physician, PA or NP meet the low volume criteria during either of the two years, the clinician would be deemed MIPS exempt.
CMS will also use this same 24 month review method to do the patient count.
Q: How will Medicare know if an individual clinician provides care to fewer than 100 Part B-enrolled Medicare beneficiaries?
A: CMS will use social security numbers reported on 1500 claims to determine this part of the exclusion. This is a count of patients, not claims. For example, if an eligible clinician provides multiple services to one RHC beneficiary over the course of the “billing year”, this only counts as one Medicare enrolled beneficiary for purposes of the low-volume threshold.
Q: Will Clinicians have to apply for the low-volume exemption?
A: No. CMS says it set up the low-volume threshold determination period in such a way that will allow CMS to notify Physicians, PAs and NPs who qualify for the exemption during the month of December preceding the quality reporting year. CMS has not specified how notification will occur. We expect that CMS will issue guidance on this within the next few weeks.
Q: How is CMS identifying individuals versus groups for the purposes of the low-volume exclusion?
A: For individuals, the low volume threshold exclusion is determined by the Tax ID Number (TIN)/National Provider Identifier (NPI) combination. For groups, low volume exclusions are determined by simply the TIN. Individual eligible clinicians that are part of a group that chooses to report as a group, will be required to participate in MIPS if the entire group qualifies.
For example, if five RHC eligible clinicians are a part of the same group (TIN) and each eligible clinician bills $10,000 of allowable Medicare Part B charges, then that group has the option to report as a group and be subject to MIPS as a group (meaning they all get one group quality score) or to report as individual eligible clinicians and take the low-volume exemption.
In this example, if they report as a group with total Medicare allowable charges of $50,000, then their Part B claims are going to be required to report MIPS quality data to CMS and have their Part B (1500) claims subject to MIPS adjustments (positive or negative). However, if the clinicians report individually, $10,000 per, then all five would be exempt from quality reporting and exempt from MIPS adjustments (positive or negative) on their Medicare Part B claims.
Q: If an eligible clinician qualifies for the low-volume exclusion, can they chose to opt-in to MIPS and receive an adjustment?
A: No. Once it has been determined that for the reporting year a clinician or group is deemed “low-volume”, the clinician or group is ineligible to participate in MIPS for that reporting year.
Q: Can Rural Health Clinics voluntarily report MIPS data?
A: Yes RHCs may voluntarily report MIPS data and receive a MIPS CPS score. However, any MIPS data reported on RHC services would not be used for the purposes of the MIPS payment adjustment on non-RHC claims.
At some point Congress may propose to extend the MIPS program to RHCs and it would be helpful to know how RHCs would fair under the MIPS data reporting requirements.
Oct. 26, 2016
CMS has produced an FAQ document that addresses many of the questions/scenarios relative to the use of the CG modifier that have been raised on this listserve.
I strongly encourage you to review this document.
As will see when you review the document, there is an FAQ that addresses one of the scenarios you posed by Lori Donals:
- If a medical service and a preventive service are furnished on the same day, should modifier CG be reported with both services?
- No. Modifier CG should be reported only with the medical service HCPCS code that represents the primary reason for the medically necessary face-to-face visit when medical and preventive services are furnished on the same day.
To your specific examples.
Scenario One: It should be the line (CPT code) that was the primary medical reason for the visit. So if in the scenario you are using, the primary medical reason the patient came into the RHC was for skin lesion removal (CPT 17000) and you also performed the introductory to Medicare physical (G0402). The CG modifier goes on the line where you report the 17000.
In this specific situation, you would get two AIR payments. One for the medically necessary visit (17000) and one for the IPPE (G0402). The coinsurance would be applied to the lesion removal (medically necessary visit) and there would be no coinsurance for the IPPE (it’s waived for this service).
Scenario two: Again, the CG modifier goes on the line that is the primary reason the patient came into the RHC for a visit. Because both are preventive visits, there is no “medical” or “mental health” visit. So here, you get to choose. Did the patient come in for the IPPE (G0402) or the Well Woman exam (G0101) and you combined them into the same visit? Either way, you pick one that is “primary” and you put the CG modifier on that line.
Typically, only one line of the claim requires the CG modifier. The principle exception to this is if you provide BOTH a Medicare covered medical visit and a Medicare covered mental health visit to the same patient during the same visit, then both lines would have the CG modifier. This is typically going to be the only time you’d have the CG modifier on the claim more than one.
Hope this helps.
Oct. 1, 2016
Hopefully everyone is aware of the HCPCS reporting changes set to kick in next week. The best place to review those changes is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1611.pdf
We also wanted to clarify a few things regarding these changes.
- The CG modifier should be used even when the only service listed on the UB-04 claim is a preventive service.
- HCPCS codes G0436 and G0437 will be discontinued effective for dates of service after 10/1/2016. The proper codes for tobacco cessation counseling are 99406 and 99407.
- For purposes of RHC billing, modifiers 25 and 59 are interchangeable. We have confirmed this with CMS.
National Association of Rural Health Clinics
Sept. 1, 2016
2018 Essential Community Provider List & Petition
Under the Affordable Care Act (ACA), Qualified Health Plans (QHPs), are required to include essential community providers (ECPs) that serve predominantly low-income, medically-underserved individuals in their networks
Rural Health Clinics are eligible for designation as ECPs
As part of the Plan Approval process, the Secretary Health and Human Services (HHS) has established criteria mandating inclusion of a sufficient number and geographic distribution of ECPs in an issuer’s network to ensure reasonable and timely access to a broad range of such providers for low-income, medically-underserved individuals in their service areas.
To demonstrate satisfaction of the ECP requirement, Qualified Health Plans must submit a list of ECP’s in the Plan’s network with whom the Plan has contracted to provide health care services to low-income, m edically-underserved individuals in their service areas. Failure to meet the ECP criteria would be grounds for rejection of the Plan’s application.
The Department of Health and Human Services (HHS) has compiled a draft non-exhaustive list of available ECPs for plan year 2018. These providers submitted an ECP petition by July 11, 2016, and were approved by CMS through the ECP petition review process. Nearly 1,000 federally certified RHCs have already been approved by HHS as ECPs.
You can see if you are on the approved ECP list by going to the searchable database and searching for your clinic by name. If you are NOT on the list, you can petition to be an ECP by going to the ECP petition webpage. If you are on the list and there is an error you would like to correct, you can do so on the ECP Petition webpage.
The Draft HHS ECP list for the 2018 benefit year is also embedded within ECP petition and can be viewed by clicking the button “Check to see if you are on the list” under question 6 of the ECP petition webpage
CMS is accepting petitions from qualified providers until 11:59 p.m. ET on October 15, 2016, for data corrections and additions to be considered for the 2018 ECP List. RHCs who need technical assistance with the petition or may have general questions may receive assistance by emailing their question(s) to the following mailbox:
Providers should write “Comments on ECP Petition.” in the subject line of the email.
HCPCS Reporting Requirements Starting Oct. 1st
Oct. 1, 2016
CMS recently released a new MLN Matters article detailing the new HCPCS reporting requirements starting on October 1, 2016. The article can be accessed HERE.
As expected, we will no longer have to deal with a qualifying visit list. Instead, we will simply use the modifier “CG” to indicate to CMS which service line should be subject to coinsurance.
Director of Government Affairs
July 13, 2016
2017 Physician Fee Schedule Updates
On July 6th, the Centers for Medicare and Medicaid Services (CMS) released the 2017 Physician Fee Schedule (PFS) proposed rule. This is one of the major annual rules CMS uses to announce proposed changes to the Medicare program. Most notably for RHCs, this year’s PFS makes numerous changes to the RHC Chronic Care Management (CCM) requirements, including changing the supervision requirement that we believe are welcome and should make it easier to implement CCM services.
Proposed Changes to CCM Requirements for RHCs
The most significant change to the RHC CCM benefit is a change to the supervision requirement from direct to general supervision. The rule states:
To enable RHCs and FQHCs to effectively contract with third parties to furnish aspects of CCM and TCM services, we propose to revise §405.2413(a)(5) and §405.2415(a)(5) to state that services and supplies furnished incident to TCM and CCM services can be furnished under general supervision of a RHC or FQHC practitioner. The proposed exception to the direct supervision requirement would apply only to auxiliary personnel furnishing TCM or CCM incident to services, and would not apply to any other RHC or FQHC services. The proposed revisions for CCM and TCM services and supplies furnished by RHCs and FQHCs are consistent with §410.26(b)(5), which allows CCM and TCM services and supplies to be furnished by clinical staff under general supervision when billed under the PFS.
This proposed change to general supervision would allow CCM services to be furnished by auxiliary personnel without the RHC practitioner in the same building. As the paragraph above alludes to, such a change would allow RHCs to contract with CCM vendors in the same manner as traditional offices.
CMS also proposed a number of other revisions to the CCM benefit designed to reduce administrative burden and improve payment accuracy for CCM services. These proposed requirements include:
Initiating Visit – Changing the requirement that the CCM service be initiated during an AWV, IPPE or comprehensive E/M visit where CCM services were discussed for all patients to only new patients or patients not seen within one year.
Editor’s note: This seemingly would allow for patients that have been seen by the RHC within the past year to have their CCM services be initiated at any visit. We believe this was CMS’s intention with this proposed change but we will be asking for clarification.
24/7 Access to Care – Clarifying that the 24/7 access requirement to care means “access to a RHC practitioner or auxiliary staff with a means to make contact with a RHC practitioner to address urgent health care needs regardless of the time of day or day of week.”
Care Plan Availability – Require timely electronic sharing of care plan information, but not necessarily on a 24/7 basis (as it is now), and allow transmission of the care plan by fax.
Care Transitions – Replacing the requirement that clinical summaries must be formatted to certified EHR technology, with the less burdensome requirement that the RHC must “create, exchange, and transmit continuity of care document(s) in a timely manner with other practitioners and providers.”
To see a full list of the changes CMS is proposing, please see page 183 of the proposed rule and the ensuing chart on page 187.
Supervision Requirement for Transitional Care Management (TCM) services
You may have noticed above that CMS is also proposing to change the supervision requirement for TCM services. As a reminder, TCM services are billable only when furnished within 30 days of hospital, SNF, or mental health center discharge. Within 2 business days, communication must be made by with the patient (may be phone/electronic/direct) and within 14 days a face-to-face visit must occur (7 days for CPT 99496).
CMS is now proposing that the communication-within-two-days-of-discharge part of the TCM benefit may now be performed by auxiliary staff under general supervision. However, the face-to-face visit aspect (within 14 or 7 days) of the benefit would still be retained as is. A TCM service and a CCM service cannot be billed during the same time period for the same patient.
The NARHC will be commenting in general support of these proposals. If anyone wants to submit their own comments, you may submit comments on www.regulations.gov by September 6, 2016.
If anyone has comments or questions, please feel free to reach out to Bill and myself.
Director of Government Affairs
June 28, 2016
RHC Chronic Care Management Claims
If you have been experiencing problems with your RHC CCM claims being paid incorrectly, the corrective action to “fix” the CMS claims processing system is schedule to be installed on July 11th. CMS has released the following statement. Note that the MAC should automatically reprocess any CCM claims that were paid the incorrect amount and no refiling of the claims on the part of the RHC is required.
Chronic Care Management Payment Correction for RHCs and FQHCs:
Effective January 1, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) began receiving payment for Chronic Care Management (CCM) services. Payment should be calculated based on the Medicare Physician Fee Schedule national average non-facility payment rate. CMS is aware that RHCs and FQHCs have been receiving a locality adjusted payment rate for CCM services. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.
May 26, 2016
MACRA, MIPS, APMs, RHCs and You
Many of you may be aware that CMS recently published a proposed rule implementing a significant piece of legislation known as “MACRA”. This rule, once finalized, will significantly change the way physicians using the Medicare Physician Fee Schedule are reimbursed for Medicare services. Naturally, many people have asked: Does this affect RHCs? At least for the near-term, the answer is: mostly no.
However, this does not mean the RHC community should ignore this proposed rule. Some of the initiatives in it may very well make their way into the RHC payment methodology at some point in the future.
Merit-Based Incentive Payment System (MIPS)
Under MIPS The Merit-Based Incentive Payment System (MIPS) physicians, PAs and NPs billing Medicare using the Physician Fee Schedule will required to report various measures which will be used to determine end-of-year payment adjustments. Although RHCs are exempt from the reporting requirements, CMS has provided RHC eligible clinicians the opportunity to “voluntarily report on applicable measures and activities for MIPS.” RHC clinicians opting to voluntarily report will have no bearing on RHC payments.
MIPS combines three quality programs (PQRS, value modifier, and EHR Meaningful Use) into one. Eligible clinicians receive an overall score called the Composite Performance Score (CPS) which then dictates what kind of Medicare Physician Fee Schedule (PFS) payment adjustment that eligible clinician will get for the corresponding payment year. Roughly half of all clinicians will receive some upward adjustment and half will receive a downward adjustment.
Similar to PQRS, MIPS does not apply to RHC services, however non-RHC services such as labs or anything billed on a 1500 form could be subject to MIPS reporting and MIPS adjustments. Unlike PQRS, there is a low-volume exemption for individual providers who “have Medicare billing charges less than or equal to $10,000 worth of allowable claims AND provides care to fewer than 100 Part B-enrolled Medicare beneficiaries.” It is our estimation that full-time RHC practitioners would likely not bill $10,000 worth of non-RHC PFS services, but could feasibly see (as an individual) 100 Medicare patients. As such, we will be asking CMS to consider changing the low-volume exception in the final rule to: bill less than $10,000 worth of claims OR fewer than 100 Medicare patients.
For those who may be interested in learning more about how MIPS works, we would refer you to our summary of the program.
Alternative Payment Models (APMs)
The ultimate goal of these payment reforms is to “encourage” providers to participate in Alternative Payment Models (APMs). These models go beyond the MIPS quality scores by incorporating quality with shared financial risk to the providers. The hope is that these APMs will transition the healthcare system from paying for volume to paying for value. For over a year, we were unsure of exactly what qualified as an APM for the purposes of MACRA, but the proposed rule gives us the first details of how these models will be structured.
Clinicians can avoid MIPS negative payment adjustments if they are instead “qualified” by their participation in so-called “advanced APM models”. Clinicians qualify if a certain percent of their revenue comes from or a certain percent of their patients participate in an “advanced APM model”.
It is important to note that the term APM has been used to describe various different “models” but many of those “APMs” do not qualify as “advanced APM models” for the purposes of MACRA.
Providers that qualify because they reach the threshold of revenue-from patients-in an APM, are considered “Qualifying Participants” and will receive a lump sum incentive payment equivalent to 5% of their total Medicare reimbursement. Because RHCs are not reimbursed under the Physician Fee Schedule (PFS), RHC services would not be considered part of the amount upon which the APM incentive payment is based.
We should note that RHCs can participate in ACOs – a type of advanced APM model – but have numerous caveats for their participation. Those RHCs that are considering joining an ACO, or are already in one, should carefully review this section of the proposed rule.
While the MIPS and APM models get their own yearly adjustments. The RHC cap will continue to be adjusted based off of medical inflation.
May 26, 2016
RHC Billing for Chronic Care Management
NARHC has been notified by CMS that there is an error in their system and RHCs are not being paid correctly for Chronic Care Management services. CMS is working on the problem. NARHC has been assured that once it is fixed, CMS will issue a notice that all RHC claims for CCM services will be automatically reprocessed and adjusted, and no action will be required by the RHCs.
We do not have a projected timeline for when the problem will be resolved but we are hopeful that it will not take long. Once we are notified that the problem has been fixed, we will post that on this listserve.
May 23, 2016
MIPS / MACRA CMS Proposed Rule
The following memo summarizes and analyzes provisions of Merit-Based Incentive Payment System (MIPS) in the so called “MACRA” CMS proposed rule.
We would note that for the sake of brevity, we could not dig into the technical details on everything. Instead we have tried to pull out the most significant aspects for purposes of our discussion. However, we have included links throughout this summary for those who wish to dive into the details.
Who will participate in MIPS?
Those clinicians affected by this rule are called “MIPS eligible clinicians” and for years 1 and 2 of MIPS will include: physicians, PAs, NPs, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists. The Secretary may broaden this group after year 3 to include other health professionals (i.e. PTs, OTs, etc.). CMS anticipates that most clinicians will be subject to MIPS (as opposed to APMs or being exempt) especially for year 1.
CMS estimates that between 687,000 and 746,000 eligible professionals will be subject to MIPS in 2019. CMS also estimates that somewhere between 30,658 and 90,000 eligible clinicians will be exempt from MIPS because of their participation in APMs or due to a “low volume” exemption.
How can clinicians participate?
Clinicians can participate as either an individual or as a group as defined by a taxpayer identification number. Depending on how you are participating, you will have slightly different reporting mechanisms/requirements.
How does MIPS score work? – Overview
Each clinician or group would receive a score from 0-100 in each of the following 4 weighted categories (percentage is year 1 weight):
-Resource Use (10%)
-Clinical Performance Improvement Activities (15%)
-Advancing Care Information Performance (25%)
Those scores would then translate into something called MIPS Composite Performance Score or CPS. Payment adjustments will be determined off of the CPS. Over time, the percentage for Quality will phase down to 30% of the total and the percentage for Resource Use (Cost) will rise to 30%. The Clinical Performance Improvement Activities (CPIA) and the Advancing Care Information Performance (ACIP) will remain unchanged.
Quality performance category overview (50% of CPS)
MIPS eligible clinicians would report at least six measures of their choosing. The measures must including one so-called “cross cutting” measure and at least one “outcome” measure. If there is no applicable “outcome” measure, then clinicians must use one “high priority” measure. MIPS eligible clinicians can select any applicable measure of the over 300 measures in total.
Additionally, all MIPS eligible clinicians will be scored on 3 “population-based” measures. These are: 1-Acute Conditions Composite, 2-Chronic Conditions Composite, and 3-the All-cause Hospital Readmission Measure.
So what exactly are these measures the clinicians choose from?
There is no easy way to look at these because CMS has released the measures in a “table” format that is not easily portrayed in a word document. The full list of measures can be found in the Appendix of the NPRM document.
Table A – list of all measures to choose from – begins on page 773
Table B – population based measures that all MIPS eligible clinicians will be measured on-begins on pg 823
Table C – list of cross cutting measures – also begins on page 823
Table D – proposed new measures – begins on page 825
Table E – list of measures broken out by specialty – begins on page 836
How do these measures affect the MIPS quality score?
Each measure a clinician reports will be given a score of 1-10. For example an orthopedic surgeon who has selected his/her 6 measures (including 1 cross-cutting and 1 high priority), would be scored on a scale of 1-10 for each of the 6 measures. Additionally, the clinician would be measured on their 3 population based measures via a 1-10 scale.
So in total we have 9 measure with a max possible score of 90. If the physician scores a 70/90 then they would receive a 78% on the quality portion of the CPS. There are, of course, caveats to all of this. For instance, MIPS eligible clinicians participating via a group have to report more measures (up to 17), certain specialties that don’t have 6 applicable measures can report less, etc. There are also bonus points awarded for various activities and measures.
On each measure, CMS will create what they call a measure benchmark. Essentially, a measure benchmark will be based on previous reported scores for that measure. Although not exactly an average, it will be a score that is representative of where a significant percentage of clinicians scored previously on that measure. The clinicians will then be given points based on how they do against their peers. If you rank in the 55% percentile according to their benchmark, for example, then you will get roughly 5.5/10. The following Table demonstrates how the scoring for a particular quality measure would look:
Furthermore, CMS is aware that many of their measures are easier to achieve than others. CMS wants to discourage clinicians from picking the “low hanging fruit” and constantly strive for improvement. Therefore, CMS penalize clinicians for picking the so-called “easy” measures. CMS does this by creating something called a “topped out measure” which is essentially a measure where a large percentage of clinicians reported a 100 performance rate. In those cases they have developed a formula to make it impossible to get the full 10 points for that measure. Essentially they want to encourage clinicians to report the measures that may not be topped out. Table 18 gives you an idea of how these topped out measures would work:
We should note that CMS would like to measure and reward improvement but is soliciting comments on how best to implement this concept. They have laid out 3 options beginning on page 324 if you would like to further examine.
Resource Use performance category overview (10% of CPS)
All measures used under the resource use performance category are derived from Medicare administrative claims data so there is no need to use another data submission mechanism. Furthermore, all measures attributed to the MIPS eligible clinician will be scored. If an eligible clinician has only one resource use measure with a required case minimum to be scored, CMS would score that measure accordingly. The resource use performance category borrows most of the measures from the existing CMS value modifier (VM) program including:
-Total per capita cost measure
-The MSPB measure
-Episode based measures
These measures will have risk adjustment as previously adopted under the VM. These will basically adjust the expected cost of each beneficiary based on the Hierarchical Condition Category model. Here is a refresher on how that works.
How does the Resource Use scoring work?
The Resource Use scoring works very similar to the existing CMS resource use scoring concept (QRUR). Essentially, eligible clinicians get a score from 1-10 on each applicable measure based on a benchmark that puts all eligible clinicians on a bell curve. One of the key differences is that, CMS will use the performance year to determine the benchmark as opposed to the “baseline” year.
The higher the cost per each measure, the lower the score. Those “expensive” clinicians will receive a low category score.
Clinical Performance Improvement Activities Performance Category Overview (15% of CPS)
Think of the CPIA performance category like a checklist. If you did the improvement activity, you get the credit for that activity. In general, CMS expects the MIPS eligible clinician to perform the improvement activity for at least 90 days. This is strictly reporting. No value or quality component to the activity.
Unlike quality and resource use, CPIA is a new program, and thus no baseline will be used for the first year. Instead each CPIA is assigned a “medium” weight worth 10 points, or a “high” weight worth 20 points. MIPS eligible clinicians will need to report 60 points worth of CPIA activities in order to receive a 100 on their CPIA scoring portion. For instance, an eligible clinician could report 6 medium weight activities, or 4 medium and 1 high weight activities in order to achieve 60 points total.
Unlike the measures in the quality and resource use programs, the CPIAs are activities where you either meet the criteria to say you did that activity or you didn’t. If you did the activity you will receive the full ten or twenty points. Table H on page 946 in the proposed rule lists all the CPIAs available for the first year.
Advancing Care Information Performance Category Overview (25% of CPS)
The successor to Medicare EHR Incentive Program, the ACIP score is comprised of both a “base score” and a “performance score”.
The “base score” involves reporting the numerator and denominator of measures adopted by the EHR Incentive Programs Stage 3. The base score accounts for 50% of the ACIP. MIPS eligible clinicians must report the numerator and denominator or yes/no statements as appropriate for each measure within a subset of objectives. Similar to the CPIAs, if clinicians report the required items properly, they will get full credit.
The “performance score” consists of eight measures each worth 10 possible points. For instance, one of the measures asks clinicians to report the total number of prescriptions they write and the total number of prescription generated via a certified EHR. If a clinician gets submits 100% of their prescriptions via a certified EHR, their performance rate for this measure would be 100. Unlike the base score, the performance score is implemented off of a decile scale. So clinicians will be rated based off their percentile of performance, similar to the quality measures scoring system.
Each of the eight measures in the performance score is worth 10 points towards the full ACIP score (so up to 80%). The base score is then added with the performance score to determine the overall ACIP score. It is possible to get over 100 on the ACIP score, but those excellent performers would be capped at 100 for purposes of calculating their CPS.
How the Overall CPS score is calculated – Overview
So we have briefly described how the 4 inputs to the CPS score will work and be scored. The weights for each of the scores work logically as you might expect. So for demonstration purposes lets calculate a hypothetical CPS score.
CATEGORY SCORE 2019 WEIGHT WEIGHTED SCORE
Quality Performance Category 75 50 37.5
Resource Use Performance Category 60 10 6
Clinical Performance Improvement
Activities Performance Category 100 15 15
Advanced Care Information
Performance Category 80 25 20
Composite Performance Score CPS N/A N/A 78.5
Incorporation of Risk Factors in the CPS score
The proposed rule, for lack of a better term, largely “punts” on including risk factors in the overall CPS scoring methodology. While there is some risk adjustment (via HCC scores) in the resource use input category, there is as of right now, no other place where risk factors are seriously considered. The proposed rule does acknowledge that the law requires CMS to consider risk factors in their scoring methodology. They note that the ASPE is currently conducting studies and making recommendations “on the issue of risk adjustment for socioeconomic status on quality measures and resource use.” Then they state that they will “closely examine the recommendations issued by ASPE and incorporate them as feasible and appropriate through future rulemaking.”
MIPS Payment Adjustments
Once everyone has their CPS score, CMS must then determine who gets the 4% upward adjustment, who gets the 4% downward adjustment, and who falls somewhere in the middle. To do this they are going to establish a “Performance Threshold” based on either the mean or median as selected by the Secretary of all the CPS scores.
CMS would then establish a linear scale by which the actual payments adjustment would be made. Of course, there are numerous caveats, but the general idea is that if your CPS score is above the performance threshold, you will receive an upwards adjustment. If your CPS score is below the performance threshold, you will receive some downward adjustment. CMS provides the following figure to help explain:
May 18, 2016
The Rural Health Clinic payment system is EXEMPT from the recently proposed MIPS initiative. MIPS is a payment adjustment (up or down) that will be applied to fee-for-service payments by Medicare beginning in 2019. Clinicians participating in MIPS will begin reporting data in 2017 that will determine their 2019 payment adjustment. The scoring for MIPS (0 – 100 point scale) will be a composite of individual/group reporting on PQRS, EHR Meaningful Use, Cost/Resource use and other quality/cost reporting requirements.
If an RHC wishes to drop their RHC status and bill fee-for-service and be subjected to MIPS, you have that option. For 2019, the maximum MIPS upward adjustment will be 4% and the maximum MIPS downward adjustment will be 4%. The MIPS program is revenue neutral meaning that CMS must “pay for” the upward adjustments with money recouped from physicians, PAs and NPs whose payments are reduced under MIPS. For 2019, the amount of the adjustments will be $833 Million. So physicians/PAs/NPs getting upward adjustments will get a total of $833 Million and physicians/PAs/NPs getting downward adjustments will have $833 million taken back by Medicare.
Keep in mind that MIPS is in lieu of automatic adjustments.
In 2019, it is estimated that the RHC cap will be automatically adjusted upwards approximately 1.2% with NO risk of downside adjustment. This will have followed two years (2017 and 2018) of automatic upward adjustments in the cap. So for the possibility of getting an additional 2.8% increase in 2019 (meaning you are one of the top performing practices in the United States) you would also be subject to a potential 4% reduction if you do not score at least in the top 1/2 of providers in the country on your MIPS score.
CMS estimates that over 80% of small practices (one or two practitioners) billing fee-for-service will experience a payment reduction under MIPS.
For RHCs not subject to the cap, annual increases are based upon clinic-specific cost increases with no downside adjustment risk. These uncapped RHCs represent the majority of RHCs.
NARHC has not taken an official position on asking CMS to expand the MIPS initiative to include RHCs. Given that RHCs have no exposure to downside adjustments and either mandatory upside annual adjustments (i.e. cap increases) or the ability to get higher payments due to higher clinic specific costs, I’m not sure that in the near-term, it would be in the best interest of MOST RHCs to participate in MIPS.
Having said that, I do believe that RHCs should have the opportunity to demonstrate that they provide quality care and be rewarded for meeting appropriate quality benchmarks. NARHC has supported this concept for some time and the Federal Office of Rural Health Policy has been working to develop RHC specific quality benchmarks.
In the MIPS proposed rule, CMS proposes to allow RHCs to begin voluntarily reporting MIPS quality data. While this is an attractive opportunity on its face, we also need to be concerned that CMS could draw inaccurate or inappropriate conclusions if voluntary reporting is limited.
NARHC is continuing to review the MIPS/APM proposed rule and will likely make comments on this major reform prior to the mid-June deadline.
May 13, 2016
Coinsurance Correction Issued
In case you missed it. The following RHC updates were announced in the latest MLN eNews newsletter:
Coinsurance Correction for Certain RHC Claims
Effective April 1, 2016, Rural Health Clinics (RHCs) began reporting Healthcare Common Procedure Coding System (HCPCS) codes for all services furnished during the visit. CMS is aware that coinsurance may not be calculated correctly when RHC claims are submitted with multiple revenue lines for medical services. A system fix was implemented on May 9, 2016, to correct this issue. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.
Billing Requirements for RHCs
CMS understands that some Rural Health Clinics (RHCs) are unable to implement the billing requirements described in MLN Matters Article #9269 due to internal systems constraints. Contact your Medicare Administrative Contractor to find out if a temporary option is available while your system is updated.
Director of Government Affairs
May 10, 2016
RHC CPT Reporting
CMS has released a new MLN Matters Article that clarifies how the CG modifier will work, and how exactly to bill all those claims you are holding until Oct. 1.
The key section:
In April 2016, CMS instructed RHCs to hold claims only for a billable visit shown in red on the RHC QVL until October 1, 2016. Upon billing these claims and/or for claim adjustments beginning on October 1, 2016, RHCs shall add modifier CG (policy criteria applied) to the line with all the charges subject to coinsurance and deductible. The subsequent paragraph explains modifier CG further.
Beginning on October 1, 2016, the MACs will accept modifier CG on RHC claims and claim adjustments. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line per day, which includes all charges subject to coinsurance and deductible for the visit. For RHCs, the coinsurance is 20 percent of the charges. Therefore, coinsurance and deductible will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG. RHCs will continue to be paid an all-inclusive rate (AIR) per visit.
For the full article, click HERE.
Director of Government Affairs
May 2, 2016
Qualifying Visit List to be Non-Exhaustive After Oct. 1
In case you missed it, (I know I did) there was a very significant change announced in the updated RHC QVL document:
The RHC QVL is intended as guidance for RHCs beginning to report HCPCS codes. It consists of frequently reported HCPCS codes that qualify as a face-to-face visit between the patient and an RHC practitioner and it is not an all-inclusive list of stand-alone billable visits for RHCs…
…For dates of service on or after October 1, 2016, a medically-necessary service not on the current QVL can be billed as a stand-alone billable visit if the service meets Medicare coverage requirements, is within the scope of the RHC benefit, and is not furnished incident to a physician’s service.
As such, there is no longer a need for quarterly updates to the QVL. After Oct. 1, the modifier “CG” will alert CMS as to which service line includes the total charges that should be subject to coinsurance and deductible.
Also, please note CMS’ disclaimer:
NOTE: The use of a HCPCS code from the below QVL does not guarantee payment of the claim. All of the conditions for coverage and payment must be met for payment to be made. RHCs must retain adequate documentation of a patient’s condition and the services furnished as part of the patient’s medical record, which, along with the claim, may be subject to review by CMS, its contractors, or other oversight authorities.
April 28, 2016
Qualifying Visit List Expanded and New FAQ
Yesterday, CMS released their updated and expanded qualifying visit list. The list contains a large number of new codes that will qualify RHC visits on their own.
Remember: If the visit is qualified solely by one of the codes listed in red, then you must wait until Oct. 1 to bill.
Additionally, CMS released a HCPCS FAQ that should clarify certain nuances in the reporting policy. While the whole FAQ is useful, I would especially review Questions 9 and 10 listed below:
Q9: How do RHCs report an E/M service and a medically-necessary service from the RHC QVL on a claim from April 1, 2016 through September 30, 2016?
A: From April 1, 2016 through September 30, 2016, RHCs should report the E/M service using the 052x revenue code with all the charges subject to coinsurance and deductible for the visit so that the charges for the visit should are rolled into the E/M service line. The medically-necessary service should be reported using the 052x revenue code with charges greater than or equal to $0.01. The E/M service line will receive the AIR and be subject to coinsurance and deductible.
Q10: Beginning on October 1, 2016, how do RHCs indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and be subject to coinsurance and deductible?
A: Beginning on October 1, 2016, the Medicare Administrative Contractors (MACs) will accept modifier CG (policy criteria applied) on RHC claims. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line, which includes all charges subject to coinsurance and deductible for the visit. Modifier CG should only be used to indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and be subject to coinsurance and deductible. Each additional service furnished during the visit should be reported with charges greater to or equal to $0.01. The additional service lines are for informational purposes only. The MACs will package/bundle the additional service lines, which do not receive the AIR.
Nathan Baugh, Director of Government Affairs
April 25, 2016
RHC Claims Fix
NARHC has confirmed with CMS that the FISS system fix that was causing claims to be held went in today, April 25, 2016.
Claims that have surpassed the 14 day processing period and were being held by CMS should begin to be released and paid today/tomorrow. If you have any claims from Date of Service April 1-April 11 that are still being held by Wednesday morning, please let us know.
Director of Government Affairs
National Association of Rural Health Clinics
(202) 544-1880, Baughn@capitolassociates.com
April 12, 2016
RHC Claims Being Held!
NARHC has been informed by CMS that due to significant problems processing claims under the FISS (Fiscal Intermediary Standard System), formerly known as the Florida Shared System (FSS) all Rural Health Clinic Medicare claims with a date-of-service on or after April 1, 2016 are being held by the Medicare Administrative Contractors (MACs).
At this time, we do not know how long this hold will be in place; however, we have been assured that this problem is being worked on as quickly as possible and officials at the highest level of CMS have been briefed on this development. NARHC staff are scheduled to get an update on this later today and once we have new information, we will pass this along via listserve.
CMS is well aware of the significant financial problems delays in payments will cause RHCs and they have assured us they are exploring all options to either avoid or minimize payment delays.
Again, we will provide you with updates as soon as we get any additional relevant information from CMS on this delay.
If you have questions about this, please do not hesitate to contact us at:
March 23, 2016
RHC Qualifying Visit List Updated
Today CMS updated the RHC Qualifying Visit List by adding many (if not all) of the most common procedures performed in an RHC to the qualifying visit list of CPT codes. You can see the expanded list here:
RHCs are being asked to hold claims that are qualified solely by one of these procedure-code visits (listed in red) until October 1, 2016. The reason for this delay is related to the amount of time it takes for CMS to amend the system on their end.
Claims that are qualified by one of the initial qualifying visit codes (listed in black) but also include a procedure code (listed in red), will not have to be held until Oct. 1, 2016.
CMS is open to updating the RHC Qualifying Visit List on a quarterly basis as needed. You can subscribe to this webpage for updates: https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html
Reminder: We will be hosting a RHC Webinar/TA Call on these new billing requirements Tuesday 3/29 at 1:30 pm EST. This call will be a great opportunity to learn about these new requirements and ask questions. There is no pre-registration required and the call-in info is below:
Webinar Link: https://hrsaseminar.adobeconnect.com/rhc-ta-webinar/
Conference number: 1-800-779-1416
Participant passcode: 4343459
December 4, 2015
Chronic Care Management Guide
The Centers for Medicare & Medicaid Services (CMS) has released a MedLearn Network Matters (MLN) article on the newly approved Rural Health Clinic, Chronic Care Management (CCM) benefit. The article outlines specific requirements & services the RHC must provide in order to qualify for the monthly CCM payment.
This is a helpful resource from CMS for those of you interested in providing CCM services to your Medicare patients. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9234.pdf
Also note that NARHC is working with CMS to present an RHC Technical Assistance webinar on the new Chronic Care Management Benefit. Our intention is to hold this technical assistance webinar in January.
Stay tuned! We will announce the specific date on the listserv once it is set.
November 20, 2015
PQRS Informal Review
Unfortunately CMS has not been able to definitively clarify how PQRS should work for EPs in RHCs. While the proposed rule from CMS clearly stated that EPs in RHCs we not subject to PQRS or the reporting requirements, many of you have received letters from CMS stating that you will indeed be subject to a negative PQRS payment adjustment.
I want to be very clear that this negative adjustment will only apply to claims that an EP submits on a 1500 form. RHC claims submitted via the UB-04 form will not be affected. For many of you, this is a relatively small portion of your claims, and appealing a 2% reduction on this portion may not be worth it. Nevertheless, those of you who would like to request an informal review of the reduction may do so at this link: CLICK HERE. The deadline is Dec. 11th.
Furthermore, we have drafted an Informal Review Form letter (CLICK HERE) for your convenience. If you have any questions on PQRS feel free to reach out.
November 20, 2015
CY 2016 RHC Rate Announced
Earlier this week, CMS announced that the CY 2016 RHC rate will be $81.32. This is only applicable to those RHCs subject to the “RHC payment limit per visit” or otherwise known as the “RHC cap.”
This is a 1.1 percent increase from the CY 2015 RHC rate of $80.44. For the full announcement CLICK HERE.
November 16, 2015
Advanced Care Planning – New Benefit
In their final rule for the 2016 Medicare Physician Fee Schedule, CMS announced that beginning on January 1, 2016 Advanced Care Planning (ACP) services will be a stand-alone billable visit in a RHC.
RHCs furnish Medicare Part B services and are paid in accordance with the RHC all-inclusive rate system. Beginning on January 1, 2016, ACP will be a stand-alone billable visit in a RHC, when furnished by a RHC practitioner and all other program requirements are met. If furnished on the same day as another billable visit, only one visit will be paid. Coinsurance and deductibles will be applied for ACP when furnished in an RHC. Coinsurance and deductibles will be waived when ACP is furnished as part of an AWV.
Additional information on RHC billing of ACP is being developed by CMS and will be available in sub-regulatory guidance.
CMS has also released some examples of how billing for ACP and Chronic Care Management (CCM) will work on the rural health clinics center website.
There are two codes describing advance care planning services:
—-CPT code 99497:
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate;
—-Add-CPT code 99498:
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure).
Technical Assistance Call with CMS planned for January
Be on the lookout for announcements regarding a webinar/call with CMS staff in January. The call will cover topics such as the HCPCS reporting requirement, billing for Chronic Care Management and billing for Advance Care Planning.
November 4, 2015
Deadline for Physician Quality Reporting System (PQRS) Informal Review Process
CMS is extending the 2014 Informal Review Period for those that believe they have been incorrectly assessed with a negative PQRS payment adjustment. The new deadline to submit an informal review is Dec. 11, 2015. You may read the full announcement here.
Unfortunately, there still seems to be confusion at CMS as to how they are applying the RHC exception to PQRS reporting. We are pressing CMS for answers but do not know exactly when we will have them.
Medicare Physician Fee Schedule 2016 Final Rule
On October 30, 2015 the Centers for Medicare and Medicaid Services (CMS) published the final rule for the 2016 Medicare Physician Fee Schedule responding to comments from the National Association of Rural Health Clinics among others and issuing their final policy. You may find our original memo on the proposed rule here. The following is a summary of the relevant sections of the final rule for Rural Health Clinics.
Chronic Care Management Benefit
CMS is moving ahead with the Chronic Care Management (CCM) benefit for Rural Health Clinics beginning on January 1, 2016 as expected. For an overview of the CCM benefit click here. With the final rule released and billing instructions soon to be finalized, NARHC is planning to offer additional technical assistance on the Chronic Care Management benefit for RHCs. Keep an eye on the listserv for an announcement soon.
CPT Code Reporting
CMS is moving forward with the Healthcare Common Procedure Coding System (HCPCS or CPT Code) reporting requirement for all RHC claims. However, CMS is delaying the effective date of this reporting requirement from January 1, 2016 to April 1, 2016.
PQRS Exemption for RHCs
Unfortunately, the PQRS eligibility of RHC providers providing non-RHC services is still unclear. It appears that CMS is using a more complex methodology to determine providers subject to the PQRS than they originally told us. We are pressing CMS for further clarification and will update the listserv as soon as we have a definitive understanding of CMS’s PQRS exemption methodology.
July 20, 2015
2016 Medicare Physician Fee Schedule Proposed Rule – RHC Relevant Sections
On July 8, 2015 CMS published the proposed rule for the 2016 Medicare Physician Fee Schedule. We believe the following provisions are of interest to the National Association of Rural Health Clinics.
Proposed Chronic Care Management Benefit
As a part of their broader goal to integrate and coordinate services, CMS is proposing to extend the Chronic Care Management benefit to RHCs. Beginning on January 1, 2016 RHCs who furnish a minimum of 20 minutes per month of chronic care management (CCM) services to qualifying patients may begin billing for these services. RHCs would also be subject to all the other requirements of providing CCM services such as having up-to-date EHR software, maintaining an electronic beneficiary care plan, and beneficiary consent. You can find a primer on the current CCM benefit here.
The proposed rate for the CCM services will be based off the national average non facility payment rate for CPT code 99490 which was $42.91 per beneficiary per month in the first quarter of 2015. In evaluating the payment methodology for the CCM benefit, CMS specifically noted comments submitted by the National Association of Rural Health Clinics. CMS proposes to waive the face-to-face requirement in order to allow CCM services to be billed as part of the RHC benefit. We expect CCM services will be billed via the CPT code field on the standard UB 04 form. Further billing details will be released after adoption of a final rule later this year.
Absent any additional information that would change our view, re recommend NARHC support this proposal and submit comments affirming our support for this approach.
Proposed HCPCS Reporting Requirement for RHCs
CMS believes that requiring RHCs to report HCPCS (CPT) codes for all services would provide useful information on RHC patient characteristics, and the types of services being furnished by RHCs. As such CMS is proposing that all RHCs must report all services furnished during an encounter using standardized coding systems beginning January 1, 2016. The proposal requires an HCPCS (CPT) code to be reported along with the standard Medicare revenue code for each service furnished by an RHC to a Medicare patient. CMS is inviting comments from RHCs on the feasibility of updating their billing systems to meet the proposed implementation date of January 1, 2016.
Absent any information suggesting that RHC Practice Management providers will be unable to upgrade or change their software in time, we recommend supporting this proposal.
Clarifying RHCs are not subject to PQRS Adjustments
CMS clarified that eligible professionals working in RHCs who perform non-RHC services (hospital inpatient visits, lab services, etc.) and bill Medicare Part B for these services, at RHCs are not subject to PQRS negative payment adjustments.
This is welcome news and recommend we communicate our appreciation & support to CMS for this information.
The Medicare Access and CHIP Reauthorization Act (MACRA) combines the PQRS, Meaningful Use, and Value Based Payment Modifier into one system called the Merit-Based Incentive Payment System (MIPS) beginning in 2019. MACRA requires the Secretary to create a low-volume exception, to exclude certain professionals who might otherwise qualify from the MIPS program. CMS is soliciting comments on what factor(s) should be used to establish this low-volume threshold.
Comments Solicited for MIPS Low-Volume Threshold Exception
We continue to review this proposal and have no recommendation at this time.
New Exception to Physician Kickback Rule
CMS is proposing a new exception to the Physician Kickback Rule to permit remuneration from a hospital, FQHC, or RHC to a physician to assist with employing a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or nurse midwife (CNM). As currently proposed, the exception only applies when the PA/NP/CNS/CNM is a bona fide employee of the physician. As such, CMS is soliciting comments as to whether or not the exception should also apply to independent contractors. Additionally, CMS is soliciting comments on two methodologies to determine the geographic area served by FQHCs/RHCs. These definitions are intended to apply to RHCs/FQHCs in the same way that they apply to hospitals and rural hospitals, for purposes of the remuneration exception.
We welcome your thoughts on this. It appears to be a reasonable proposal but we’re not sure how important or significant this is for RHCs.
Ambulance Fee Schedule – Extension of the Super Rural Bonus
CMS is proposing to amend federal code in order to extend the “Super Rural Bonus” rate modifier for ambulance services through January 1, 2018 in accordance with MACRA.
Ambulance Fee Schedule – Staffing Requirement Revisions
Current staffing requirements require that Basic Life Support and Advanced Life Support ambulance providers must have two staffers present, but only one of these staffers must meet certain requirements. CMS is proposing to revise the staffing requirements such that all Medicare-covered (BLS and ALS) ambulance transports must be staffed by at least two people who meet the requirements of state and local law, in addition to the Medicare requirements. CMS believes these proposals would enhance the quality and safety of ambulances services provided to Medicare beneficiaries and strengthen the federal government’s ability to prosecute ambulance staffing violations.
Although not specifically an RHC issue, many of you are familiar with local ambulance services and we wondered if you had any thoughts on this. Will the additional staffing requirements (education/certification, etc.) adversely affect the availability of ambulance services in rural areas?
Comments must be submitted by 5 p.m. on September 8, 2015, you may submit comments electronically at www.regulations.gov
Capitol Associates, Inc.
July 7, 2015
Traditional coding conventions require that a claim be submitted using the diagnosis code the most accurately describes the medical condition for which payment is being sought. This is true for ICD-9 and it will continue to be true for ICD-10. However, because ICD-10 coding can be to a much higher degree of specificity than is currently available under ICD-9, there has been some concern that beginning October 1, 2015, Medicare will reject legitimate claims due to lack of specificity. Yesterday, CMS released the following statement, clarifying that they will not enforce the “specificity” requirement for 12 months after the October 1, 2015 effective date.
The diagnosis code being used must still be supported by the documentation in the medical record and CMS will NOT accept an ICD-9 coded claim after October 1, 2015. You are strongly encouraged to undertake ICD-10 testing with your vendors/payers where possible, to ensure their ability to appropriately accept and process an ICD-10 coded claim. If your vendors/payers are unable to engage in ICD-10 testing, you would have reason to be concerned. Furthermore, you should not simply accept at face-value assertions from your vendors that they are ICD-10 ready. Ask them for documentation to justify that assertion.
May 28, 2015
Veterans Choice Program
Click here for a Provider Application
Click here for a Facility Application
Click here to see if your provider has been added
January 30, 2015
Revised Guidance from CMS
The Centers for Medicare & Medicaid Services (CMS) has updated its interpretive guidelines in the following State Operations Manual (SOM) Appendices to reflect recent amendments to the applicable Conditions of Participation (CoPs), Conditions for Coverage (CfCs) and Conditions for Certification: o Appendix A – Hospitals o Appendix T – Hospital Swing Beds o Appendix L – ASCs o Appendix G – RHCs and FQHCs We are also taking this opportunity to update and clarify some portions of the existing guidance.
Effective Dates: The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one Nurse Practitioner (NP) or Physician’s Assistant (PMA); this latter change was effective July 1, 2014.
- Guidance Updated: The Centers for Medicare & Medicaid Services (CMS) has updated its interpretive guidelines in the following State Operations Manual (SOM) Appendices to reflect recent amendments to the applicable Conditions of Participation (CoPs), Conditions for Coverage (CfCs) and Conditions for Certification:
o Appendix A – Hospitals
o Appendix T – Hospital Swing Beds
o Appendix L – ASCs
o Appendix G – RHCs and FQHCs
We are also taking this opportunity to update and clarify some portions of the existing guidance.
- Effective Dates: The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one Nurse Practitioner (NP) or Physician’s Assistant (PA); this latter change was effective July 1, 2014.
RHCs/FQHCs, 42 CFR Part 491
- Definitions, §491.2
The definition of a “physician” has been revised to include a doctor of dental surgery or dental medicine, a doctor of podiatry or surgical chiropody, or a chiropractor, within the limitations of services these types of physicians are permitted to offer under Section 1861(r) Page 5 – State Survey Agency Directors of the Social Security Act. However, it continues to be the case that only MDs or DOs may fulfill the requirements for supervision, collaboration and oversight of non-physician practitioners in an RHC or FQHC.
- Staffing and Staff Responsibilities, §491.8
- 8(a)(3) was revised to permit an RHC to have a nurse practitioner or physician assistant provide services under contract to the RHC. This increased flexibility does not eliminate the longstanding statutory and regulatory requirement that the RHC must have at least one employee who is a nurse practitioner or physician assistant. This change was effective July 1, 2014.
- 8(a)(6) was revised to require for RHCs that a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services at least 50% of the time the RHC operates. This aligns the regulatory language with the current statutory requirement. Note that since the statutory provision was self-implementing, CMS has enforced the 50% standard even prior to this regulation change. (See S&C 09-14)
- 8(b) has been revised to delete the requirement formerly at §491.8(b)(2) for a physician to be present in the RHC or FQHC at least once every two weeks. This recognizes that many of the physician’s required functions may be performed remotely via electronic means, but does not remove the requirement that a practitioner, whether a physician or non-physician practitioner, must be present at all times the RHC or FQHC operates. Provisions formerly at §491.8(b)(1)(i) – (iii) have been renumbered to be §491.8(b)(1) – (3), but are otherwise the same.
We have also removed outdated material and clarified the guidance for §491.8.
CLICK HERE to read all
August 18, 2014
Preventive Services & RHCS
You & your patients won!
Late last week, CMS formally announced that they were rescinding a policy adopted earlier this year which denied payment for certain preventive services provided as stand-alone services when delivered in the RHC setting. Although NARHC had been notified a few weeks ago by CMS officials that the reversal was going to take place, we decided to wait until CMS made the formal announcement before writing this message.
This change in policy by CMS comes about after intense pressure generated by NARHC, our members and friends and our bi-partisan Congressional Allies. I want to thank all of you who took the time to contact your Congressional offices to make them aware of the impact the change in policy was having on you and your patients. While this is an important victory for the RHC community, it is even more important for your patients!
When the RHC Community acts together and engages our allies, we can successfully advocate for policy changes that improve your ability to provide quality healthcare and the ability of your community to enjoy a better quality of life. I also want to take this opportunity to thank the CMS staff and Leadership for listening to the RHC community and acting to address our concerns.
According to the CMS announcement, ALL denied claims for the following preventive services back to January 1, 2014, should be resubmitted as an adjustment for appropriate payment.
|Service||HCPCS Code||Long Descriptor||Pd at the AIR||Eligible for Same Day Billing||Coinsurance/Deductible|
|Screening Pelvic Exam||G0101||Cervical or vaginal cancer screening; pelvic and clinical breast examination||Yes||No||Waived|
|Prostate Cancer Screening||G0102||Prostate cancer screening; digital rectal examination||Yes||No||Not Waived|
|Glaucoma Screening||G0117||Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist||Yes||No||Not Waived|
|G0118||Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist||Yes||No||Not Waived|
Eligible preventive services (identified above) shall be paid based on a RHC’s AIR when submitted on a 71X TOB with revenue code 052X.
July 31, 2014
ICD-10 Deadline for Compliance
Earlier this year, Congress adopted legislation that postponed the ICD-10 effective date from October 1, 2014 to a date – no sooner than October 1, 2015. Because of the way the legislation was written, it left it up to the Secretary of HHS to set a new effective date.
For many months, CMS officials have stated publicly that it was their intent to set the new effective date for October 1, 2015. However, until this date was published in the Federal Register, it was not official.
A short while ago, the Department of Health and Human Services issued a Final Rule officially setting the ICD-10 effective date as October 1, 2015. In addition, HHS is also mandating continued use of ICD-9 through September 30, 2015. By mandating use of ICD-9 through the end of September, 2015, individual payers cannot voluntarily seek to adopt ICD-10 prior to October 1 as some had suggested.
It is hoped that the additional time afforded the industry will be sufficient to ensure wide-spread industry readiness for adoption of ICD-10 by the new effective date.
July 18, 2014
New National Accrediting Organization – The Compliance Team
If you have clinics seeking RHC accreditation/certification, The Compliance Team is now officially approved as an accrediting agency for RHC certification. Providing multiple non-governmental options for RHC certification is a tremendous achievement for NARHC and the RHC community. This is a goal Ron Nelson and I set several years ago. It is so gratifying that RHCs now have choices! If you have any questions about their process, you are encouraged to contact The Compliance Team. I hope you will join me in welcoming The Compliance Team as an official member of the RHC family!
79 FR 42019
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
Medicare & Medicaid Programs; Initial Approval of The Compliance Team’s (TCT) Rural Health Clinic (RHC) Accreditation Program
AGENCY:Centers for Medicare and Medicaid Services, HHS.
SUMMARY:This final notice announces our decision to approve The Compliance Team (TCT) for initial recognition as a national accrediting organization for Rural Health Clinics (RHCs) that wish to participate in the Medicare or Medicaid programs.
DATES: This final notice is effective July 18, 2014 through July 18, 2018.
FOR FURTHER INFORMATION CONTACT:Valarie Lazerowich, (410) 786-4750, Cindy Melanson, (410) 786-0310, or Patricia Chmielewski, (410) 786-6899.
July 11, 2014
Preventive Services billable when performed as stand-alone services in RHCs???
I wanted to take this opportunity to update you on our efforts to get CMS to recognize Medicare covered preventive services delivered as “stand-alone” visits in the RHC setting as billable RHC encounters. At this time, CMS policy has not changed. CMS continues to instruct their Contractors to deny payment for most preventive services delivered as stand-alone visits when performed in the RHC setting. The only exception to this policy at this time is the performance of the Introduction to Medicare Physical (IPPE) and the Annual Wellness Visit (AWV). These two services are billable as stand-alone services in the RHC.
However, on Wednesday (7/9), I met with the Director and Deputy Director of the Medicare program specially to discuss this policy, it’s ramifications for RHC patients and clinics and the intent of Congress in creating the preventive services benefit. Based upon our conversation, the CMS leadership has agreed to review and reassess the policy that denies these preventive visits as billable visits when performed as stand-alone services in an RHC. Although no timetable was set for when we can expect a response, I do not believe it will take a long time for them to complete the reassessment.
You should know that I left the meeting believing that the reassessment would be a sincere reexamination of the law and Congressional intent. Depending upon the outcome of that review, we will determine next steps. I remain hopeful that CMS will find the latitude in the law to permit these preventive services visits to be billed when delivered as stand-alone visits.
In the event CMS continues to maintain that they do not have the statutory authority to make such a determination, then we have also agreed to work together to identify language that can be submitted to Congress to change the law such that it would give Medicare the statutory authority to cover these preventive services as stand-alone billable visits. It is important that we continue to put pressure on CMS to ensure that Medicare beneficiaries receiving care in the RHC setting are not disadvantaged relative to their urban counterparts in their ability to easily access preventive services.
Please do not hesitate to contact me if you have any questions.
June 24, 2014
Annual Wellness Visits & IPPE
Recently, CMS announced that preventive services would no longer be considered medically necessary face-to-face visits when done in a RHC except for an Initial Preventive Physical Examination (IPPE) or the Annual Wellness Visit (AWV). Therefore, the only time the provider will be reimbursed their all inclusive rate when performing preventive services is when the provider performs an IPPE or AWV.
Below is the link to the revised MLN Matters Number SE1039 that clarifies how these preventive services should be billed.
Below is the link of Medicare preventive services that will be required to be performed with another medically necessary face-to-face visit or the preventive service will be denied except for the IPPE and AWV in RHCs.
May 29, 2014
Medicare Coverage of Preventive Services Provided in the RHC Setting
I am writing to alert you to a disturbing determination by CMS that will not only affect you as RHCs, but, more importantly, your patients.
Since 2011, Medicare has been covering certain preventive services. In most instances the co-pay and deductible are waived as long as the patients and providers adhere to the frequency scheduled established for that particular preventive service. This expansion occurred as a result of changes mandated by enactment of the Affordable Care Act.
Services such as Cervical or Vaginal Cancer screening; pelvic and breast examinations; and, screening pap smears have been covered as “stand-alone” services and billable as RHC visits in accordance with CMS published policy (see link below).
Recently, CMS announced that these services are no longer considered “medically necessary” face-to-face visits when performed in an RHC or FQHC and therefore not billable as stand-alone services.
Here is the specific language published by one of the Medicare contractors: “…HCPCS G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination and Q0091, screening papanicolaou smear, are not considered to be a medically necessary face-to-face visits and will not be billed or paid at the all-inclusive rate when performed alone.”
The RHC/FQHC policy announcement goes on to state, “Claims billed with a preventive service code(s) that does not generate a separate payment without another covered service will be rejected”
What makes this determination particularly offensive is that CMS will continue to pay for these preventive services as stand-alone services when provided in other settings. Here is how CMS describes coverage for screening pelvic exams in the non-RHC setting:
The screening pelvic examination benefit covered by Medicare is a stand-alone billable service. It is separate from the Initial Preventive Physical Examination (IPPE) or the Annual Wellness Visit (AWV). Medicare beneficiaries may obtain a screening pelvic examination at any time following Medicare Part B enrollment, including during their IPPE or AWV encounter.
In other words, if an otherwise healthy woman on Medicare living in a rural underserved area wants a screening pelvic exam as a stand-alone service and goes to a physician’s office in an urban area, Medicare will deem that service medically necessary and reimburse the physician 100% of the Medicare allowable charge for that service as a stand-alone service. But if that same woman were to go to the RHC in her rural underserved community and have that screening pelvic exam performed as a stand-alone service, Medicare would deem the screening pelvic exam NOT medically necessary and deny the claim.
The idea that a service is NOT medically necessary if provided in an RHC or FQHC setting but IS medically necessary if provided in a non-RHC setting is absurd and offensive. This represents a huge barrier for rural women and discourages them from obtaining care in RHCs and FQHCs.
I want you to know that NARHC is not taking this new policy lightly. NARHC is requesting a meeting with CMS Administrator Marilyn Tavenner to discuss this policy and its ramifications for rural Medicare patients and we are letting our allies in Congress know about this gross misapplication of policy.
On May 30th, NARHC will be alerting our friends in Congress about this problem. The principle health advisor for each Senator and Representative who is a member of the House and Senate Rural Caucus/Coalition will get a detailed message alerting them to this development and asking them for assistance. I would ask that all of you consider contacting your Representative and Senators to reinforce the message we will be delivering. Please do not hesitate to share examples of how this policy will be harmful to Medicare beneficiaries if it is allowed to stand.
We will work to keep you informed of any progress we make in this area.
Bill Finerfrock, 202-544-1880, email@example.com
May 8, 2014
Payments to RHCs for covered RHC services furnished to Medicare beneficiaries are made on the basis of an all-inclusive rate (AIR) per covered visit. Information on preventive services payable under the AIR is available in CMS Pub 100-04, Chapters 9 and 18. The chart below lists preventive services that are eligible to be paid based on the provider’s AIR when billed without another covered visit.
|Service||HCPCS Code||Long Descriptor||Eligible service paid at the AIR||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||Waived||Ch 9 §150Ch 18 §80|
|Annual Wellness Visit||G0438||Annual wellness visit, including PPPS, first visit||Yes||Waived||Ch 18 §140|
|G0439||Annual wellness visit, including PPPS, subsequent visit||Yes||Waived|
* This service is payable with another encounter/visit on the same day at the provider’s AIR.
May 7, 2014
Final Rule (Physician On-Site Hours, Telemedicine, etc.)
A short while ago, the Centers for Medicare and Medicaid (CMS) released “for public inspection” a regulatory relief final rule that includes an important change for RHCs.
As you know, RHCs have been required to have a physician on-site in the RHC a minimum amount of time as mandated by the federal government. This, despite the fact that most state laws governing NP and PA practice permit the PA or NP to practice either independently/collaboratively for NPs or under remote/telephonic supervision for PAs.
Under the new rules, the federal minimum physician on-site requirement in the RHC rules is being modified such that RHCs will be required to follow state law or state regulatory requirements. If there is no physician on-site requirement for NPs or PAs, then as long as the PA or NP is practicing in accordance with state law/state regulatory mechanism you will have satisfied the new requirement.
The NEW requirement goes into effect in 60 days from the date the Final Rule officially appears in the Federal Register. That should be in a few days and we will announce that date once the final rule is published.
Other technical changes were made to “clean up” the RHC regulations and CMS officially responded to industry proposals dealing with other issues, such as regulatory relief on telemedicine. We will be making an official response to the CMS response after we have had an opportunity to fully analyze the final rule.
In the meantime, we want to thank CMS for recognizing the unnecessary burden the physician on-site requirement was causing for RHCs and the acknowledgement that state laws were a better standard for ensuring the appropriate relationship between physicians and PAs and NPs.
May 1, 2014
On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.
April 29, 2014
The Centers for Medicare and Medicaid Services (CMS) has released for “public display”, the final rule authorizing RHCs to contract with some PAs and NPs via an independent contractor relationship. This policy change was included in a much larger rule changing the way FQHCs are reimbursed under Medicare. The new RHC policy will take effect on July 2, 2014, 60 days after it appears in the federal register (May 2nd).
The new policy will amend the RHC regulations to permit RHCs to contract with PAs and NPs as long as ONE PA or NP working in the RHC is an employee of the clinic. CMS has previously maintained that the RHC statute requires that ALL PAs and NPs working in the RHC must be employees. The new policy clarifies that only one PA or NP must be an employee. All other PAs or NPs working in the RHC can employees OR independent contractors.
Although the policy does not go as far as NARHC had recommended – we proposed that ALL PAs and NPs working in the RHC could be “employed” as independent contractors – we are pleased that CMS is providing this level of flexibility. In response to the NARHC recommendation, CMS maintains that the RHC law does not permit them to go as far as we recommended. Therefore, CMS states that any additional changes the RHC community might seek in this area would have to be pursued via the Congress.
Additional changes in the RHC rules providing added flexibility are expected to be released by CMS in the very near future. One of the expected changes will be a relaxation of the RHC physician on-site requirement to reflect state law rather than the current federal minimum physician on-site requirement. NARHC will announce those changes as soon as they are released by CMS.
March 31, 2014
SGR Patch/ICD-10 Delay
The United States Senate has joined the House of Representatives and passed legislation to prevent a 24% cut in physician fee schedule payments from occurring tomorrow (4/1) as previously scheduled. Instead, Medicare physician fee schedule payments will continue to be paid as they have been for the past 3 months. Although the legislation must be signed by the President in order to become effective, the President has indicated that he will sign this legislation once it reaches his desk.
In addition to preventing the SGR related reduction, Congress approved language extending various other Medicare provisions slated to expire at Midnight tonight. These include:
Extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year
- Extends Medicare therapy cap exception process for 1 year
- Extends Medicare ambulance add-on payments for 1 year
- Extends Medicare adjustment for Low-Volume hospitals for 1 year
- Extends Medicare-dependent Hospital (MDH) program for 1 year
In addition to these “extenders” Congress also approved a one-year delay in the effective date of the ICD-10 transition. As you know, ICD-10 has been scheduled to take effect on October 1, 2014. Due to Congressional intervention, the new effective date will be October 1, 2015.
January 6, 2014
Medicare Benefit Policy Manual Change…
CMS issued a change request for MLN Article MM8504 with changes to the Medicare Benefit Policy Manual – RHC and FQHC Update – Chapter 13.
Effective January 1, 2014 the venipuncture will be included in the all-inclusive rate and will not be separately billed to Medicare Part B.
Here is the section from the article that reflects the change:
- Although RHCs and FQHCs are required to furnish certain laboratory services (for RHCs see section 1861(aa)(2)(G) of the Act), and for FQHCs see section 330(b)(1)(A)(i)(II) of the PHS Act), laboratory services are not within the scope of the RHC or FQHC benefit. When clinics and centers separately bill laboratory services, the cost of associated space, equipment, supplies, facility overhead and personnel for these services must be adjusted out of the RHC or FQHC cost report. This does not include venipuncture, which is included in the all-inclusive rate when furnished
Link to the article: MM8504
December 17, 2013
RHC Upper Payment Limit for 2014
CMS has officially announced that the 2014 RHC upper payment limit (aka cap) will be $79.80 per visit. This represents a .8% increase over the 2013 Upper Payment Limit of $79.17 per visit. The RHC cap does not apply to provider-based RHCs owned by hospitals with fewer than 50 beds. This new cap is effective for services delivered on or after January 1, 2014. Please contact your Medicare Administrative Contractor if you have questions about this new cap.
December 2, 2013
Updates to Chapter 13 – Medicare Benefit Policy Manual
This link is an article on a CMS change request that advises MACs to updates to Chapter 13 of the “Medicare Benefit Policy Manual.” The updates include new information on transitional care management and hospice payment exceptions, RHC employment, and provides clarification of existing information.
November 5, 2013
Billing Behavioral Health Services
A Master’s level Clinical Social Worker is a recognized provider in the RHC setting. It is not sufficient that the individual be licensed by the state. He/she must have the minimum educational credential of a Master’s degree as a Clinical Social Worker.
Mental health services within the scope of practice for the CSW are covered as RHC mental health visits to the extent the visit is face-to-face, medically necessary and otherwise covered by the Medicare program. The payment adjustments applicable to mental health services would apply.
Note that beginning January 1, 2014, there will no longer be a mental health adjustment. Mental health services covered by Medicare will be paid the same as medical services (i.e. 80% of allowable or cost-based rate).
September 12, 2013
ALL Employers Required to Notify Their Employees of Health Insurance Options!
A little noticed provision in the Patient Protection and Affordable Care Act (ACA) requires ALL employers to notify their employees of the health insurance options they have available to them as a result of enactment of the ACA. According to the Department of Labor, all employers covered by the Fair Labor Standards Act (FSLA) are obligated to make the health insurance notification by OCTOBER 1, 2013. An FSLA covered employer is one with at least one employee and $500,000 in revenue.
This notification MUST occur whether the employer provides health insurance to the company’s employees or not. The Department of Labor has provided information about this mandatory notification and made model forms available for employers to use.
Here are the links:
One for employers that DO offer health insurance:
One for employers that DO NOT offer health insurance:
Spanish language versions of these model forms are also available for download.
There is some work involved in being able to accurately complete the form – particularly for employers that offer health insurance. This is not a simple “cut and paste” exercise.
The notification must be in writing AND written in manner that can be expected to be understood by the “average” employee. The written notification can be hand delivered or it may be sent to the employee via first class mail or electronic mail. Although employers are not required to obtain written verification from the employee indicating receipt of the notice, employers may wish to obtain verification in the event there is a question.
Failure to make the required notification could result in a fine of up to $100.00 per day.
For new employees (those hired after 10/1/2013), the communication must be given to new employees within 14 days of the beginning of their employment. There is also An ACA notification requirement when an employee leaves if that employee is eligible for COBRA benefits.
To learn more about the employee notification requirement, you can also visit the Department of Labor’s website: http://www.dol.gov/ebsa/newsroom/tr13-02.html
Electronic Eligibility Verification Function
As of January 1, 2013, ALL health plans, including Medicaid, are required under HIPAA and the Affordable Care Act to have an electronic eligibility verification function (270/271) available.
Plans are required to have a “real time” eligibility verification system as part of the transaction code set standards and the operating rules. Under the operating rules standards, the Health Plan must respond (271) to an electronic eligibility verification inquiry (270) in less than 20 seconds. You should ask your health plans how you go about connecting with the plan to do electronic verification and what information they will require in order to process the inquiry. This is particularly important for Medicaid plans where eligibility can change on a month-to-month basis.
If you use a billing service or clearinghouse to submit claims, either should be able to assist you. If you have a practice management program, you should also contact your practice management vendor to ask about whether their software supports electronic transaction inquiries such as eligibility verification, claims status, etc.
If a payer tells you that they cannot support a 270/271 eligibility inquiry/response, they are in violation of the HIPAA and ACA requirements and you can file a complaint against the payer.
April 24, 2013
RE: Revised HIPAA Privacy Standards
In January, the Department of Health and Human Services issued newly revised HIPAA privacy standards. These new standards went into effect in late March but they will not be enforced until late September. Several changes were made to ensure even greater privacy of Protected Health Information (PHI).
Click HERE for a link to the final rule.
The new HIPAA standards grant individuals the right to restrict disclosure of PHI to Health Plans for treatment the patient received for which the individual paid in full (i.e. no Health Plan payment was received).
The idea is that this is the patient’s information and the insurance company has no legal right to that information because the insurance company did not pay for that healthcare. In the past, this information was generally disclosable because Health plans could use this as part of their underwriting efforts. Given that health insurers can no longer “experience rate” health insurance premiums based upon health status and cannot deny health insurance due to a pre-existing condition, there is no reason that the insurance company would need to know about any healthcare the individual paid for out-of-pocket.
March 8, 2013
Re: Medicare Claims Processing & Sequestration; Reducing Regulatory Burden for Rural Health Providers
As you know, on March 1st, President Obama issued a sequestration order as required by the Budget Control Act of 2011. Although for most federal programs the effects of sequestration began immediately, for Medicare Part A and Part B, the sequestration related cuts do not take effect until April 1st.
For Medicare Part B, CMS has been ordered to reduce Medicare outlays for 2013 by $5.1 Billion dollars. For Part A, the sequester related reduction is $5.6 Billion
Here is the CMS Guidance explaining how they intend to comply with the sequestration order:
Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration”
The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.
This listserv message is directed at the Medicare FFSprogram (i.e., Part A and Part B). In general, Medicare FFSclaims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DMECompetitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.
The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.
Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.
Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.
January 22, 2013
RE: New RHC Billing “cheat sheet”
CMS recently published a “cheat sheet” for rural provider billing, including RHCs (both independent and provider-based). The document covers billing Medicare for traditional RHC services as well as how (and to whom) RHCs should bill Medicare for non-RHC services. In addition to RHC billing, the document covers billing for: CAHs, SNFs, Home Health, FQHCs.
There are both “quick reference” charts, as well as more detailed billing charts for each of the providers listed above. You may want to download this document and make it available to your billing staff.
January 2, 2013
Re: Fiscal Cliff/SGR Update
Yesterday, the United States Congress approved legislation that prevents most taxpayers from experiencing a tax increase; prevents the scheduled 26.5% SGR related cut in physician fee schedule payments; and delays (until early March) the 2% across-the-board cut in Medicare payments due to sequestration.
In lieu of the 26.5% SGR cut, the Congress approved a one-year freeze in the Medicare conversion factor used to calculate Medicare Physician Fee Schedule payments. The Congress also approved a one-year extension of several Medicare payment policies that were set to expire. Finally, the Congress approved a series of payment reductions in other provider payments as a way to “pay for” the SGR fix.
Other than the 2% sequester cut that has been delayed, none of these changes directly affects RHCs. However, we thought it would be helpful to make you aware of these changes as many RHCs are part of larger organizations (hospitals, CAHs, group practices, etc.) that may be affected by some of these changes.
A list of the Medicare provisions “extended” is below, along with the list of payment reductions the Congress approved as “offsets”.
Medicare Provider Payment provisions extended as part of the Fiscal Cliff compromise.
Work Geographic Adjustment. This provision extends the existing 1.0 floor on the “physician work” index through December 31, 2013.
Payment for Outpatient Therapy Services. This provision extends the exception process through December 31, 2013. The provision also extends the cap to services received in hospital outpatient departments only through December 31, 2013.
Ambulance Add-On Payments. This provision extends the add]on payment for ground including in super rural areas, through December 31, 2013, and the air ambulance add]on until June 30, 2013.
Extension of Medicare inpatient hospital payment adjustment for low volume hospitals. This provision extends the payment adjustment until December 31, 2013.
Extension of the Medicare-Dependent hospital (MDH) program. This provision extends the MDH program until October 1, 2013.
Other Health Provisions used to offset the cost of a temporary SGR fix.
Documentation and Coding (DCI) adjustment. This provision will phase in the recoupment of past overpayments to hospitals made as a result of the transition to Medicare Severity Diagnosis Related Groups (MS]DRGs). Savings: $10.5 billion.
Rebase End Stage Renal Disease (ESRD) payments. This provision incorporates recommendations from the General Accountability Office by re]pricing the bundled payment to take into account changes in behavior and utilization of drugs for dialysis. Savings: $4.9 billion.
Therapy Multiple Procedure Payment reduction. This provision further reduces payment for subsequent therapies when therapies are provided on the same day. Savings: $1.8 billion.
Payment for Certain Radiology Services. This provision would equalize payments for stereotactic radiosurgery services provided under Medicare hospital outpatient payment system. Savings: $0.3 billion.
Adjustment of Equipment Utilization Rate for Advance Imagining Services. This policy would increase the utilization factor used in the setting of payment for imaging services in Medicare from 75% to 90%. Savings: $0.8 billion.
Competitive Prices for Diabetic Supplies. This proposal would apply competitive bidding to diabetic test strips purchased at retail pharmacies. Savings: $0.6 billion.
Adjust Payment Adjustment for Non-Emergency Ambulance Transports For ESRD Beneficiaries. This provision reduces the payment rates for ambulance services by 10% for individuals with ESRD obtaining non]emergency basic life support services involving transport, based on a recent General Accountability Office report. Savings: $0.3 billion
Increase statute of limitations for recovering overpayments. This provision increases the statute of limitations to recover overpayments from three to five years, based on recommendations from the Office of Inspector General at the Department of Health and Human Services. Savings: $0.5 billion.
Medicare Improvement Fund. This provision eliminates funding for the Medicare Improvement Fund. Savings: $1.7 billion.
Rebase Medicaid Disproportionate Share Hospital (DSH) payments to extend the changes from the Affordable Care Act (ACA) for an additional year. This proposal rebases DSH allotments to maintain the level of changes achieved in the ACA, and determines future allotments off of the rebased level using current law methodology. Savings: $4.2 billion.
Repeal of Class Program. The provision repeals the Community Living Assistance Services and Supports (CLASS) program established by the Affordable Care Act. This provision has no scoring implications.
Coding Intensity Adjustment. Under current law, Medicare Advantage plans receive riskadjustment payments that are further adjustment to reflect differences in coding practices between Medicare fee-for-service and Medicare Advantage. This provision increases this coding intensity adjustment. Savings: $2 billion.
Consumer Operated and Oriented Plan (CO-OP). This provision will rescind all unobligated CO-OP funds under section 1332(g) of the Affordable Care Act. This provision also creates a contingency fund of 10 percent of the current unobligated funds to be used to further assist currently approved co-ops that have already been created. The provision does not take away any obligated CO-OP funds. Savings: $2.3 billion.