Rural Health Clinic Policies Revised
Don’t send another RHC claim until you’ve reviewed these key changes for 2022.
A Rural Health Clinic (RHC) is a clinic located in a rural, underserved area with a shortage of primary care providers, personal health services, or both. Medicare pays RHCs for the provision of certain primary care and preventive health services in these underserved rural areas, and the Centers for Medicare & Medicaid Services (CMS) just updated coverage policies for RHC payments and services. Make sure your billing staff is aware of these modifications that went into effect Jan. 1, 2022.
There are currently about 4,500 RHCs nationwide, expanding access to high-quality, affordable, accessible healthcare. To be certified as an RHC, these clinics must meet all state and federal requirements, including location, staffing, and healthcare services requirements, and have a quality assessment and program improvement program. CMS did not modify RHC certification requirements, but the agency did revamp RHC payments, visit sites, and services.
On Jan. 1, CMS implemented the following updates affecting RHCs:
- Specification that the bundled payment, or All-Inclusive Rate (AIR), Medicare pays RHCs is per visit, for qualified primary care and preventive health services provided by an RHC practitioner.
- Addition of hospice to the list of locations where RHC visits can take place.
- RHCs can now bill Transitional Care Management (TCM) and general care management services furnished to the same patient during the same service period, provided the RHC meets the billing requirements for each code.
- As of April 1, 2021, RHCs will receive a prescribed national statutory payment limit per visit increase over an eight-year period for each year from 2021 through 2028.
- In addition to flu, pneumococcal, and COVID-19 shots, Medicare now covers COVID-19 monoclonal antibody products and their administration at 100 percent of reasonable cost.
- RHCs can report and get paid for mental health visits furnished via real-time telecommunication technology.
- RHCs are eligible to get paid for hospice attending physician services when provided by an RHC physician, nurse practitioner, or physician assistant who’s employed or working under contract for an RHC but isn’t employed by a hospice program.
Let’s take a closer look at these changes.
CMS added verbiage to clarify that it pays RHCs a bundled payment, or AIR, per visit, for qualified primary care and preventive health services an RHC practitioner provides. Also added are the following specifications:
We subject the AIR to a payment limit per visit, meaning an RHC won’t get any payment beyond the specified limit amount per visit. For independent RHCs, provider-based RHCs in a hospital with 50 or more beds, and RHCs enrolled in Medicare on or after January 1, 2021:
- Payment limit per visit based on these national statutory limits:
- January 1, 2021–March 31, 2021 = $87.52
- April 1, 2021–December 31, 2021 = $100.00
- Calendar Year (CY) 2022 = $113.00
For specified provider-based RHCs in a hospital with less than 50 beds:
- Medicare Administrative Contractors (MACs) calculate the payment limit per visit for provider-based RHCs that meet certain criteria
Unchanged, Medicare will pay the full AIR for certain preventive services. For most other services, Medicare Part B deductible and coinsurance rates apply.
Hospice is the latest addition to the list of locations RHC visits can take place. RHC visits can also take place in the patient’s home (including assisted living facility), RHC, Medicare-covered Part A skilled nursing facility, or the scene of an accident.
There are no changes to Hepatitis B or telehealth payment guidelines. The only change to virtual communication services is the addition of HCPCS Level II code G0071 Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only beside “Virtual Communication Services.” Virtual Communication Services FAQs has more information.
CMS also made the following modifications to care management and immunizations/monoclonal antibody services:
Care Management Services
RHCs may provide general care management services, and CMS expanded the list of Medicare now covers. For TCM, the agency clarified that “Beginning January 1, 2022, RHCs can bill TCM and general care management services furnished for the same patient during the same service period, if the RHC meets the requirements for billing each code.”
Added to the list of care management services:
- General Care Management (G0511)
- Chronic Care Management (CCM)
- General Behavioral Health Integration (BHI)
- Principal Care Management (PCM)
- Psychiatric Collaborative Care Model (CoCM) (G0512)
Immunizations and Monoclonal Antibody Therapy
Now, in addition to Medicare paying for flu, pneumococcal, and COVID-19 shots, it will also pay for COVID-19 monoclonal antibody products and their administration at 100 percent of reasonable cost. RHCs report these services on a separate cost report worksheet, not on their RHC billing claims.
CMS updated the RHC cost report to reflect costs related to COVID-19 vaccines and COVID-19 monoclonal antibody products and their administration. MLN Matters® Article SE20016 has more information on new and expanded COVID-19 RHC flexibilities during the public health emergency.
New RHC Services
CMS also expanded the list of covered services. Medicare will now pay RHCs can for mental health visits and hospice attending physician services when the RHC meets certain conditions. The two new additions are as follows:
Mental Health Visits Furnished Using Telehealth – “Beginning January 1, 2022, RHCs can report and get payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the patient isn’t capable of, or doesn’t consent to, using video technology.
An in-person, non-telehealth visit must be furnished at least every 12 months for these services; however, we may make exceptions to the in-person visit requirement based on patient circumstances (with the reason documented in the patient’s medical record) and also allow more frequent visits as driven by clinical needs on a case-by-case basis.”
Hospice Attending Physician Services Payment – “Beginning January 1, 2022, RHCs and FQHCs will be eligible to get payment for hospice attending physician services when provided by an RHC physician, NP, or PA who’s employed or working under contract for an RHC, but isn’t employed by a hospice program. During a hospice election, attending physician services can take place at the patient’s home, a Medicare-certified hospice freestanding facility, skilled nursing facility, or hospital.”
For more information, see MLN 006398.
Learn about covered services, visits, payment policies, and other information in Medicare Benefit
Policy Manual, Chapter 13.
Learn how CMS processes RHC claims in Medicare Claims Processing Manual, Chapter 9.
- Check Out These Changes to Outpatient CAR-T Coding - February 28, 2023
- AAPC International Is Advancing the Business of Healthcare Worldwide - July 1, 2022
- Take Steps to Safeguard Your Family’s Health - June 1, 2022