Correctly Report Rural Preventive Services’ Claims

The Centers for Medicare & Medicaid Services (CMS) has identified a claims processing issue that affects rural health clinics (RHCs) submitting claims for preventive health care services on or after Jan. 1, 2011.  Vigilance will help you assure proper reimbursement.

Provisions in the Patient Protection and Affordable Care Act of 2010 (PPACA) waive the coinsurance and deductible for the initial preventive physical examination (IPPE), the Annual Wellness Visit (AWV) and other Medicare-covered grade A or B preventive services recommended by the U. S. Preventive Services Task Force (USPSTF), effective Jan. 1, 2011. Medicare contractors, however, will not implement the systems changes necessary to correctly process claims for these services until April 4, 2011.

According to a National Institutes of Health (NIH) listserv, since additional revenue lines are not separately payable, contractors have been instructed to move the associated charges to the noncovered field and to override reason code 31577 More than one unit is reported with revenue code 052X. This will allow claims to continue processing and not delay payments.

Providers who submit claims between Jan. 1, 2011 and April 3, 2011 should not resubmit affected claims. To ensure the charges are reflected as covered, contractors will mass adjust the affected claims within 30 days after the claims processing instructions in Transmittal 2122, Change Request (CR) 7208 are implemented April 4, 2011.

Detailed HCPCS Level II coding is required, however, to ensure that coinsurance and deductibles are not applied to these preventive services when submitted by RHCs on a 71X type of bill with dates of service on or after Jan. 1, 2011.

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

See Transmittal 2122 for the official instruction. Attachment A includes a list of CPT® codes that are defined as preventive services under Medicare and the HCPCS Level II codes for the IPPE and AWV.

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