(Medicare Benefit Policy Manual)

130.1 - NP, PA, and CNM Requirements  (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  Services performed by NPs, PAs, and CNMs must be:    Furnished under the general (or direct, if required by state law) medical supervision of a physician;    Furnished in accordance with RHC or FQHC policies and any physician medical orders for the care and treatment of a patient;    A type of service which the NP, PA, or CNM who furnished the service is legally permitted to f urnish by the state in which the service is rendered;    Furnished in accordance with state restrictions as to setting and supervision;    Furnished in accordance with written RHC or FQHC policies that specify what services these practitioners may furnish to patients; and    A type of service which would be covered under Medicare if furnished by a physician.   130.2 - Physician Supervision  (Rev . 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  RHCs and FQHCs which are not physician -directed must have an arrangement with a physician that provides for the supervision and guidance of NPs, PAs, and CNMs.  The arrangement must b e consistent with state law.    130.3 - Payment to Physician Assistants  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Section 1842(b)(6)(C) of the Act prohibits PAs from enrolling in and being paid directly for Part B services.  The only exception to this is found in Section 4205(d)(3)(B) of the Balanced Budget Act (BBA), which amended Section 1842(b)(6)(C) of the Act to allow Medicare to directly pay a PA when the PA was the owner of an RHC for a continuous period beginning befor e the date of the enactment of the BBA, and ending on the date the Secretary determines the RHC no longer meets the requirements of Section 1861(aa)(2) of the Act.  140 - Services and Supplies Furnished Incident to NP, PA, and CNM Services  (Rev. 239, Issue d: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Services and supplies that are integral, though incident to an NP, PA, or CNM service are:   Commonly rendered without charge or included in the RHC or FQHC payment    Commonly furnished in an outpatient clinic setting;    Furnished under the direct supervision of an NP, PA, or CNM, except for authorized care management services which may be furnished under general supervision; and   Furnished by a member of the RHC or FQHC staff. NOTE:  The direct  supervision requirement is met in the case of an NP, PA, or CNM who supervises the furnishing of the service only if such a person is permitted to exercise such supervision under the written policies governing the RHC or FQHC.  Services and supplies covered under this provision are generally the same as described in section 120 as incident to a physicians services and include services and supplies incident to the services of an NP, PA, or CNM. 150 - Clinical Psychologist (CP) and Clinical Social Worker (CS W) Services  (Rev. 252, Issued: 12-  07-18, Effective: 01- 01-19, Implementation: 01-  02-19)  A CP is an individual who:   Holds a doctoral degree in psychology, and   Is licensed or certified, on the basis of the doctoral degree in psychology, by the state in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.  A CSW is an individual who:   Possesses a masters or doctors degree in social work;   After obtaining the degree, has performed at least 2 years of supervised clinical social work; and   Is licensed or certified as a clinical social worker by the state in which the services are performed; or, in the case of an individual in a state that doe s not provide for licensure or certification, meets the requirements listed in 410.73(a)(3)(i) and (ii).   Services may include diagnosis, treatment, and consultation.  The CP or CSW must directly examine the patient, or directly review the patients medical information.  Except for services that meet the criteria for authorized care management or virtual communication services, telephone or electronic communication between a CP or CSW and a patient, or between such practitioner and someone on behalf of a pa tient, are considered CP or CSW services and are included in an otherwise billable visit.  They do not constitute a separately billable visit.  CSWs are statutorily authorized (1861(hh)(2) of the Act) to furnish services for the diagnosis and treatment of mental illnesses only.   Services that are covered are those that are otherwise covered if furnished by a physician or as incident to a physicians professional service.  Services that a hospital or SNF is required to provide to an inpatient or outpatient as a requirement for participation are not included.   Services performed by CPs and CSWs must be:   Furnished in accordance with RHC or FQHC policies and any physician medical orders for the care and treatment of a patient;   A type of service which the CP or CSW who furnished the service is legally permitted to furnish by the state in which the service is rendered; and   Furnished in accordance with state restrictions as to setting and supervision, including any physician supervision requirements.   160 - Service s and Supplies Incident to CP and CSW Services  (Rev. 252, Issued: 12- 07-18, Effective: 01- 01-19, Implementation: 01-  02-19)  Services and supplies that are integral, though incident to a CP or CSW service are:   Commonly rendered without charge or included in the RHC or FQHC payment;   Commonly furnished in an outpatient clinic setting;   Furnished under the direct supervision of the CP or CSW, except for  authorized care management  services which may be furnished under general supervision; and  Furnished by a member of the RHC or FQHC staff.   NOTE:  The direct supervision requirement is met in the case of a CP or CSW who supervises the furnishing of the service only if such a person is permitted to exercise such supervision under the written policies governing the RHC or FQHC.  Services and supplies covered under this provision are generally the same as described in section 120 as incident to a physicians services and include services and supplies incident to the services of a CP or CSW.   170 - Mental Health Visits  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)   A mental health visit is a medically -necessary face -to-face encounter between an RHC or  FQHC patient and an RHC or FQHC practitioner during which time one or more RHC or FQH C mental health services are rendered.  Effective January 1, 2022, a mental health visit is a face -to-face encounter or an encounter furnished using interactive, real- time, audio and video telecommunications technology or audio -only interactions in cases w here the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder. The CAA, 2023 extends the telehealth policies of the CAA, 2022 through December 31, 2024 if the PHE ends prior to that date .  The in -person visit requirements for mental health telehealth services and mental health visits furnished by RHCs and FQHCs begin on January 1, 2025 if the PHE ends prior to that date. There must be an in-person mental health service furnished within 6 months prior to the furnishing of the mental health service furnished via telecommunications and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patients medical record. RHCs and FQHCs are instructed to append modifier 95 (Synchronous Telemedicine Service Rendered via Real -Time Interactive Audio and Video Telecommunications System) in instances where the mental health visit was furnished using audio-video communication technology and to append modifier 93 (Synchronous Tel emedicine Service Rendered Via Telephone or Other Real- Time Interactive Audio -Only Telecommunications System) in cases where the service was furnished using audio-only communication. Mental health services that qualify as stand -alone billable visits in an FQHC are listed on the FQHC center website,  http://www.cms.gov/Center/Provider- Type/Federally -Qualified -Health -Centers -FQHC - Center.html . Services  furnished must be within  the practitioners  state scope of practice.   Medicare-covered mental health services furnished incident to an RHC or FQHC visit are  included in the payment for a medically  necessary  mental health  visit when an RHC or  FQHC  practitioner  furnishes  a mental  health  visit.  Group mental  health  services  do not      meet  the criteria  for a  one-one- one, face -to-face encounter  in an FQHC  or RHC.   A mental health service should be reported using a valid HCPCS code for the service furnished, a mental health revenue code, and for FQHCs, an appropriate FQHC mental health  payment code.  For detailed  information  on reporting mental  health  services and  claims processing, see Pub. 100-04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations- and- Guidance/Guidance/Manuals/downloads/clm104c09.pdf   Medication  management, or  a psychotherapy  add  on service,  is not  a separately  billable  service in an RHC or FQHC and is included in the payment of an RHC or FQHC medical  visit.  For example, when a medically -necessary medical visit with an RHC or FQHC  practitioner  is furnished, and on the same day  medication  management or  a psychotherapy add on service is also furnished by the same or a different RHC or FQHC  practitioner,  only one payment  is made for the qualifying medical services  reported  with a medical revenue code.  For FQHCs, an FQHC mental health payment code is not  required for reporting medication management or a psychotherapy add on service  furnished on the  same day  as a medical service.   180 - Physical Therapy, Occupational Therapy, and Speech Language Pathology Services (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)  Physical Therapy (PT), Occupational Therapy (OT), and Speech Language Pathology (SLP) services may be provided in the RHC or FQHC directly by a physician, NP, or PA, if included in the practitioners scope of practice.  A physician, NP, or PA may also supe rvise the provision of PT, OT, and SLP services provided incident to their professional services in the RHC or FQHC by a PT, OT, or SLP therapist.  PT, OT, and SLP therapists who provide services incident to a physician, NP, or PA visit may be an employee of the RHC or FQHC or contracted to the RHC or FQHC.  PT, OT, and SLP services furnished by an RHC or FQHC practitioner or furnished incident to a visit with an RHC or FQHC practitioner are not billable visits.  If the services are furnished on a day when no otherwise billable visit has occurred, the PT, OT, or SLP service provided incident to the visit would become part of the cost of operating the RHC or FQHC.  The cost would be included in the costs claimed on the cost report and there would be no billable visit.   190 - Visiting Nursing Services (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)