(Medicare Benefit Policy Manual)

 An NP or PA who is working as a substitute in an arrangement  similar to a locum tenens physician.  An RHC practitioner is a physician, NP, PA, CNM, CP, or CSW.  At least one of these practitioners must be present in the RHC and available to furnish patient care at all times the RHC is in operation.  A clinic that is  open solely to address administrative matters or to provide shelter from inclement weather is not considered to be in operation during this period and is not subject to the staffing requirements.  An NP, PA, or CNM must be available to furnish patient care  at least 50 percent of the time that the RHC is open to provide patient care.  This requirement can be fulfilled through any combination of NPs, PAs, or CNMs as long as the total is at least 50 percent of the time the RHC is open to provide patient care.  Only the time that an NP, PA, or CNM spends in the RHC, or the time spent directly furnishing patient care in another location as an RHC practitioner, is counted towards the 50 percent time.  It does not include travel time to another location, or time sp ent not furnishing patient care when in another location outside the RHC (e.g. home, SNF, etc.).   A clinic located on an island that otherwise meets the requirements for RHC certification is not required to employ an NP or PA, although it is still required to have an NP or PA at least 50 percent of the time that the RHC is in operation (OBRA 89, Sec 4024).  An island is a body of land completely surrounded by water, regardless of size and accessibility (e.g., bridges).  As of July 1, 2014, RHCs may contract  with non- physician practitioners (PAs, NPs, CNM, CPs or CSWs) if at least one NP or PA is employed by the RHC (subject to the waiver provision for existing RHCs set forth at section 1861(aa)(7) of the Act).  It is the responsibility of the RHC to assure th at all staffing requirements are met and that RHC practitioners provide services in accordance with state and federal laws and regulations.  See section 80.4 of this chapter for information on productivity standards for RHCs. 30.2 - RHC Temporary Staffing Waivers  (Rev. 239, Issued: 01 -09-18, Effective: 1-22- 18, Implementation: 1-22-18)  An existing RHC may request a temporary staffing waiver if the RHC met the staffing requirements before seeking the waiver, and either or both of the following occur:    An NP or PA is not currently employed by the RHC.   An NP, PA, or CNM is not furnishing patient care at least 50 percent of the time the RHC operates.  To receive a temporary staffing waiver, an RHC must demonstrate that it has made a good faith effort to recruit and retain the required practitioner(s) in the 90 day period prior to the waiver request.  Recruitment activities should begin as soon as the RH C becomes aware that they will no longer be in compliance with this requirement.  Good faith efforts can include activities such as advertising in an appropriate newspaper or professional journal, conducting outreach to an NP, PA, or CNM school, or other a ctivities.  Staffing waivers are for a period not to exceed 1 year.  The waiver cannot be extended beyond 1 year, and another waiver cannot be granted until a minimum of 6 months have elapsed since the prior waiver expired.  RHCs should continue their recruitment activities during the waiver period to avoid termination when the waiver period ends. An RHC will be terminated if any of the following occur:   The RHC does not meet the staffing requirements and does not request a temporary staffing waiver;    The RHC requests a temporary staffing waiver and the request is denied due to a lack of good faith effort to meet the requirements;   The RHC does not meet the staffing requirements and is not eligible for a temporary staffing waiver because less than 6 months have passed since the expiration of the previous waiver;    The RHC reaches the expiration date of the temporary staffing waiver and has not come into compliance; or    Other non- compliance issue.   30.3 - FQHC Staffing Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  FQHCs must have a core staff of appropriately trained primary care practitioners and meet other clinical requirements.  It is the responsibility of the FQHC to assure that all staffing requirements are met and that FQHC practitioners provide services in accordance with State and Federal laws and regulations.  Additional information on FQHC staffing requirements can be found at: http://bphc.hrsa.gov/about/requirements/index.html.  40 - RHC and FQHC Visits (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23) An RHC or FQHC visit is a medically -necessary medical or mental health visit, or a  qualified preventive health visit. The visit must be a face -to-face (one -on-one) encounter between  the patient  and a physician,  NP, PA, CNM,  CP, or a CSW  during which  time one or more RHC or FQHC services are rendered . However, 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 where 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.  A Transitional Care Management  (TCM) service can also be an RHC or FQHC visit.  Services furnished must be within the  practitioners state scope of practice, and only services that require the skill level of the RHC  or FQHC practitioner  are considered RHC or FQHC visits.  An RHC or FQHC visit can also be a visit between a home-bound patient and an RN or LPN under certain conditions. See section 190 of this chapter for information on visiting nursing services to home-bound patients.  Under certain conditions, an FQHC visit also may be provided by qualified pr actitioners  of outpatient DSMT  and MNT  when  the FQHC  meets  the relevant  program requirements  for provision of these services.   RHC  and FQHC  visits  are typically  evaluation  and management  (E/M) type  of services  or screenings for certain preventive services. A list of qualifying visits for FQHCs is  located  on the FQHC  web page at https://www.cms.gov/Center/Provider- Type/Federally - Qualified -Health -Centers -FQHC -Center.html.   40.1  Location  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)   RHC  or FQHC  visits may  take place  in:  the RHC  or FQHC,   the patients  residence (including  an assisted  living  facility),   a Medicare-covered Part A SNF (see Pub. 100- 04, Medicare Claims Processing  Manual,  chapter  6, section 20.1.1),   the scene of an accident , or  the location of the patient during a Hospice election, including a patients residence or a Medicare certified facility  RHC  and FQHC visits may  not take place in:  an inpatient or outpatient department  of a hospital, including a CAH,  or  a facility which has specific requirements that preclude RHC or FQHC visits  (e.g., a Medicare comprehensive outpatient rehabilitation facility, a hospice facility (except when the RHC/FQHC is furnishing hospice attending physician services during a hospice election),  etc.) . Qualified  services  provided to a RHC  or FQHC  patient are considered  RHC  or FQHC  services  if:  the practitioner  is compensated by the RHC  or FQHC  for the services provided;  the cost of the service  is included in  the RHC  or FQHC cost  report;  and;  other requirements  for furnishing services are met. This applies to full and part time practitioners, and it applies regardless of whether the  practitioner is an employee of the RHC or FQHC, working under contract to the RHC or  FQHC,  or is compensated  by the RHC  or FQHC  under  another  type  of arrangement.  RHCs and FQHCs should have clear policies regarding the provision of services in other  locations and include this in a practitioners employment agreement or contract. RHCs  and FQHCs providing RHC or FQHC service s in locations other than the RHC or FQHC  facility must continue to meet all certification and cost reporting requirements.  Services  in other locations may be subject to review by the A/B MAC. RHC or FQHC services  furnished by an RHC or FQHC practitioner m ay not be billed separately by the RHC or  FQHC practitioner, or by another practitioner or an entity other than the RHC or FQHC, even  if the service is not a stand -alone  billable  visit.  Services  furnished to  patients  in any type of hospital setting (inpatient, outpatient, or emergency department) are statutorily  excluded  from  the RHC/FQHC  benefit and  may  not be billed  by the RHC  or FQHC.   40.2 - Hours of Operation  (Rev. 239, Issued: 01 -09-18, Effective: 1-22- 18, Implementation: 1-22-18)  RHCs and FQHCs are required to post their hours of operations at or near the entrance in a manner that clearly states the days of the week and the hours that RHC or FQHC services are furnished, and days of the week and the hours that the building is open solely for  administrative or other purposes, if applicable.  This information should be easily readable, including by people with vision problems and people who are in wheel chairs.  Qualified services provided to an RHC or FQHC patient other than during the posted hours of operation are considered RHC or FQHC services when the practitioner is compensated by the RHC or FQHC for the services provided, and when the cost of the service is included in the RHCs cost report.  Services furnished at times other than the RHC or FQHC posted hours of operation to Medicare beneficiaries who are RHC or FQHC patients may not be billed to Medicare Part B if the practitioners compensation for these services is included in the RHC/FQHC cost report.  (See Section 100 on Commingling).  This applies to full and part time practitioners, practitioners who are employees, practitioners working under contract to the RHC or FQHC, and practitioners who are compensated by the RHC or FQHC under another type of arrangement.  RHCs and FQHCs should have clear policies regarding the provision of services at other times, and include this in a practitioners employment agreement or contract.   40.3 - Multiple Visits on Same Day  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Except as noted below, encounters with more than one RHC or FQHC practitioner on the  same day, or multiple encounters with the same RHC or FQHC practitioner on the same  day, constitute a single RHC or FQHC visit and is payable as one visit. This policy  applies regardless of the length or complexity of the visit, the number or type of  practitioners seen, whether the second visit is a scheduled or unscheduled appointment, or  whether the first visit is related or unrelated to the subsequent visit. This would include  situations where an RHC or FQHC patient has a medically -necessary face- to-face visit  with an RHC or FQHC practitioner, and is then seen by another RHC or FQHC  practitioner, including a specialist, for further evaluation of the same condition on the same day, or is then seen by another RHC or FQHC practitioner, including a specialist,  for evaluation of a different condition on the same day.   Exceptions are for the following circumstances  only:  The patient, subsequent to the first visit , suffers an illness or injury that requires  additional diagnosis or treatment on the same day (for example, a patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the RHC or FQHC). In this situation only , the FQHC would  use modifier 59 on the claim and the RHC would use modifier 59 or 25 to attest that the conditions being treated qualify as 2 billable  visits;    The patient has a medical visit and a mental health visit on the same day (2 billable visits ); or