(Medicare Benefit Policy Manual)

110.1 - Dental, Podiatry, Optometry, and Chiropractic Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Dentists, podiatrists, optometrists, and chiropractors are defined as physicians in Medicare  statute, and qualified services furnished by physicians are billable visits in an RHC or FQHC.  These practitioners can provide RHC or FQHC services that are within their scope of practice and not excluded from coverage (e.g., Medicare coverage of chiropr actic services is limited to manual manipulation of the spine for a demonstrated subluxation).  An RHC or FQHC can bill for a face -to-face, medically necessary visit furnished by a dentist, podiatrist, optometrist, or chiropractor if the service furnished i s a qualifying visit for RHCs or FQHCs and all other requirements are met.  All services furnished must be within the state scope of practice for the practitioner, and all HCPCS codes must reflect the actual services that were furnished.  RHCs and FQHCs are  required to primarily provide primary health care.  Since dentists, podiatrists, optometrists, and chiropractors are not considered primary care physicians, they do not meet the requirements to be either i) a physician medical director or ii) the physicia n or non-physician  practitioner (NP, PA, or CNM) that must be available at all times the clinic is open.  Therefore, a dentist, podiatrist, optometrist, or chiropractor can provide a medically necessary, face- to-face visit with an RHC or FQHC patient only when the statutory and regulatory staffing requirements are otherwise met.  For additional information on these services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15 on Covered Medical and Other Health Service at http://www.cms.gov/Regulations -and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf .   110.2 - Treatment Plans or Home Care Plans  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Except for comprehensive care plans that are a component of authorized care management services (see section 230), treatment plans and home care oversight provided by RHC or FQHC physicians to RHC or FQHC patients are considered part of the RHC or FQHC visit and are not a separately billable service.   110.3 - Graduate Medical Education  (Rev. 263, Issued: Effective: 01-01-20, Implementation: 01-23-20)  Freestanding RHCs and FQHCs may receive direct graduate medical education (GME) payment for residents if the RHC or FQHC incurs the salaries and fringe benefits (including travel and lodging expenses where applicable) of residents training at the RHC or FQHC.  Allowable costs incurred by the RHC or FQHC for GME are paid on a reasonabl e cost basis and are not subject to the payment limit.  RHCs and FQHCs may claim allowable costs only while residents are on their RHC or FQHC rotation.  RHCs and FQHCs that are receiving GME payment may not separately bill for an RHC or FQHC visit provided by a resident, as the cost of these practitioners is included in the GME payment.  A medically -necessary medical, or a qualifying preventive health, face -to-face encounter with a teaching physician who is an RHC or FQHC practitioner may be a billable visit if applicable teaching physician supervision and documentation requirements are met.    Under Pub. 100-04, Chapter 12, section 100.1.1.C., the Primary Care Exception (PCE) only applies in an outpatient department or an ambulatory setting where a hospita l is claiming on the cost report the residents for indirect medical education and direct GME purposes.  Therefore, in the instance where the RHC or FQHC is incurring the cost of the resident(s), the PCE would not apply.  For additional information see 42 CFR 405.2468 (f)  and 42 CFR 413.75(b).  120 - Services and Supplies Furnished Incident to Physicians Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Incident to refers to s ervices and supplies that are an integral, though incidental, part of the physicians professional service and are:   Commonly rendered without charge and included in the RHC or FQHC payment;     Commonly furnished in an outpatient clinic setting;    Furnished under the physicians direct supervision; except for authorized care management services which may be furnished under general supervision; and   Furnished by RHC or FQHC auxiliary personnel.   Incident to services and supplies include:    Drugs and biologicals  that are not usually self -administered, and Medicare -covered preventive injectable drugs (e.g., influenza, pneumococcal);    Venipuncture;    Bandages, gauze, oxygen, and other supplies; or    Services furnished by auxiliary personnel such as a nurse, medical a ssistant, or other clinical personnel acting under the supervision of the physician.  Supplies and drugs that must be billed to the DME MAC or to Part D are not included. NOTE:   Payment for Medicare -covered Part B drugs that are not usually self -administered and are furnished by an RHC or FQHC practitioner to a Medicare patient are included in the RHC AIR or the FQHCs PPS per diem payment.  However, Section 1861(s)(2)(G) of the  Act provides an exception for RHCs when a physician prepares a specific formulation of an antigen for a patient if the antigen is forwarded to another qualified person (including a rural health clinic) for administration to such patient, by or under the  supervision of another such physician.  An RHC practitioner (physician, NP, PA, or CNM) acting within their scope of practice may administer the drug and the cost of the administration may be included on the RHC's cost report as an allowable expense.  Th e cost of the antigen prepared by a physician outside of the RHC is not included in the RHC AIR.  Physicians who prepare an antigen that is forwarded to an RHC should submit a claim for the antigen in accordance with instructions from the contractor that p rocesses their Part B claims and applicable CMS requirements.   120.1 - Provision of Incident to Services and Supplies  (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)  Incident to services and supplies can be furnished by auxiliary personnel.  All services and supplies provided incident to a physicians visit must result from the patients encounter with the physician and be furnished in a medically appropriate timeframe.  More than one incident to service or supply can be provided as a res ult of a single physician visit.    Incident to services and supplies must be provided by someone who has an employment agreement or a direct contract with the RHC or FQHC to provide services.  Services or supplies provided by individuals who are not emplo yed by or under direct contract with the RHC or FQHC, even if provided on the physicians order or included in the RHC or FQHCs bill, are not covered as incident to a physicians service.  Services that are not considered incident to include the services of an independently practicing therapist who forwards his/her bill to the RHC or FQHC for inclusion in the entitys statement of services, services provided by an independent laboratory or a hospital outpatient department, services furnished by a nurse, medical assistant, or other auxiliary personnel who is not an employee of or working under contract to the RHC or FQHC, including services provided by a third party under contract, etc.    Services and supplies furnished incident to physicians services are limited to situations in which there is direct physician supervision of the person performing the service, except for authorized care management services (as described in section 230) which may be furnished under general supervision.  Direct supervision does not require the physician to be present in the same room.  However, the physician must be in the RHC or FQHC and immediately available to provide assistance and direction throughout the time the incident to service or supply is being furnished.    When services and supplies are furnished incident to an RHC or FQHC visit, payment for the services are included in the RHC AIR or the FQHC PPS rate.  An encounter that includes only an incident to service(s) is not a stand- alone billable visit for RHCs or FQHC s.  120.2 - Incident to Services and Supplies Furnished in the Patients Home or Location Other than the RHC or FQHC  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Except for authorized care management services, services furnished incident to a physicians visit by RHC or FQHC auxiliary personnel in the patients home or location other than the RHC or FQHC must have direct supervision by the physician.  For example, if an RHC or FQHC nurse accompanies the physician to a pa tients home and administers an injection, the nurses services would be considered incident to the physicians visit.  If the same nurse makes the call alone and administers an injection, the services are not incident to services since the physician is not providing direct supervision.  The availability of the physician by telephone and the presence of the physician somewhere in the building does not constitute direct supervision.  (This rule applies only to the incident to provision.  It does not apply to visiting nursing services described in section 190.)  For additional information on supervision requirements for Part B services incident to physician services see Pub. 100 -02, Medicare Benefit Policy Manual, chapter 15, section 60.1. 120.3 - Payment for Incident to Services and Supplies  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Services that are covered by Medicare but do not meet the requirements for a medically necessary or qualified preventive health visit with an RHC or  FQHC practitioner (e.g., blood pressure checks, allergy injections, prescriptions, nursing services, etc.) are considered incident to services.  The cost of providing these services may be included on the cost report, but the provision of these services does not generate a billable visit.  Incident to services provided on a different day as the billable visit may be included in the charges for the visit if furnished in a medically appropriate timeframe.  Incidental services or supplies must represent an exp ense incurred by the RHC or FQHC.  For example, if a patient purchases a drug and the physician administers it, the cost of the drug is not covered and cannot be included on the cost report. If a Medicare- covered Part B drug is furnished by an RHC or FQHC practitioner to a Medicare patient as part of a billable visit, the cost of the drug and its administration is included in the RHCs AIR or the FQHCs PPS payment.  RHCs and FQHCs cannot bill separately for Part B drugs or other incident to services or supplies.   130 - Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services  (Rev. 252, Issued: 12-  07-18, Effective: 01- 01-19, Implementation: 01-  02-19)  Professional services furnished by an NP, PA, or CNM to an RHC or FQHC patient are services that would be considered covered physician services under Medicare (see section 110), and which are permitted by state laws and RHC or FQHC policies.  Services may include diagnosis, treatment, and consultation.  The NP, PA, or CNM must directly exa mine the patient, or directly review the patients medical information such as X -rays, EKGs and electroencephalograms, tissue samples, etc.  Except for services that meet the criteria for authorized care management or virtual communication services, telephone or electronic communication between an NP, PA, or CNM and a patient, or between such practitioner and someone on behalf of a patient, are considered NP, PA, or CNM services, and are included in an otherwise billable visit.  They do not constitute a separately billable visit.   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;