(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 13 - Rural Health Clinic (RHC) and  Federally Qualified Health Center (FQHC) Services   Table of Contents (Rev. 11803, 01-26-23)  Transmittals for Chapter 13   Index of Acronyms  10 - RHC and FQHC  General Information  10.1 - RHC General Information  10.2 - FQHC General Information  20 - RHC and FQHC Location Requirements  20.1 - Non -Urbanized Area Requirement for RHCs  20.2 - Designated Shortage Area Requirement  for RHCs  30 - RHC and FQHC Staffing Requirements  30.1 - RHC Staffing Requirements  30.2 - RHC Temporary Staffing Waivers  30.3 - FQHC Staffing R equirements  40 - RHC and FQHC Visits  40.1 - Location  40.2 - Hours of Operation  40.3 - Multiple Visits on Same Day  40.4 - Global Billing  40.5 - 3 Day Payment Window  50 - RHC and FQHC Services  50.1 - RHC Services  50.2 - FQHC Services  50.3 - Emergency Services  60 - Non RHC/FQHC Services  60.1 - Description of Non RHC/FQHC Services  70 - RHC  and FQHC  Payment Rate   70.1 - RHCs Billing Under the AIR  70.2 - RHC Payment Limit and Exceptions  70.2.1 -  Payment Limits Applicable to Independent RHCs, and Provider -Based RHCs in a Hospital with 50 or More Beds, and New RHCs  70.2.2  Payment Limits Applicable to Provider -Based RHCs in a Hospital with Less than 50 Beds  70.2.2.1 -  Determining Payment Limits for Specified (that is, Grandfathered) Provider -Based RHCs with an AIR Established for RHC Services Fu rnished in 2020 70.2.2.2 -  Determining Payment Limits for Specified (that is, Grandfathered) Provider -Based RHCs that did not have an AIR Established for RHC Services Furnished in 2020  70.3 -  FQHC PPS  Payment Rate and Adjustments  70.4 -  FQHC  Payment Codes  80 - RHC and FQHC Cost Reports  80.1 -  RHC and FQHC Cost Report Requirements  80.2 -  RHC and FQHC Co nsolidated Cost Reports  80.3 -  RHC and FQHC Cost Report Forms  80.4  RHC Productivity Standards  90 - RHC and FQHC Charges, Coinsurance, Deductible, and Waivers  90.1 -  Charges and Waivers  90.2 -  Sliding Fee Scale  100 -  Commingling  110 -  Physician Services  110.1 -  Dental, Podiatry, Optometry, and Chiropractic Services  110.2 -  Treatment Plans or Home Care Plans  110.3 -  Graduate Medical Education  120 -  Services and Supplies Furnished Incident to Physicians Services  120.1 -  Provision of Incident to Services and Supplies  120.2 -  Incident to Services and Supplies Furnished in the Patients Home or Location Other than the RHC or FQHC  120.3 -  Payment for Incident to Services and Supplies  130 -  Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services  130.1 -  NP, PA, and CNM Requirements  130.2 -  Physician Supervision  130.3 -  Payment to Physician Assistants  140 -  Services and Supplies Furnished Incident to NP, PA, and CNM Services  150 -  Clinical Psychologist a nd Clinical Social Worker Services  160 -  Services and Supplies Incide nt to CP Services  170 -  Mental Health Visits  180 -  Physical Therapy, Occupational Therapy, and Speech Language P athology Services  190 -  Visiting Nursing Services  190.1 -  Description of Visiting Nursing Services  190.2 -  Requirements for Furnishing Visiting Nursing Services  190.3 -  Home Health Agency Shortage Area  190.4  Authorization for Visiting Nursing Services  190.5  Treatment Plans  for Visiting Nursing Services  200 -  Telehealth Services  210 -  Hospice  Services  210.1 -  Hospice Attending  Physician Services Payment  210.2 -  Provision of Services to Hospice Patients in a n RHC or FQHC  220 -  Preventive Health Services  220.1 -  Preventive Health Services in RHCs  220.2 -  Copayment and Deductible for RHC Preventive Health Services  220.3-  Preventive Health Services in FQHCs  220.4 -  Copayment for FQHC Preventive Health Services  230  Care Management Services   230.1 -  Transitional Care Management Services  230.2 -  General Care Management  Services  Chronic Care Management, Principal Care Management, and General Behavioral Health Integration Services  230.2.1  Chronic Care Management (CCM) Services  230.2.2  Principal Care Management (PCM) Services  230.2.3  Chronic Pain Management (CPM) Services  230.2.4  General Behavioral Health Integration (BHI) Services  230.2.5  Payment for General C are Management Services   230.3 -  Psychiatric Collaborative Care Model Services   240  Virtual Communication Services   Index of Acronyms (Rev. 10729, 04- 26-21)  AIR  all inclusive rate  AWV  annual welln ess visit  BHI  behavioral health integration  CCM  chronic care management  CCN  CMS certification number  CNM  certified nurse midwife  CoCM  collaborative care model  CP  clinical psychologist  CSW  clinical social worker  DSMT  diabetes self -management training  EKG  electrocardiogram  E/M  evaluation and management  FQHC  Federally qualified health center  FTE  full time equivalent GAF  geographic adjustment factor  GME  graduate medical education  HCPCS  Healthcare Common Procedure Cod ing System  HHA  home health agency  HHS  Health and Human Services  HPSA  Health Professional Shortage Area  HRSA  Health Resources and Services Administration IPPE  initial preventive physical exam LDTC  low dose computed tomography  LPN  licensed practical nurse  MAC  Medicare Administrative Contractor  MEI  Medicare Economic Index  MNT  medical nutrition therapy  MSA  metropolitan statistical area  MUA  Medically -Underserved Area  MUP  Medically -Underserved Population NCD  national coverage determina tion NECMA  New England County Metropolitan Area  NP  nurse practitioner  OBRA -  Omnibus Budget Reconciliation Act  PA  physician assistant  PCE -  Primary Care Exception  PCM  Principal Care Management  PFS  physician fee schedule PPS  prospective payment system  PHS  Public Health Service  RHC  rural health clinic  RN  registered nurse  RO  regional office  RUCA  Rural Urban Commuting Area  SLP  speech language therapy  TCM  transitional care management  UA  urbanized area  USPSTF  U.S. Preventive Services  Task Force 10 - RHC and FQHC General Information  (Rev. 239, Issued: 01 -09-18, Effective: 1 -22-18, Implementation: 1-22-18)   10.1 - RHC General Information  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Rural  Health  Clinics  (RHCs)  were established  by the Rural  Health  Clinic  Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas.  RHCs have been eligible to participate in the  Medicare program since March 1, 1978, and are paid an all -inclusive rate (AIR) for  medically -necessary primary health services, and qualified preventive health services,  furnishe d by an RHC practitioner.  RHCs are defined in section 1861(aa)(2) of the Social Security Act (the Act) as facilities  that are engaged primarily in providing services that are typically furnished in an  outpatient  clinic.  RHC services  are defined  as:    Physician  services;    Services  and supplies  furnished incident  to a physicians  services;    NP, PA, certified  nurse  midwife  (CNM),  clinical  psychologist  (CP),  and clinical  social worker  (CSW) services; and    Services and supplies furnished incident to an NP, PA, CNM, or CP  services.  RHC services may also include nursing visits to patients confined to the home that are  furnished by a registered professional  nurse  (RN) or a licensed  professional  nurse  (LPN)  when  certain conditions are  met.  (See section 190 of  this manual)   To be eligible for certification as an RHC, a clinic must be located in a non -urbanized area, as determined by the U.S. Census Bureau, and in an area designated or certified  within the previous 4 years by the Secretary, Health and Human Services ( HHS), in any  one of the four types of shortage area designations that are accepted for RHC  certification.  (See section 20 of  this manual)   In addition to  the location  requirements,  an RHC  must:     Employ  an NP or  PA;  Have an  NP, PA, or CNM  working  at the clinic  at least  50 percent  of the time the clinic  is operating  as an  RHC;    Directly  furnish  routine  diagnostic  and laboratory  services;    Have arrangements with one or more hospitals to furnish medically necessary  services  that are not available  at the  RHC;    Have available drugs  and biologicals  necessary  for the  treatment  of emergencies;    Meet  all health  and safety  requirements;    Not be a rehabilitation agency  or a facility  that is primarily  for mental health  treatment;   Furnish onsite  all of the following  six laboratory  tests:    Chemical  examination of  urine  by stick  or tablet  method or  both;   Hemoglobin or  hematocrit;   Blood sugar;   Examination  of stool  specimens  for occult  blood;   Pregnancy  tests; and   Primary  culturing  for transmittal to  a certified  laboratory.    Not be concurrently  approved as  an FQHC,  and   Meet  other  applicable State  and Federal  requirements. RHCs can be either independent or provider -based. Independent RHCs are stand- alone  or freestanding clinics and submit claims to a Medicare Administrative Contractor (A/B  MAC).  They are assigned a CMS Certification Number (CCN) in the range 3800- 3974 or 8900- 8999. Provider -based RHCs are an integral and subordinate part of a hospital  (including a critical access hospital (CAH)), skilled nursin g facility (SNF), or a home  health agency (HHA).  They are assigned a CCN in the range 3400 -3499, 3975- 3999, or  8500- 8899. ( NOTE: A provider -based CCN is not an indication that the RHC has met the qualifications for the special payment rules applicable  to payment limit s discussed in section 70.2 of this chapter .) The statutory  requirements for  RHCs are  found in  section  1861(aa) of the Act. Many  of the regulations pertaining to RHCs can be found at 42 CFR 405.2400 Subpart X   and following, and 42 CFR 491 Subpart A   and following.  For inform ation on claims processing, see Pub. 100- 04, Medicare Claims Processing  Manual, chapter 9, http://www.cms.gov/Regulations -and- Guidance/Guidance/Manuals/downloads/clm104c09.pdf    For information on certification requirements, see Pub. 100-07, State Operations Manual, Chapter 2, and Appendix G, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf