(Medicare Benefit Policy Manual)

190 - Visiting Nursing Services (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  190.1 - Description of Visiting Nursing Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  A visiting nu rse provides skilled nursing services.  The determination of whether a service requires the skills of a nurse is based on the complexity of the service (e.g., intravenous and intramuscular injections or insertion of catheters), the condition of the patient  (e.g., a non -skilled service that, because of the patients condition, can only be safely and effectively provided by a nurse), and accepted standards of medical and nursing practice.  All services must be reasonable and necessary to the diagnosis and tre atment of the patients illness or injury within the context of the patients unique medical condition.  A service that can be safely and effectively self -administered or performed by a nonmedical person without the direct supervision of a nurse, is not considered a skilled nursing service, even if provided by a nurse. A service which, by its nature, requires the skills of a nurse to be provided safely and effectively continues to be a skilled service even if it is taught to the patient, the patients family , or other caregivers.  If a patient needs skilled nursing care and there is no one trained or able and willing to provide it, the services of a nurse would be reasonable and necessary to the treatment of the illness or injury.  The determination of whether visiting nurse services are reasonable and necessary is made by the physician based on the condition of the patient when the services were ordered and what is reasonably expected to be appropriate treatment for the illness or injury throughout the certifi cation period.  190.2 - Requirements for Furnishing Visiting Nursing Service  (Rev. 252, Issued: 12- 07 -18, Effective: 01-01-19, Implementation: 01- 02-19)   RHCs and FQHCs are paid for visiting nursing services when G0490 is on an RHC or FQHC claim and all of the following requirements are met:   The patient is considered confined to the home as defined in section 1835(a) of the Act and the Medicare Benefit Policy Manual, Chapter 7 (see http://www.cms.gov/Regulations -and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf ;   The RHC or FQHC is located in an area that has a shortage of home health  agencies;   The services and supplies are provided under a written plan of treatment;   Nursing services are furnished on a part- time or intermittent basis only; and   Drugs and biological products are not provided.   190.3 - Home Health Agency Shortage Area  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  A shortage of HHAs exists if an RHC or FQHC is currently located in a county, parish or similar geographic area in which the Secretary has determined that:    There is no participating HHA under Medicare, or adequate home health services are not available to RHC or FQHC patients even though a participating HHA is in the area; or   There are patients whose homes are not within the area serviced by a participating HHA; or considering the ar eas climate and terrain, whose homes are not within a reasonable traveling distance to a participating HHA.   190.4 - Authorization for Visiting Nursing Services  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   RHCs or FQHCs that are located in an area that has not been determined to have a current HHA shortage and are seeking to provide visiting nurse services must make a written request to the CMS RO along with written justification that the area it serves meets the required  conditions.  190.5 - Treatment Plans  for Visiting Nursing Services  (Rev. 252, Issued: 12- 07 -18, Effective: 01-01-19, Implementation: 01- 02-19)  For services and supplies that require a treatment plan, the treatment plan must be written and reviewed by a supervising physician, NP, PA, CNM, or CP, as appropriate, at least once every 60 days; and meet other documentation requirements.  If the patient does not receive at least one covered nursing visit in a 60- day period, the plan is considered terminated for the purpose of Medicare coverage unless:    The supervising physician has reviewed the plan of treatment and made a recertification within the 60- day period which indicates that the lapse of visits is a part of the physicians regimen for the patient, or   Nursing visits are required at intervals less frequently than once every 60 days, but the intervals are predictable (e.g., it is predictable that a visit is required only every 90 days for the purpose of changing a silicone catheter, etc.).   Home nursing visits furnished before the plan is put into writing are covered if authorized in writing by the supervising physician.   200 - Telehealth Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs and FQHCs may serve as an originating site for telehealth services, which is the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.  RHCs and FQHCs that serve as an originating site for telehealth services ar e paid an originating site facility fee.  Although FQHC services are not subject to the Medicare deductible, the deductible must be applied when an FQHC bills for the telehealth originating site facility fee, since this is not considered an FQHC service.  RHCs and FQHCs are not authorized to serve as a distant site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished, and may not bill or include the cost of a visit on the cost report.  This includes telehealth services that are furnished by an RHC or FQHC practitioner who is employed by or under contract with the RHC or FQHC, or a non -RHC or FQHC practitioner furnishing services through a direct or indirect contract.  For more information on Medicare telehealth services, see Pub. 100 -02, Medicare Benefit Policy Manual, chapter 15, and Pub. 100- 04, Medicare Claims Processing Manual, chapter 12.  210 - Hospice Services  (Rev. 230, Issued: 12- 09-16, Effective: 03- 09-17, Implementation: 03- 09-17)  210.1 - Hospice Attending  Physician Services Payment   (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Medicare beneficiaries who elect the Medicare hospice benefit may choose either an  individual physician, NP  or PA to serve as their designated attending practitioner (Section 1861(dd) of  the Act).  Beginning January 1, 2022, under  section 132 of the CAA 2021, RHCs and FQHCs are authorized to serve in this role. A physician , NP, or PA  who works for an RHC or  FQHC may p rovide hospice attending physician services during a time when he/she is working  for the RHC  or FQHC  (unless  prohibited by  their RHC  or FQHC  contract  or employment          agreement).  The RHC or FQHC would bill for these services as they would for any oth er qualified service to be paid the RHC AIR or the FQHC PPS rate, respectively.  A physician, NP, or PA who works for an RHC or FQHC may provide hospice attending services during a time when he/she is not working for the RHC  or FQHC  (unless prohibited by their RHC  or FQHC  contract or employment          agreement).  These services would not be considered RHC or FQHC services  and the physician or NP would bill for these services under regular Part B rules using his/her own  provider number. Any service prov ided to a hospice beneficiary by an RHC or FQHC practitioner must comply with Medicare prohibitions on commingling. (See section 100  of this chapter).      210.2 - Provision of Services to Hospice Patients in an RHC or FQHC  (Rev. 11803; Issued: 01-26-23; Effective: 01 -01-23; Implementation: 02-27-23)  For hospice services that are not described above in section 210.1, RHCs and FQHCs can treat hospice beneficiaries for medical conditions not related to  their terminal illness.  However, if a Medicare benefici ary who has elected the hospice benefit receives care from an RHC or FQHC related to his/her terminal illness, the RHC  or FQHC cannot be reimbursed for the visit, even if it is a medically necessary, face- to- face visit with an RHC or FQHC practitioner, since that would result in duplicate payment for services, except  under either  of the following circumstances:   The RHC or FQHC has a contract with the hospice provider to furnish core hospice services related to the patients terminal illness and related conditions when extraordinary circumstances exist within the hospice.  Extraordinary circumstances are described as unanticipated periods of high patient loads; staffing shortages due to illness or other short- term temporary situations that interrupt patie nt care; and temporary travel of a patient outside the hospices  service area ( 42CFR 418.64);   The RHC or FQHC has  a contract with the hospice provider to furnish highly specialized  nursing services that  are provided by the hospice so infrequently that  it would be impractical and prohibitively expensive for the hospice to employ a practitioner to provide these services.  For example, a hospice may infrequently  have a pediatric patient, and in those situations, contract with an RHC or FQHC that has a pediatric  nurse on staff to furnish hospice services  to the patient.  In these situations, all costs associated with  the provision of hospice services must be carved  out of the RHC  or FQHC  cost report,  and the RHC  or FQHC  would be reimbursed  by the hospice.  ( 42 CFR 418.64(b)(3)).  Any service provided to a hospice beneficiary by an RHC or FQHC practitioner must comply with Medicare prohibitions on commingling.  (See section  100 of this chapter).   220 - Preventive Health Services  (Rev. 230, Issued: 12-09-16, Effective: 03-09-17, Implementation: 03-09-17)  RHCs and FQHCs are paid for the professional component of allowable preventive services when all of the program requirements are met and frequency limits (where applicable) have not been exceeded.  The beneficiary copayment and deductible (where applicable) is waived by the Affordable Care Act for the IPPE and AWV, and for Medicare-covered preventive services recommended by the USPSTF with a grade or A or B.    220.1 - Preventive Health Services in RHCs  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23) Influenza  (G0008) , Pneumococcal  (G0009)  and COVID -19 vaccines, and certain COVID -19 monoclonal antibody products  Influenza, pneumococcal and COVID-19 vaccines and covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration are paid at 100 pe rcent of                                           reasonable cost through the cost report. No visit is billed, and these costs should not be included on the claim.  The beneficiary  coinsurance and deductible are waived.   Hepatitis  B Vaccine (G0010)  Hepatitis B vaccine and its administration is included in the RHC visit and is not separately billable.  The cost of the vaccine and its administration can be included in the line item for the otherwise qualifying visit.  A visit cannot be billed if vaccine administration is the only service the RHC provides. The beneficiary coinsurance and  deductible are waived.   Initial Preventive Physical  Exam (G0402)  The IPPE is a face- to-face one- time exam that must occur within the first 12 months  following the benefic iarys enrollment.  The IPPE can be billed as a stand -alone visit if it is the only medical  service provided on that day with an RHC practitioner.  If an IPPE  visit is furnished on the same day as another billable visit, two visits may be billed.  The beneficiary  coinsurance and deductible are waived.   Annual  Wellness  Visit  (G0438 and G0439)