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The Least You Need to Know
This LCD addresses the
medical necessity of the face to face visit in the RHC place of service.
Its companion artical addresses statutorily based billing, coding and
reimbursement considerations; that article is the definitive reference
for RHC coverage interpretations at Riverbend. This LCD provides the
medical necssity basis for that article.
Rural Health Clinics provide covered services that can be divided into
RHC services and non-RHC services; RHC services are further subdivided
into physician services (evaluation and treatment by a physician or
physician extender) and services that are "incident to"
a physician service.
The definition of a face to
face encounter is detailed in the accompanying article. Patients that
present to the clinic for services that do not require the expertise of a
qualified RHC practitioner may receive those services "incident
to" a prior physician/extender service (face-to-face visit) but this
does not require a new face to face encounter. Even if the provider of
the service is a qualified RHC practitioner, the episode still does not
constitute a medically necessary visit unless physician/extender services
are provided in addition to the "incidental" services. Further,
the face to face encounter is not medically necessary because the service
does not require a practitioner level of expertise.
Thus there are situations
in which the provider of the service (e.g. the person giving an
injection) may be a qualified practitioner and the service (e.g. the
injection) may be medically necessary but it is not medically necessary
to have the practitioner re-examine the patient to deliver the service.
In these cases it is the physician/extender services that are medically
unnecessary; using physician/extenders for services routinely
performed by ancillary staff does not create additional reimbursable
face-to-face encounters as Medicare is specifically prohibited from
reimbursing medically unnecessary services [Section 1862(a )(1) of the
Act]. Riverbend is further charged with ensuring that RHC utilization
patterns do not diverge from hospital outpatient and physician office
patterns, as would be the case here.
Note that the services that do not require physician/extender expertise
(and are "incidental" services) are medically necessary
incidental services and are reimbursable through the cost report.
Many specialty services,
such as PT, cardiac rehab, and coumadin clinics, provide primarily
non-physician services and therefore generate a high level of costs per
face to face visit. These services are not prohibited in the RHC
environment, but the RHC may find that excluding them into a non-RHC
provider type creates a more appropriate reimbursement model. [Refer to
Pub 100-02, chpt 13, Sect 30.3]
This is neither a new
limitation on medically necessary services nor a new interpretation of
policy; rather it represents a compendium and explication of Riverbend's
longstanding interpretation of the various CMS regulations that govern
RHC services. Specific billing instructions and documentation
requirements are included.
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Rural health centers (RHCs) provide primary care services to beneficiaries
in rural physician shortage areas. To assist them in that mission, Congress
created a special reimbursement mechanism. Independent RHCs are paid a flat
rate for each face-to-face encounter based on the anticipated average cost
for direct and supporting services, with reconciliation of costs occurring
at the end of the fiscal year. This policy applies specifically to
independent (free-standing) RHCs but also applies to facility-based institutions
except where certain filing instructions are obviously inapplicable due to
the different mechanism of reimbursement.
The services provided at a rural health center can be divided into four
categories:
1. Face-to-face encounters (or "visits")[Pub 100-04, chpt 9, sect
40.4].
2. RHC services incident to a face-to-face encounter. These services are
not directly billed but are reimbursed through the cost report. [Pub
100-04, chpt 9, sect 40.2] Incidental services are typically provided by
non practitioners under general physician/extender supervision, although
practitioners (particularly therapists who are directly employed by the
RHC) frequently also provide incidental services.
3. Non RHC services. RHCs can provide part B covered services that do not
fall within their congressional mandate. Examples include physician
services to hospital inpatients and physical therapy by contracted
therapists. Non RHC services are not reimbursed under the all inclusive
rate; rather, they must be billed separately to the appropriate carrier.
[Pub 100-04, chpt 9, sect 40.1 and Pub 100-02, chpt 13, sect 30.3]
4. Noncovered services. Noncovered services may be provided and billed
directly to RHC patients. However, in no instance can Medicare
beneficiaries be billed for services that would be covered under Medicare.
[Pub 100.04, chpt 9, sect 210.1]
The correct assignment of charges into these categories is the crucial
element of correct Medicare billing and is discussed in the companion
article. This policy focusses on the medical necessity element of that
determination, specifically the medical necessity of the face to face
encounter with a practitioner.
Physician Services
For a face-to-face encounter to be medically necessary, providing
evaluation and management services at a skill level that requires the
assessment, clinical reasoning, and judgment of a qualified RHC
practitioner (i.e. the metaphorical "laying on of hands"). The
condition of the patient must warrant the specialized skills of the qualified
RHC practitioner. It is expected that either:
1) The patient will initiate the visit with a new problem or an
exacerbation of an existing problem that a prudent layperson would believe
requires evaluation and/or diagnosis by a qualified RHC practitioner OR
2) The patient has been rescheduled by the practitioner for a follow-up
visit under circumstances in which the specified frequency of follow-up is
customary, reasonable and necessary.
Medical necessity is required for Medicare services to be reimbursable.
This includes a necessity for a physician or physician extender level of
care in the case of a face-to-face encounter. Services that do not
medically require active physician/extender involvement during any given
trip to the facility lack medical necessity for a face-to-face encounter
even though the services themselves may well be medically necessary
ancillary or incidental services. As a corollary, a visit solely to obtain
an ancillary or incidental service does not constitute a medically
necessary face-to-face encounter.
In addition to billing constraints described in the companion article,
multiple encounters on the same day are not medically necessary except in
the unusual instance in which a patient acutely develops a new condition or
complication that medically necessitates a second evaluation on that same
day [42 CFR 405.2463(a)(3) and Pub 100-04, chpt 9, sect 40.4].
Medical services that do not follow usually accepted standards of current
medical practice are not medically necessary. This includes experimental
and investigational treatment, unproven applications of existing
technology, and diagnostic/treatment plans outside the mainstream of the
practice of medicine. In these instances the service is not medically
necessary, as is any visit whose primary purpose is to order, render or
evaluate the non-covered service.
Incidental ("Incident to") Services
Services that fit the description of incidental services do not establish
medical necessity for a face to face encounter. Services that are routinely
provided by ancillary personnel such as nurses, therapists, aides,
etc.--i.e. incidental services--do not constitute medically necessary face
to face encounters even if provided by a physician/extender, unless
specific documented medical necessity exists to require a
physician/extender level of expertise to render the service. However,
medical necessity does exist for periodic physician/extender evaluations to
manage the incidental services; only those intermittent evaluation and
management encounters should be billed as face to face visits. For the
purposes of determining whether a service is customarily a physician
service or an incidental/ancillary service, the FI will look at the usual
practices of the RHC for non-Medicare patients, the usual practice of other
RHCs, and the usual practice of outpatient clinics and traditional
physician offices.
Mental Health Services
Clinical Social Worker services in the RHC are medically necessary as a
separate face to face encounter only when they replace the services of
another practitioner (e.g. physician), not when they merely provide an
incidental service in support of a prior physician visit. CSW services are
typically medically necessary but not as a separate encounter. Billing of
CSW services is primarily a regulatory issue and is discussed in the
companion article.
Clinical Psychologist services in the RHC are also medically necessary as a
separate face to face encounter only when they replace the services of
another practitioner (e.g. physician), not when they merely provide an
incidental service in support of a prior physician visit. Psychologist
services are typically medically necessary but not as a separate encounter.
Billing of Clinical Psychology services is primarily a regulatory issue and
is discussed in the companion article.
Therapy Services
When personally performed by a physician/extender, therapy services are
valid physician services [42 USC 1395l(g)(1)]. One on one therapy services
with a physician/extender may be billed as face to face visits IF it is
medically necessary to utilize that level of expertise. For the purposes of
determining whether a given service is a physician service or an
incidental/ancillary service, the FI will look at the usual practices of
the RHC for non-Medicare patients and the usual practice of other RHCs.
Further, utilization patterns will be compared with outpatient clinics and
traditional physician offices. Face to face therapy encounters that are
uncharacteristically shorter or less intensive than their traditional
ancillary service counterparts (i.e. typically less than 30 minutes) will
be denied as not medically necessary.
Cardiac and Pulmonary rehabilitation (CR/PR) are NOT therapies. Based on
utilization patterns in other outpatient environments, up to three
physician contacts ("face-to-face visits") will be considered
medically appropriate to monitor the course of cardiac or pulmonary rehab.
Typically the first CR/PR visit will consist of the new patient
comprehensive examination and associated stress test, while the remaining
two visits consist of examinations needed to monitor patient progress (and
effect routine medication and treatment changes) and/or a post-service
evaluation and stress-test. Additional face to face visits only demonstrate
medical necessity when precipitated by a sudden deterioration or acute
event that necessitates a physician evaluation. A rhythm strip
interpretation would be covered (charges bundled) along with the face to
face in the setting of a physician evaluation following an acute event, but
the routine review of strips generated during CR/PR is typically done after
the fact, so additional face to face encounters are not medically
necessary. Similarly, routine changes in treatment regimens are usually
done based on reported progress, not a face to face exams, so again
medically necessary face to face encounters do not occur.
Monitoring and medically supervising rehabilitation is not within the scope
of practice of physician extenders. Physician extenders can and do provide
the individual services, but the individual services themselves do not
require a physician/physician extender level of expertise. Therefore the
individual rehabilitation sessions do not represent medically necessary
face to face encounters even when rendered by a physician/extender.
Injections
A visit solely to receive an injection does not constitute a medically
necessary face-to-face visit if the need for the injection was previously
determined. This is true even if a face-to-face contact is made. [CMS Pub
100-4, chpt 12-§200, 100-04, chpt 9, sect 20.1 and 40.4, CMS Pub 100-4,
17-§20]
Allergy shots. A visit solely to receive an allergy shot does not
constitute a medically necessary face-to-face visit even if a face-to-face
contact is made. The allergy shot is generally administered by ancillary
personnel and represents a service that is incident to a prior physician
visit. However, if the patient has an adverse reaction that necessitates a
physician/extender evaluation (and that examination, assessment and plan is
appropriately documented), the encounter may then be appropriately billed
as a face-to-face visit.
Methotrexate. Methotrexate in immunomodulating doses does not
require a physician visit beyond the frequency necessitated by the underlying
disease.
Vitamin B12. The IM administration of B12 may be transiently
necessary in any B12 deficiency state but is only medically necessary
chronically following a diagnosis of pernicious anemia or chronic
iatrogenic low stomach acid state. However, even when appropriately
administered, a face to face encounter is not medically necessary with each
injection. In the setting of newly diagnosed B12 deficiency with symptoms,
patient evaluations may be required weekly times four and then monthly
times twelve. In the absence of symptoms attributable to B12 deficiency,
two or three visits within the first six months may be necessary for
patient education and re-evaluation . Following this initial period, annual
visits may be necessary (whether or not the patient is continuing
injections) if the patient is not being otherwise seen for chronic
problems. More frequent physician/extender encounters are not medically
necessary due to the slow rate of relapse following B12 repletion.
Flu shots and vaccinations (influenza, hepatitis B and pneumonia
vaccines) do not necessitate a face to face visit.
Other injections (such as epogen) also usually represent incidental
services when the need for the injection is previously established, even if
the physician/extender specifies a change in dosage. This is because the
physician/extender is merely responding to a lab test; a re-evaluation of
the patient is not indicated with each adjustment. Conversely, a face to
face encounter is medically necessary when it is the accepted standard of
practice in physician offices and outpatient clinics, generally because a
clinical re-evaluation of the patient is also indicated (e.g. 24 hours
after an initial dose of IM antibiotics but not routinely after each
subsequent dose).
Dressing changes
There may be instances when a caretaker is unable to adequately perform
dressing changes or where the level of complexity of the care requires the
skills of a nurse. These dressing changes do not constitute medically
necessary face to face visits solely because the service was provided by a
physician/extender if similar services could be provided by nurses or other
designated office staff. Except in the special case of visiting nurse
services, medical necessity for a face to face encounter is based on:
1) The need for a physician/extender to monitor the underlying wound at a
frequency that does not differ from the usual patterns of utilization in an
office or outpatient clinic OR
2) An exacerbation or complication that would trigger an examination in
those environments OR
3) Sharp debridement requiring the skills of a physician/extender.
Lab tests
An encounter expressly for the purpose of obtaining blood for lab tests
does not constitute a medically necessary face-to-face visit even if a
face-to-face contact with the provider is made. To be considered as a
face-to-face visit, there must be some additional medically necessary
evaluation or management component.
The process of reporting a lab result to the patient, even if a medication
is changed as a result, is also usually incidental to the initial visit. A
visit for the purpose of reporting the lab result is only medically
necessary (in the absence of a separately indicated evaluation) when the
information being reported to the patient is of sufficient complexity or
gravity to demand an additional extended physician/extender discussion with
the patient. Examples of this would include (but are not limited to) a
complex metabolic profile with multiple abnormalities, an evaluation for
cancer, and a finding of a new disease (e.g. diabetes). The periodic
monitoring of a given test (e.g. INR, CBC, etc.) should not be associated
with routine follow-up visits to report the results as this does not
reflect the practice in physician offices and outpatient clinics. The
routine use of a visit to discuss lab results is not medically necessary.
Prescription Services
Writing or refilling prescriptions and services such as intermittently
dispensing medications (oral or injectable) to psychiatric patients or drug
abusers and counting/filling pill dispensers for disabled or demented
beneficiaries do not require a face to face evaluations in the typical
outpatient setting. Thus the need for a prescription refill or medication
disbursement will not contribute to establishing medical necessity for the
face to face encounter. These are covered services, but are incidental to
the underlying physician/extender examination and treatment.
Pain management is a covered RHC service but the enabling of a drug
addiction (either within or outside of a drug rehabilitation program) is
not. Frequent medication refills for narcotics do not represent medically
necessary face to face encounters, but they nonetheless indicate a
potential quality of care issue and the overall pain management strategy
should be well documented in the chart. Visits for the injection of
narcotics usually require an evaluation and thus a face to face visit, but
they should also be part of a well documented pain management strategy that
includes diagnostic investigations and/or pain specialty consultations that
attempt to minimize addiction and maximize patient well being. A pattern of
over-utilization of the RHC for multiple patients in the absence of pain
management strategies is not medically necessary and additionally may be an
indicator of more serious problems.
Paperwork
The paperwork involved in maintaining records, documenting encounters for
third parties and completing forms for patients is an incidental part of
medical practice. These services (when provided in support of an activity
not otherwise excluded from coverage, such as disability examinations) are
reimbursed by Medicare through the cost report as services incidental to
the covered encounter. A period of time spent solely in record keeping
cannot be considered as a face to face visit. An actual face to face
encounter solely for the purpose of creating or filling out paperwork is
not a medically necessary visit; the visit must be justified by a medically
necessary evaluation or treatment.
Visit for Non-covered Service
Face to face encounters primarily to receive services that are not
considered to be medically necessary (such as alternative medicine
interventions) are themselves not medically necessary.
Routine Services
Routine physician/extender examination, vision exams and examinations for
hearing aids are not Medicare covered services but are additionally
considered to be not medically necessary. The routine physical checkup
exclusion applies to all examinations performed without a relationship to
the treatment or diagnosis of a specific illness, symptom, complaint, or
injury; it also applies to examinations required by third parties (such as
employment or insurance evaluations). Eye examinations are not covered for
the purpose of prescribing, fitting or changing eyeglasses (e.g.
refractions). Eye examinations are only covered in conjunction with a
medically necessary evaluation to diagnose or treat an eye disease, and
hearing exams must be directed to uncovering a specific pathology.[Pub
100-02, chpt 16, sect 90] Routine foot care is not covered except in the
setting of a systemic disease that requires care to be performed by a
skilled practitioner in order to avoid the risk of injury to the
patient.[Pub 100-02, chpt 15, sect 290]
Unless specifically covered by statute, primary preventive services are not
covered and are additionally not considered to be medically necessary for
the diagnosis or treatment of disease. Screening tests are not medically
necessary for diagnosis when used for screening; they are only considered
medically necessary when used in the diagnosis or exclusion of suspected
disease. Preventive services therefore include medical social services, most
nutritional assessments, preventive health education, prenatal and
postpartum care, routine physicals (including well child care),
immunizations, eye and ear screening, family planning, routine screening
procedures (urine dipstick, stool guaiac, serum cholesterol, weight and
BP), risk assessment (including undirected history taking and physical exam
to ascertain risks), and thyroid screening, among others.
Certain screening and/or preventive services such as mammography have a
special benefit delineated by Congress. If a face-to-face visit is
medically necessary, it is covered and may be billed on that basis. However
the visit is only medically necessary if the practitioner personally
performed the service and the service is not typically performed by a
non-practitioner. Bone mass measurement therefore does not typically
support medical necessity for a visit unless the practitioner is need to
perform the exam itself. Stool guaiac for cancer screening would similarly
not support a face to face (unless the digital rectal exam benefit was
being provided).
Although Diabetes self management (DSM) must be certified as medically
necessary by a physician/extender, the actual educational intervention is
usually provided by other professionals, typically nurses. A face-to-face
service beyond that which occurred when the intervention was ordered
(certified) is not medically necessary.
Recurrent Services
1. Blood Pressure Measurement: Follow-up visits to monitor blood
pressure which include physician/extender evaluation and management
services are appropriately identified as encounters. The documentation
should reflect the performance of these services over and above the simple
measurement of a blood pressure. The frequency of follow-up is medically
necessary when consistent with the recommendations of The Sixth Report
of the Joint National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure.
[http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm] Specific
medical necessity must be clearly documented to support frequencies greater
than:
New diagnosis (first 6 months); lifestyle modification: monthly (q 30 days)
New diagnosis (first 6 months); pharmacological management: monthly (q 30
days)
Established diagnosis; lifestyle modification; controlled: quarterly (q 90
days)
Established diagnosis; pharmacological management; uncontrolled: monthly as
long as at least every other visit supports active intervention (change in
therapy)
Established diagnosis; pharmacological management; controlled: quarterly (q
90 days)
Accelerated or unstable hypertension with a need for rapid control of
pressure: medically necessary as long as each visit supports ongoing direct
and active intervention (change in therapy) during the period of frequent
follow-up.
Visits solely to obtain BP measurements are incidental to the primary
E&M visit, and any follow-up at a frequency that is not supported by
current standards of care is not medically necessary.
2. Disease Management Clinics: Disease Management clinics do not
represent a special Medicare benefit category. Visits to clinics of this
type are subject to the same requirements for medical necessity as all
other face-to-face encounters: namely, there must be a requirement for a
physician/extender level evaluation, re-evaluation or therapeutic
intervention at each visit. Routine visits, i.e. visits at a frequency
greater than that which is supported by current standards of care in
physician offices and outpatient departments, are not medically necessary
and are not covered.
3. Lab Follow-up Clinics: Visits to lipid clinics, prothrombin
(Coumadin) clinics and other lab-based follow-up clinics generally do not
demonstrate a need for physician/extender face-to-face discussion of
results other than in the two or three visits following diagnosis.
Exceptions are expected to demonstrate a well-documented and unique need
for the face to face interaction. The routine use of a visit to discuss lab
results is clearly not medically necessary; medical necessity for this is
discussed above.
4. Specially Clinics: Diabetes clinic visits are medically necessary
when medical complications of the disease are addressed, or when monitored
at a frequency consistent with recommended standards of care. Routine Foot Care
clinics are always not medically necessary except in the setting of
diabetes with loss of protective sensation [Pub 100-04, chpt 32, sect 80].
Pain Management clinic visits demonstrate medical necessity for a given
frequency of visits when supported by the immediate pain management needs
at the time of each visit and by the documentation of progress with respect
to the overall pain management strategy.
5. Chiropractic clinics: Coverage of chiropractic services is
determined primarily by regulations, discussed in the companion article.
Off-site Services
A physician/extender visit to a beneficiary in a skilled SNF bed or a swing
bed is medically necessary on a monthly basis to evaluate the patient
status as it relates to the skilled service. A physician/extender visit may
constitute a medically necessary face-to-face more often than monthly only
if the medical record supports the necessity of more frequent evaluation.
(For the purposes of medical review, monthly shall mean no less than 21
days between visits.)
A physician/extender visit to a beneficiary in a non-skilled bed,
intermediate care facility or nursing home is not medically necessary on a
routine basis even if the nursing facility requires it as a condition of
patient residence. However, Medicare does "presume" visits to be
medically necessary if they are used to satisfy Federal Regulations. Based
on these requirements, detailed in the Code of Federal Regulations [42 CFR
483.40], a visit to a patient in a non-skilled bed, ICF or nursing home
will be considered medically necessary if it has been approximately 60 days
(for the purposes of medical review at least six weeks) since the last
visit. At frequencies greater than this the encounter is only medically
necessary if it occurs in response to a patient complaint or in follow-up
to an established medical condition; in both instances the visit is
medically necessary only if an office visit would be medically necessary
under the same circumstances.
Visiting Nurse Services
A physician/extender home visit to perform services typically rendered by
home health or visiting nurses is only covered as a distinct benefit when
the criteria for VNS are met. When VNS criteria are not met, the home visit
is subject to the same medical necessity requirements as an office-based
face to face encounter, and a physician/extender home visit solely to
perform home health services will be denied as not medically necessary for
a physician level of expertise.
Home Visit
Medical necessity for the home visit is identical to medical necessity for
office visit -- i.e. the fact that the patient is homebound does not confer
any additional necessity for a physician/extender level of care. A home
visit is not medically necessary if an office visit would not be medically
necessary for the same patient condition.
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