Payment for Medicare Rural Health Clinic claims on hold, awaiting fix

April 19, 2016

WSHA has been actively following recent developments in Medicare payment for Rural Health Clinics (RHCs).  Medicare Administrative Contractors have been instructed temporarily to hold all claims from RHCs for dates of service after April 1, 2016 until a correction is made in the payment file. The Centers for Medicare and Medicaid Services (CMS) anticipates providing a corrected file by April 24. Since the Medicare contractors already must hold claims at least 15 days before payment, we anticipate this will not impact cash flow for clinics. WSHA, the Rural Health Clinic Association of Washington, and other groups have expressed concern to CMS that this must be resolved quickly to avoid serious impacts.

At issue are files related to the new billing requirement that RHCs must bill the CPT code for services provided as of April 1, 2016. Specific CPT codes will qualify the visit for encounter payment. In late March, the CMS expanded the list of codes that qualify for encounter payment to include a number of minor dermatology and orthopedic services often done in primary care clinics. These additional services have not yet been added to the files provided to the contractors and clinics have been told to delay billing claims that contain these additional codes until October 2016. There appear to be additional issues with the payment file that needed to be addressed.

We have been told the need to delay billing applies only in cases where these new codes are the only code that would qualify the visit as an encounter. No delay in billing is needed when the code is billed in conjunction with a separate office visit code or with another code that qualifies the visit as an encounter. (Andrew Busz,


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