Rural Health Clinic

Table of Contents

• Counseling to Prevent Tobacco Use
  • Diagnosis Coding
  • Billing RHC for Smoking and Tobacco Cessation Services
  • Billing Multiple Visits on the Same Day
• Related Content

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Counseling to Prevent Tobacco Use

Coverage for tobacco cessation counseling for outpatient Medicare beneficiaries include those

• who use tobacco, regardless if they have signs or symptoms of tobacco-related disease,
• who are competent and alert at the time counseling is provided, and
• whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner (PA or NP).

Medicare covers two individual tobacco cessation counseling attempts per year.

• Each attempt may include a maximum of four intermediate or intensive sessions, with a total benefit covering up to eight sessions per year in a 12-month period:
  • 99406: Intermediate – more than three minutes up to ten minutes
  • 99407: Intensive – more than ten minutes
• To start the count for the second or subsequent 12-month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.

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Diagnosis Coding

• F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.221, F17.223, F17.228, F17.229, F17.290, F17.291, F17.293, F17.298, F17.299, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A and Z87.891

Additional ICD-10 codes may apply.

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Billing RHC for Smoking and Tobacco Cessation Services

RHCs are paid an AIR for qualified primary and certain preventive health services. In this setting, a smoking and tobacco use cessation counseling service can be considered a qualifying visit if it’s the only service performed that day. If another service was performed that’s considered a qualifying visit, the smoking and tobacco use cessation counseling service is billed as incident-to.

When an IPPE is billed on the same day as a smoking and tobacco use cessation counseling service, each service may be billed as a qualifying visit on the same claim. Report modifier CG for the service(s) that are considered to be the qualifying visit(s) for the proper payment to be generated for the services rendered.

When the smoking and tobacco use cessation counseling is the only service provided on the DOS and is reported as the qualifying visit, an RHC reports the following on a UB04 or electronic Part A claim:

• Revenue code 052X with preventive service CPT/HCPCS code
• One unit with associated charges
• AIR payment generated
• Coinsurance waived based on CPT/HCPCS

Example: Smoking and tobacco use cessation counseling as the only service provided on DOS.

This claim would generate one AIR payment.

When the smoking and tobacco use cessation counseling is reported in addition to a qualified medical visit, an RHC reports the following on a UB04 or electronic Part A claim:

• On separate claim line report.
  • Revenue code 052X with preventive service CPT/HCPCS code.
  • One unit with associated charges.
• Do not include the preventive service charges in qualifying visit total charges.
  • Ensure coinsurance does not include preventive service costs.

Example: Smoking and tobacco use cessation counseling provided on same DOS as billable encounter.

This claim would generate one AIR payment.

• Deductible applies
• Coinsurance applies to nonpreventive claim lines.
  • 20% total charges on qualified visit line.

The beneficiary copayment is waived by the Affordable Care Act for Medicare-covered preventive services recommended by the United States Preventive Services Task Force with a grade or A or B, which includes the smoking and tobacco use cessation counseling.

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Billing Multiple Visits on the Same Day

Encounters with more than one RHC practitioner on the same day, or multiple encounters with the same RHC practitioner on the same day, constitute a single RHC visit payable as one visit, except for the following.

The patient has an IPPE and a separate medical and/or mental health visit on the same day. IPPE is a once in a lifetime benefit and is billed using HCPCS code G0402 and revenue code 052X. The beneficiary coinsurance and deductible are waived.

Modifier CG does not need to be reported with the IPPE HCPCS code whether it’s billed alone or with other payable services on a claim. When the IPPE is furnished with another medically necessary face-to-face service, modifier CG is reported with the HCPCS code for the other billable service.

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Related Content

• Centers for Medicare & Medicaid Services (CMS) Rural Health Clinics Center
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 12
• CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Part 4, Section 210.4.1
• MLN® Educational Tool:Medicare Preventive Services
• Rural Health Clinics (RHCs) Reporting Requirements Frequently Asked Questions (FAQs)
• MLN Matters® MM9269 Revised: Required Billing Updates for Rural Health Clinics
• Rural Health Clinic (RHC) Preventative Services Chart

Reviewed 10/10/2024