Coding methods differ by who is doing the billing. Both providers and facilities must use the ICD-10-CM for diagnosis coding. But, health facilities code using ICD-10-PCS for treatments and procedures, while providers must use the AMA’s Current Procedural Terminology (CPT).

ICD-10-CM guide: https://www.cms.gov/medicare/Coding/ICD10/index.html
CPT Guide and Details: https://www.ama-assn.org/amaone/cpt-current-procedural-terminology

Rural Health Centers (RHCs) have specific billing procedures and coverage considerations.

RHC Billing: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf

RHC Coverage: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

Three warnings about billing procedures:

  • Just because a service is a benefit – does not mean it’s billable.
  • Just because there is an ICD-10 code for a service does not mean it’s billable.
  • Just because a service is billable – does not mean your practice will get paid (see coverage).

While careful coding can aide your practice it does not guarantee payout; however, maintaining best practices and careful documentation will aid in capturing payment. Medicare and Medicaid use the UB-04 form to determine payouts, but many issues can stand between you and payment. A simple check-list implemented before sending your UB-04 can help you receive your RHC payments. Checklist:

  1. Each line must include a Revenue Code (usually 052x/900).
  2. Must add CG (Policy Criteria Applied) Modifier on the line of the UB-04 that totals all bundled charges.
  3. Must list on a separate line each service of more than $0.01 that was bundled.
  4. Each preventative service must be listed on a separate code.

A simple thing that you can do to ensure smooth billing is to print out all revenue codes that pertain to your practice. Not every practice will need to use every code, so keeping an up to date list of your commonly used revenue codes will help your staff in the billing process.


Medical necessity is one of the most common reasons for payers to deny claims. Clearly specifying the reasons and outcomes of medical procedures initially in the billing record will reduce back work and increase payouts to your practice. There are a few common issues that should be kept in mind when preparing billing documentation:

  • Should be defined from a medical payer’s point of view, which may differ from the clinical view.
  • Requires documentation that the ordered treatment is necessary along with why it is necessary.
    • Any ordered diagnostic test/procedure should have an “indication,” e.g. the reason for conducting the test, and be linked to a diagnosis documented in the chart.
  • Reviewer for payer is often not clinically trained, so words should be common, and treatments should be clearly linked to symptoms.
  • Some insurers/payers will not pay for procedures that could be performed in outpatient settings. Refer to the most recent Medicare Inpatient Only Chart for more details (https://www.medicare.gov/coverage/inpatient-hospital-care).


Here are key factors to consider for inpatient billing:

  1. If your practice is a critical access hospital (CAH), there is a 4 day standard, which means that payment schemes are built around a 4 day average timeline of care.
    • Your practice is not forced to keep or discharge a patient for 4 days; the payment scheme is just built with that as an average.
  2. “Medical Necessity” of staying in inpatient care must be established.
  3. Documentation must be given by the provider for:
    • Diagnosis
    • Expected effect of admission
    • Expected Length of stay
    • Expected post discharge plan
    • Potential risks of not admitting (important to qualify as medically necessary)


There are few criteria for a qualifying outpatient visit for an RHC:

  1. Must be medically necessary, face-to-face encounter with a provider.
    1. No patient care is allowed before a provider is on-site. Before rooming a patient, a provider must be present on site.
    2. Cannot be in a Hospital/CAH.
    3. Could be in swing bed located in a hospital.
    4. Cannot have an RHC visit in hospice (unless for non-hospice reason).
  2. Dentists, podiatrists, optometrists, and chiropractors are eligible for care within their scope covered by Medicare. These do not qualify as only providers on site.
  3. Some preventative services can qualify (i.e. vaccinations for flu, HepB, etc.).
  4. Can be virtual communication (see below).
  5. Can be a visit between a home-bound patient and RN/LPN for skilled nursing services.
  6. Non-provider visits can be added to provider encounters 30 days before or after non-provider visit.


A swing bed is a lower acuity of care classification that can be thought of essentially as nursing home care within a hospital building. There are two main considerations when billing for swing bed care:

  1. The care is assumed to be less intense than standard inpatient care meaning fewer check-ins, less documentation, and fewer staff.
  2. To enter swing care, patients must be discharged from acute care and must be admitted to swing care.
    1. Documenting this helps limit liability for intensity of care provided.


Coding for RHC ancillaries (lab testing/EKG/X-Ray) can be a source of confusion. A fundamental tactic to keep in mind is to split up the technical (performing the test) and professional components (interpreting the test) for coding, since each goes on a different bill. The technical component (performing the test) cannot go on a RHC bill; instead, it is billed by whoever performs that test. RHCs are only able to bill for professional components (usually using code 93005 and 93010… not 993000).


Incident to refers to subsequent ‘incidental’ services that are part of a physician’s treatment plan, which are thus billed under the physician’s provider code. These can cause difficulty in determining billing appropriateness (detailed information can be found https://www.texmed.org/Template.aspx?id=2274).

Care provided by a non-physician can be billed under a physician’s number if the following criteria are met:

  • Patient is an established patient seen for the medical problem by the physician who created the treatment plan.
  • Subsequent visit is for only the same medical problem.
  • Documentation for visits clearly establishes relationships between visits.
  • The physician is in the office at the times of subsequent visits.


E&M refers to coding done for professional services. Medical licensure rules prohibit medical coders from assuming, guessing, or coding without documentation present (this also means that the coder cannot code and then get documentation). Coders are able to question but not lead, recommend, or suggest, and cannot code a DX (“probable” or “rule out” diagnoses in any setting). Utilizing clinical document improvement forms that key in physicians to key phrases can help overcome these issues. Common codes and more details can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243514.html.

Changes in E&M for 2019

  • No longer must document medical necessity for a home visit in lieu of a hospital visit.
  • Documentation is only required for changes since last payment.
  • Ancillary staff can document Chief complaint.
  • No longer have to re-document information from medical students or residents.

Changes in E&M for 2020

  • Same payment for all E&M levels.
  • Documentation required for a level 2 visit.
  • New “extended visit” codes.

Codes for are based off levels of History, Examination, and Medical Decision Making; time is not a factor in deciding billing codes for E&M.


Medicare Learning Matters – Articles published by the Medicare administration focused on coverage, billing and payments typically centered on common mistakes in billing. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html[/vc_column_text][/vc_column][/vc_row]