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41.4.2.2 Hospital-Based Rural Health Clinic Services
Hospital-based RHCs must use the encounter code 1-T1015. A hospital-based RHC is paid based on an all-inclusive encounter rate.
One of the following modifiers must be billed for general medical services: AJ, AM, or SA with POS 2, or U7.
The services listed below cannot be reimbursed to hospital-based RHCs using the RHC nine-digit provider identifier. Use of the RHC nine-digit provider identifier for billing these services causes claims to deny. Services in any of these four categories must be billed using the appropriate practitioner's group/individual, THSteps, or family planning agency provider identifier:
• THSteps medical check ups.
•THSteps dental.
•Family planning services (including implantable contraceptive capsules provision, insertion, or removal).
•Immunizations provided in hospital-based RHCs.
These services must be billed with an AM, U7, or SA modifier if performed in an RHC setting. Claims are paid under the PPS reimbursement methodology. When billing on the CMS-1500 claim form, use the appropriate national POS (72) for an RHC setting.
Outpatient hospital services (including emergency room services) and inpatient hospital services provided outside the RHC setting are to be billed using the individual or group physician provider identifier.
Hospital-based RHCs should bill pneumococcal and influenza vaccines as non-RHC services, under their hospital provider identifier.
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