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41.4.2.1 Freestanding Rural Health Clinic Services
The services listed below cannot be reimbursed to freestanding RHCs using the RHC nine-digit provider identifier. Use of the RHC 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, Texas Health Steps (THSteps), or family planning agency Medicaid nine-digit provider identifier:
• THSteps medical check ups.
•THSteps dental services.
•Family planning services (including implantable contraceptive capsules provision, insertion, or removal).
•Immunizations, unless they are billed outside of a THSteps medical check up.
These services (except for THSteps dental) must be billed with an AJ, AM, SA, or U7 modifier if performed in an RHC setting. Claims are paid under the Prospective Payment System (PPS) reimbursement methodology. When billing on the CMS-1500 claim form, use the appropriate national place of service code (POS) (72) for an RHC setting.
Payment to physicians for supplies is not a benefit of the Texas Medicaid Program. Costs of supplies are included in the reimbursement for office visits.
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 Medicaid nine-digit provider identifier.
Exception: If later in the same day the client suffers an additional illness or injury requiring diagnosis or treatment, the clinic may bill for a second visit.
Freestanding RHCs bill an all-inclusive encounter for services provided.
All services provided that are incidental to the encounter must be included in the total charge for the encounter. They are not billable as a separate encounter.
Exception: When billing for immunizations outside of a THSteps medical check up, procedure codes given in the THSteps section of this manual should be used. This is the only circumstance in which a freestanding RHC can bill for a procedure other than 1-T1015.
All services provided during a freestanding RHC encounter must be billed using procedure code 1-T1015. The total billed amount should be the combined charges for all services provided during that encounter.
One of the following modifiers must be reported with procedure code 1-T1015 to designate the health-care professional providing the services: AJ, AM, or SA with POS 2, TH, or U7.
Reminder: The primary initial contact is defined as "the health-care professional who spends the greatest amount of time with the client during that encounter."
If more than one health-care professional is seen during the encounter, the modifier (if appropriate) must indicate the primary contact. For example, if an NP, CNS, or PA performs an antepartum exam, modifiers SA or U7, and TH, must be entered. A maximum of two modifiers may be reported with each encounter.
If the encounter is for antepartum or postpartum care, use modifier TH. FQHCs and RHCs must continue to use a TD or TE modifier if billing for visiting nurse services in a client's home or if billing THSteps for a service performed by a nurse.
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