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HCPCS Reporting Requirements

In April 2016, CMS instructed RHCs to hold claims only for a billable visit shown in red on the Rural Health Clinic Qualifying Visit List until October 1, 2016. Upon billing these claims and/or for claim adjustments beginning on October 1, RHCs must add modifier CG (policy criteria applied) to the line with all the charges subject to coinsurance and deductible.

As of October 1, the MACs will accept modifier CG on RHC claims and claim adjustments. RHCs must report modifier CG on one revenue code 052x and/or 0900 service line per day, which includes all charges subject to coinsurance and deductible for the visit.

Coinsurance and deductible are waived for the approved preventive health services in Table 1 (below). When a preventive health service is the primary reason for the visit, RHCs should report modifier CG on the revenue code 052x service line with the preventive health service. Medicare will pay 100% of the AIR for the preventive health service.

When a patient requires a second visit on the same day, the subsequent medical service should be billed using revenue code 052x and modifier 59. Starting October 1, RHCs can also report modifier 25 to indicate the subsequent visit was distinct from an earlier one the same day. When modifiers 59 or 25 are reported, RHCs will receive the AIR for an additional visit. This is the only time modifiers 59 or 25 should be used.

There have been a number of questions on these reporting requirements. The National Association of Rural Health Clinics has confirmed:

  • Every Medicare RHC claim must have one “CG” modifier on it, even claims with only one service.

  • If an RHC is billing for only a preventive service, they still use the CG modifier.

  • For the purposes of RHC billing, modifiers 25 and 59 are interchangeable.

  • HCPCS codes G0436 and G0437 (tobacco cessation counseling) are discontinued for dates of service after October 1, 2016.

You can find CMS's full MLN Matters article on HCPCS reporting requirements here.

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