CMS Pub. 100-04, ch. 9, § 60.1

When billing Medicare, RHCs must report all services provided during the

encounter/visit by listing the appropriate revenue and HCPCS code. The additional

revenue lines with detailed HCPCS code(s) are for information and data gathering

purposes.

Encounters with more than one health professional and multiple encounters with the same

health professionals that take place on the same day and at a single location generally

constitute a single visit. For RHCs, the payment is applied to the service line with

revenue code 052X for medical and revenue code 0900 for mental health visits with

modifier (MOD) CG.

For example:

Appropriate

Rev Code

Appropriate

HCPCS code

MOD DOS Charges

0521 99213 -Evaluation

and Management

(E&M)

CG 01/01 300.00

Note: The examples in this chapter may vary and are subject to change as needed.

Please see section 50 for more information on reporting modifier CG.

For example:

Appropriate

Rev Code

Appropriate

HCPCS Code

MOD DOS Charges

0521 99213 - E&M CG 01/01 300.00

0770 G0402 -

Preventive Service

(PS)

01/01 50.00

Medicare will make an additional AIR payment for IPPE, when billed on the same day

with a qualified encounter/visit. When reporting an additional encounter/visit for IPPE,

the RHC reports the Appropriate HCPCS Code for the service. The revenue lines should

be reflected as follows:

For example:

Appropriate

Rev Code

Appropriate

HCPCS code

MOD DOS Charges

0521 99213 - E&M CG 01/01 75.00

0419 94640 - Breathing

treatment

01/01 75.00

0521 G0402 - Initial

Preventive

01/01 150.00

Physical

Examination

(IPPE)

For RHCs, Medicare will make an additional AIR payment for a subsequent illness or

injury that occurs on the same day. This is reported on the claim with an additional

service line with revenue code 052X, a valid HCPCS code and modifier 59. Please see

section 50 for more information on reporting modifier 59.

For example:

Appropriate

Rev Code

Appropriate

HCPCS code

MOD DOS Charges

0521 99213 - E&M CG 01/01 150.00

0479 69209 - Removal

of Wax from Ear

01/01 50.00

0521 99212 - OV

(Office Visit)

59 01/01 135.00

0272 A6402 - Surgical

Dressing

01/01 25.00

0279 29130 - Finger

Split

01/01 95.00