FQHC Billing Guide - JE Part A
Federally Qualified Health Centers (FQHC) Billing Guide
Requirement | Description |
---|---|
FQHC Provider Number Ranges |
3rd - 6th digits:
|
FQHC Bill Type CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100A |
|
Billable Visit CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100 CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 110.1 |
Face-to-face encounter between the patient and a Physician, Physician Assistant (PA), Nurse Practitioner (NP), Certified Nurse Midwife (CNM), Visiting Nurse , Clinical Psychologist (CP) or Clinical Social Worker (CSW) during which a FQHC service is rendered. FQHCs can bill for a face-to-face, medically necessary visit furnished by a dentist, podiatrist, optometrist, or chiropractor if the service furnished is on the list of qualifying visits for the FQHC and all other requirements are met. All services furnished must be within the state scope of practice for the practitioner and all HCPCS codes must reflect the actual services that were furnished. |
Grandfathererd Tribal FHQCs CMS Medicare Learning Network (MLN) Matters (MM)11203 |
IHS and tribal facilities and organizations that met the conditions of section 413.65(m) on or before April 7, 2000, and have a change in their status on or after April 7, 2000 from HIS to tribal operation, or vice versa or the realignment of a facility from one IHS or tribal hospital to another IHS or tribal hospital such that the organization no longer meets the CoPs, may seek to become certificated as grandfathered tribal FQHCs. These grandfathered tribal FQHCs would be required to meet all FQHC certification and payment requirements. The grandfathered PPS rates equals the Medicare outpatient per visit payment rate paid to them as a provider-based department, as sent annually by the IHS. Grandfather tribal FQHCs are paid the lesser of their chargers or a grandfathered tribal FQHC PPS rate for all FQHC services furnished to a beneficiary during a medically-necessary, face-to-face FQHC visit. January 1, 2020 through December 31, 2020, grandfathered tribal FQHC PPS rate is $427.00. FQHCs for grandfathered tribal FQHCs submitted with dates of service on or after January 1, 2020 through June 30, 2020 paid at the CY 2019 rate of $405.00 must be adjusted and paid at CY 2020 rate. The grandfathered tribal FQHCs rate will not be adjusted by the FQHC GAFs or be eligible for special payment adjustments under FQHC PPS for new patients, patients receiving an IPPE or AWV. The rate is also ineligible for exceptions to the single per diem payment that is available for FQHCs paid under FQHC PPS. In addition, the FQHC market basket adjustment that is applied annually to the FQHC PPS base rate will not apply to the grandfathered tribal FQHC PPS rate. For more information about Grandfathered Tribal FQHCs, please read MM11203. |
FQHC Practitioners CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section10.2 |
|
FQHC Revenue Codes CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B |
FQHC services must be billed with the FQHC revenue codes listed belowand a Healthcare Current Procedural Coding System (HCPCS) code describing the encounter:
|
Behavioral Health CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 160 |
Revenue code 0900 Allowed as second encounter on same day as medical visit, Diabetic Self-Management Training (DSMT) or Medical Nutrition Therapy (MNT) |
FQHC Services CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 50.2 |
|
Advance Care Planning (ACP) 2016 Physician Fee Schedule Final Rule - CMS-1631-FC CMS Advance Care Planning (ACP) Booklet |
ACP is considered a face-to-face service between a practitioner and a patient on advance directives and it is a stand-alone billable FQHC visit. If an ACP is rendered on the same day as the AWV it is considered a preventive service and must be reported with modifier 33.
|
General Care Management - Chronic Care Management, Principal Care Management CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 230.2 CMS Medicare Learning Network (MLN) Matters (MM)10175 |
CMS waived face-to-face requirement for Chronic Care Management (CCM).
CCM services are billable by adding G0511. General Behavioral seCare Management and Psychiatric Collaborative Care Model (CoCM) codes are billable FQHC services. Policy requirements can be found in MLN10175.
Effective January 1, 2021, FQHCs are paid for Principal Care Management (PCM) services when a minimum of 30 minutes of qualifying PCM services are furnished during a calendar month.
|
Transitional Care Management (TCM) CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 100.4 |
|
Telemedicine Services CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B |
Telemedicine is a non-FQHC service; however, FQHCs are allowed to bill the originating fee. Coinsurance and deductible will apply to the service. Allowed to process on claim when it is the only encounter listed on claim.
|
Virtual Communcations CMS Medicare Learning Network (MLN) Matters (MM)10843 |
Effective for services furnished on or after January 1, 2019, FQHCs are paid for virtual communication services. Virtual communication services can be billed along or with other payable services on an FQHC claim. Face-to-face requirements are waived when services are furnished to FQHC patient. Payment will be received for communications technology-based services or remote evaluation services when at least 5 minutes of communcations-based technology or remote evaluation servides are furnished by FQHC practitioner to an established patient. Services may only be billed when medical discussion or remote evaluation is for a condition not related to an FQHC service provided within the previous 7 days and does not lead to an FQHC services within the next 24 hours or at the soonest available appointment. More information for virtual communcations can be found in MM10843.
|
Visiting Nurse Services CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 190 CMS IOM, Publication 100-04, MEdicare Claims PRocessing Manual, Chapter 9, Section 50 |
Visiting Nurse services must be billed with:
|
Preventive Services CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 210.3 |
Not an all-inclusive list.
Hepatitis B Vaccine (G0010)
Hepatitis C Screening (GO472)
IPPE (G0402)
AWV (G0438 and G0439)
DSMT (G0108)
MNT (97802 and 97803)
Screening Pelvic and Clinical Breast Examination (G0101)
Screening Papanicolaou Smear (Q0091)
Prostate Cancer Screening (G0102)
Glaucoma Screening (G0117 and G0118)
Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)
|
Hospice Services MM12357 |
Beginning January 1, 2022, an FQHC can bill and get payment under the FQHC PPS respectively, when their employed and designated attending physician provides services during a patient’s hospice election.
|
HCPCS Codes for PPS Reimbursement CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 70.2.1 FQHC-PPS Specific Payment Codes |
List a specific payment code for each encounter:
Each specific payment code listed above must be submitted with a qualifying visit code on a separate line. For a list of qualifying visits refer to the FQHC-PPS Specific Payment Codes. |
Payment Type CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 10.2 |
FQHCs are paid under PPS per encounter for Medicare covered services, rate does not include services that are not defined as FQHC services.
FQHC is paid the lesser of the amount charged on the payment code or the PPS rate. |
"Incident-to" Services CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 110 |
"Incident to" refers to services and supplies that are an integral, though incidental, part of the service and are:
"Incident to" services and supplies include:
Submit separate service lines with revenue codes and HCPCS codes to reflect any cost associated with incident to services for data reporting purposes only. |
Frequency of Billing - Multiple visits on same date of service CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100 |
Per encounter date of service.
Modifier 59 - Distinct procedural service. Modifier 59 is the FQHC's attestation that the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day.
|
Supplemental PPS payment for FQHCs under contract with MA Plans CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.5 |
Do not bill on same claim as revenue codes 052X or 0900 Payment is based on the PPS rate without comparison to the provider's charge. The rate is also not adjusted for coinsurance or preventive services. The PPS rate will be compared with the MA plan rate for the FQHC visit. When the MA plan rate is lower than the PPS rate, the provider will be paid the different between the MA plan rate and the PPS rate. No payment will be made when the MA plan rate is higher than the PPS rate.
|
Non-allowed Revenue Codes CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 50 |
|
Non-FQHC Services CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 60 |
The below items are not FQHC services and are paid according to Medicare provisions for each type of service.
|
Laboratory Services CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 30.1.1 |
Bill all laboratory services, except for venipunctures, separately:
|
Beneficiary Coinsurance CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 80 |
Not applicable to preventive services |
Deductible CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Sections 50.1 |
Part B deductible does not apply to FQHC services |
Last Updated Tue, 25 Apr 2023 19:18:57 +0000