Federally Qualified Health Centers (FQHC) Billing Guide

Requirement Description
FQHC Provider Number Ranges 3rd  - 6th  digits:
  • 1000-1199
  • 1800-1989
FQHC Bill Type

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100A
  • 771 - Admit to discharge
  • 777 - Adjustment
  • 778 - Cancel
  • 770 - No payment
  • 77Q - Reopening
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.
FQHC Practitioners

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 10.2
  • Physicians
  • NP
  • PA
  • CNM
  • CP
  • CSW
FQHC Revenue Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B
FQHC services must be billed with the below FQHC revenue codes and a Healthcare Current Procedural Coding System (HCPCS) code describing the encounter:
  • 0521 - Clinic visit by member to FQHC
  • 0522 - Home visit by FQHC practitioner
  • 0524 - Visit by FQHC practitioner to a member in a covered Part A stay at SNF (Skilled Nursing Facility)
  • 0525 - Visit by FQHC practitioner to a member in a SNF (not in a covered Part A stay) or Nursing Facility (NF) or Intermittent Care Facility (ICF) or other residential facility
  • 0527 - FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area
  • 0528 - Visit by FQHC practitioner to other non- FQHC site (e.g., scene of accident)
  • 0519 - Clinic, Other Clinic (only for the FQHC supplemental payment)
  • 0900 - Behavioral Health Treatments/Services
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
Subject to Outpatient Mental Health Limitation which was phased out in 2014:
  • 2013 - Limitation is 81.25% of Medicare approved amount for service (Medicare pays 65% and patient pays 35%)
  • 2014 onward - the limitation is 100% of Medicare approved amount for service (Medicare pays 80% and patient pays 20%)
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
  • Physicians services, including services and supplies incidental to a physician services
  • NP, PA and CNM services, including services and supplies incidental to the NP, PA and CNM services
  • VN services to the homebound
  • CP and CSW Services, including services and supplies incidental to the CP and CSW services
  • Face-to-face medical or mental health services
  • Advance Care Planning (ACP) on/after January 1, 2016
  • Chronic Care Management (CCM) on/after January 1, 2016
  • Transitional Care Management (TCM)
  • Influenza, Pneumococcal and Hepatitis B vaccines
  • Hepatitis C screenings
  • Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)
  • Screening mammography
  • Screening pap smear and screening pelvic exam
  • Prostate cancer screening tests
  • Colorectal cancer screening tests
  • Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (MNT)
  • Diabetes screening tests
  • Bone mass measurement
  • Screening for glaucoma
  • Cardiovascular screening blood tests
  • Venipuncture, when rendered at FQHC
  • Ultrasound Screening for abdominal aortic aneurysm
  • Part B covered drugs that are furnished by, and "incident to", services of physicians and non physician practitioners of the FQHC
  • Medicare-covered preventive services recommended by U.S. Preventive Services Task Force (USPSTF) with a grade of A or B, as appropriate for individual
  • Prenatal and perinatal services
  • Appropriate cancer screening
Advance Care Planning (ACP)

2016 Physician Fee Schedule Final Rule - CMS-1631-FC
Effective January 1, 2016, 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.
  • Can be billed with another billable visit on the same date of service
  • CPT 99497 - First 30 minutes
  • CPT 99498 - Second 30 minutes
  • Append modifier 33 when ACP is rendered on same day as an AWV to waive coinsurance
Chronic Care Management (CCM)

CMS Medicare Learning Network (MLN) Matters (MM)9234
Effective January 1, 2016, CCM is a billable FQHC service. CMS waived face-to-face requirement for CCM. Policy requirements for CCM can be found in MM9234.
  • Can be billed with another billable visit on same date of service
  • CPT code 99490
  • Subject to coinsurance
  • Cannot be billed in conjuction with a TCM service
Transitional Care Management (TCM)

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 100.4
  • Can be billed as an encounter if it is the only service provided on the day
  • If occurs on the same date as another visit, only one encounter is allowed
  • Only one TCM visit paid and allowed for a 30-day post discharge period
  • Subject to coinsurance
  • Must be furnished within 30 days of date of discharge from hospital (including outpatient observation), SNF, or Community Mental Health Center
  • Direct contact, telephone or electronic communication with patient/caregiver must begin within two business days of discharge
  • Face-to-face visits must occur within seven days of discharge for high complexity decision making (CPT code 99496) or within 14 days of discharge for moderate complexity decision making (CPT code 99495)
Telehealth Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 80
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.
  • Revenue code 0780
  • HCPCS code Q3014
  • Use appropriate revenue code 052X or 0900
Visiting Nurse Services

Beginning with dates of service on or after April 1, 2016, Visiting Nurse services must be billed with:

  • FQHC Prospective Payment System (PPS) HCPCS payment code G0466 or G0467
  • Qualifying HCPCS code G0490
Preventive Services

CMS IOM, Publication 100-02, Medicare Claims Processing Manual, Chapter 13, Section 210.3
Influenza and Pneumococcal Vaccines
  • Vaccines and administrations are paid at 100 percent of reasonable cost through cost report
  • Cost is included in cost report and no visit is billed
  • FQHCs billing under All Inclusive Rate (AIR) must report these services with their charges on claim for informational and data collection purposes
  • FQHCs billing under PPS must include these charges on claim if furnished as part of an encounter
  • Beneficiary coinsurance is waived
Hepatitis B Vaccine (G0010)
  • Hepatitis B vaccine and administration is included in FQHC visit and is not separately billable
  • Cost of vaccine and its administration can be included in line item for otherwise qualifying visit
  • A visit cannot be billed if vaccine administration is only service FQHC provides
Hepatitis C Screening (GO472)
  • Screening is included in a FQHC visit and is not separately billable
  • Cost of professional component of screening can be included in line item for otherwise qualifying visit
  • A visit cannot be billed if this is only service FQHC provides
  • Effective for claims with dates of service on/after June 2, 2014, beneficiary coinsurance is waived
IPPE (G0402)
  • IPPE is a one-time exam that must occur within first 12 months following beneficiary's enrollment
  • IPPE can be billed as a stand-alone visit if it is only medical service provided
  • Paid Under AIR - If an IPPE visit is furnished on same day as another billable visit may bill for two visits
  • Paid Under PPS - If an IPPE visit is furnished on same day as another billable visit may not bill for a separate visit if IPPE is furnished on same day as another billable visits
  • Coinsurance is waived
AWV (G0438 and G0439)
  • AWV is a personalized prevention plan for beneficiaries who are not within first 12 months of their first Part B coverage period and have not received an IPPE or AWV within past12 months
  • Can be billed as a stand-alone visit if it is only medical service provided on date of service
  • If AWV is furnished on same day as another medical visit, it is not a separately billable visit
  • Coinsurance is waived
DSMT (G0108)
  • Qualify as FQHC visit when provided one-on-one in face-to-face encounter and all program requirements are met. Group sessions do not qualify as an encounter
  • Paid Under AIR - Separate encounter may be billed on same day as a medical or mental health encounter visit. Cannot be billed on same day as MNT
  • Paid Under PPS - Separate encounter is not allowed to be billed on same day as a medical or mental health encounter visit. Cannot be billed on same day as DSMT visit
  • Coinsurance is waived
MNT (97802, 97802 and G0270)
  • Qualify as FQHC visit when provided one-on-one in face-to-face encounter and all program requirements are met. Group sessions do not qualify as an encounter
  • Billing Under AIR - Separate encounter may be billed on same day as a medical or mental health encounter visit. Cannot be billed on same day as DSMT
  • Billing Under PPS - Separate encounter is not allowed to be billed on same day as a medical or mental health encounter visit. Cannot be billed on same day as DSMT visit
  • Coinsurance is waived
Screening Pelvic and Clinical Breast Examination (G0101)
  • Can be billed as a stand-alone visit if it is only medical service provided on that day
  • If it is furnished on same day as another medical visit, it is not a separately billable visit
  • Coinsurance is waived
Screening Papanicolaou Smear (Q0091)
  • Can be billed as a stand-alone visit if it is only medical service provided on that day
  • If it is furnished on same day as another medical visit, it is not a separately billable visit
  • Coinsurance is waived
Prostate Cancer Screening (G0102)
  • Can be billed as a stand-alone visit if it is only medical service provided on that day
  • If it is furnished on same day as another medical visit, it is not a separately billable visit
  • Coinsurance applies
Glaucoma Screening (G0117 and G0118)
  • Glaucoma screening for high risk patients can be billed as a stand-alone visit if it is only medical service provided on that day
  • If it is furnished on same day as another medical visit, it is not a separately billable visit
  • Coinsurance applies
HCPCS Codes for AIR Reimbursement

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Sections 100, 110.1B, 120
Required to report specific HCPCS codes when billing for FQHC services.

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:
  • G0466 - FQHC visit, new patient (reported with revenue codes 052X or 0519)
  • G0467 - FQHC visit, established patient (reported with revenue codes 052X or 0519)
  • G0468 - FQHC visit, Initial Preventive Physical Exam (IPPE) or Annual Wellness Visit (AWV) (reported with revenue codes 052X or 0519)
  • G0469 - FQHC visit, mental health, new patient (reported with revenue codes 0900 or 0519)
  • G0470 - FQHC visit, mental health, established patient (reported with revenue codes 0900 or 0519)
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
Cost report periods beginning prior to October 1, 2014; FQHCs paid under an all-inclusive rate per encounter for Medicare covered services; rate does not include services that are not defined as FQHC services.
  • 2015 Urban Upper Payment Limit - $130.05
  • 2015 Rural Upper Payment Limit - $112.56
Effective January 1, 2016, all FQHCs are paid under PPS per encounter for Medicare covered services, rate does not include services that are not defined as FQHC services.
  • Facility PPS rate is determined by multiplying the PPS Base Rate by the location's Geographical Adjustment Factor (GAF)
  • New Patient Visits and Preventive Health encounters will receive an additional 1.3416 adjustment
  • 2015 PPS Base Rate - $158.85
  • 2016 PPS Base Rate - $160.60
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:
  • Commonly rendered without charge or included in FQHC bill
  • Commonly furnished in an outpatient clinic setting
  • Furnished under physician's direct supervision
  • Furnished by a member of FQHC staff
"Incident to" services and supplies include:
  • Drugs and biologicals that are not usually self-administered, and Medicare-covered preventive injectable drugs (e.g., influenza, pneumococcal)
  • Venipuncture
  • Bandages, gauze, oxygen, and other supplies
  • Physical Therapy, Occupational Therapy and Speech Language Pathology
  • Assistance by auxiliary personnel such as a nurse, medical assistant, or anyone acting under supervision of physician
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.
  • When multiple encounters occur on same date of service, only one claim is submitted including coding for both encounters
  • Second encounter rendered must include modifier 59 signifying separate time of day, treatment and illness occurred subsequent to another medical or mental health visit.
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.
  • Append to services when when reporting unrelated services that occurred at separate times during day (e.g., patient left FQHC and returned later in day for an unscheduled visit for a condition that was not present during first visit)
  • Append on FQHC Payment Code G0467
  • Do not append to services when a patient sees more than one practitioner on same day, or has multiple encounters with same practitioner on same day, unless patient, subsequent to first visit, leaves FQHC and then suffers an illness or injury that requires additional diagnosis or treatment on same day
Supplemental AIR payment for FQHCs under contract with Medicare Advantage (MA) Plans

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.4
Do not bill on same claim as revenue codes 052X or 0900
Payment equals the difference between 100% of the FQHC's all-inclusive cost-based per visit and the average per visit rate received by the FQHC from the MA plan, less the beneficiary cost sharing allowed under the MA plan.
  • Revenue code 0519
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.
  • Revenue code 0519
Non-allowed Revenue Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B
  • 002x-024X
  • 029x
  • 045x
  • 054x
  • 056x
  • 060x
  • 065x
  • 067x-072x
  • 080x-088x
  • 093x
  • 096x-310x
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.
  • Chronic Care Management (CCM) prior to January 1, 2016
  • Hospital Services
  • Services provided by practitioners other than those specified above
  • Laboratory services
  • Technical components of diagnostic services
  • Telehealth distant-site services
  • Hospice services
  • Ambulance
  • DME
  • Prosthetic devices/body braces
  • Auxiliary services
Laboratory Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 130
Bill all laboratory services, except for venipunctures, separately: 
  • Provider-based FQHCs bill under parent provider to Part A on CMS UB-04 Claim Form
  • Independent FQHCs bill on CMS-1500 Claim Form to Part B
Beneficiary Coinsurance

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 80
  • FQHCs billing under AIR, coinsurance is 20% of charges for FQHC services
  • FQHCs billing under PPS, coinsurance is 20% of lesser of FQHCs charge for specific payment code or PPS rate
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 Sep 06, 2018