FQHC Billing Guide - JE Part A

Federally Qualified Health Centers (FQHC) Billing Guide

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

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 34, Section 10.4

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70

771 - Admit to discharge
777 - Adjustment
778 - Cancel
770 - No payment
77Q - Reopening

Note: "XXXQ" claim reopening request guidance found on Timely Filing

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.

Grandfathered Tribal FQHCs

CMS Change Request (CR) 13511

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.

Grandfathered 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. Effective January 1, 2025, through December 31, 2025, the grandfathered tribal FQHC PPS rate is $718. FQHC claims (TOB 77X) for grandfathered tribal FQHCs submitted with dates of service on or after January 1, 2025, paid at the CY 2024 rate of $667 must be adjusted and paid at the CY 2025 rate of $718.00. Grandfathered tribal FQHC claims with dates of service on or after January 1, 2025, through December 31, 2025, should be paid at the CY 2025 rate of $718.00 until CMS provides an updated payment rate for CY 2025. 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, read CR 13942.

FQHC Practitioners

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 10.2

CMS MLN006397

MM 13452 Medicare Physician Fee Schedule Final Rule Summary: CY 2024

CMS MLN1986542

Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) Provider Enrollment Frequently Asked Questions (FAQs)

Physicians
Nurse practitioners (NPs)
Physician assistants (PAs)
Certified nurse-midwives (CNMs)
Clinical psychologists (CPs)
Clinical social workers (CSWs)
Marriage and family therapists (MFTs)
Mental health counselors (MHCs)

FQHC Revenue Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100B

CMS Medicare Learning Network (MLN) Matters (MM) 13264

FQHC services must be billed with the FQHC revenue codes listed below 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 the 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
0905 - Intensive Outpatient Program (IOP) Services CMS MM 13264

Behavioral Health

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 70.5

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.2

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 40.3

Revenue code 0900
Allowed as second encounter on same day as medical visit, Diabetic Self-Management Training (DSMT) or Medical Nutrition Therapy (MNT)
FQHC would use modifier 59 on the claim to show that the treatment qualifies for 2 billable visits CMS MLN1783722

FQHC Services

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 50.2

CMS MLN006397

CMS MM 13264

CMS Health-Related Social Needs FAQ

CMS MM 13946

Physicians' services, including services and supplies incidental to a physician's 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)
Care Coordination (formerly Care Management) Services
Caregiver Training Services (CTS)
Intensive Outpatient Program (IOP) Services
Social Determinant of Health (SDOH) Risk Assessment
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 the U.S. Preventive Services Task Force (USPSTF) with a grade of A or B, as appropriate for the individual
Prenatal and perinatal services
Appropriate cancer screening
Dental services closely (inextricably) linked to specific medical services and meeting clinic policies

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.

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

General Care Management

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 230.2

CMS MLN006397

CMS MM 13452 - Medicare Physician Fee Schedule Final Rule Summary: CY 2024

Medicare Physician Fee Schedule for Calendar Year 2021 Fact Sheet

CR 12446

Advanced Primary Care Management Services

CMS MM 13946

Effective January 01, 2024, Care Coordination Services provided in FQHCs include:

Transitional Care Management (TCM)
Chronic Care Management (CCM)
Principal Care Management (PCM)
Chronic Pain Management (CPM)
General Behavioral Health Integration (BHI)
Remote Physiologic Monitoring (RPM)
Remote Therapeutic Monitoring (RTM)
Community Health Integration (CHI)
Principal Illness Navigation (PIN) and PIN-Peer Support (PIN-PS)
Psychiatric Collaborative Care Model (CoCM)
Advanced Primary Care Management (APCM)

Care Coordination services are billable FQHC services. Policy requirements are found in CMS MLN006397

G0511 General Care Management
G0512 Psychiatric CoCM
G0467 Transitional Care Management

General Care Management services are an FQHC services for treatment of patients with chronic conditions.

Bill the individual CPT or HCPCS code and add-on codes for each care coordination service, instead of HCPCS code G0511 (discontinue use by July 1,2025)
Can be billed multiple times for the same patient on the same date of service if the FQHC meet the requirements for billing each service code, medically necessary and reasonable, and no time counted twice.
Can be billed alone or with other payable FQHC services
Only one billing practitioner per facility can furnish and be paid for these services per month
Services are incidental to professional services of a physician or other billing practitioner, under general supervision
General Care Management Services include CCM, PCM, BHI, CPM, RPM, RTM, CHI, PIN, PIN-PS, and APCM
Require separate billable initiating visit with an FQHC primary care practitioner before care management services can be furnished
Requires an advance patient consent (verbal or written) documented in the patient's medical record
Can be billed in conjunction with a TCM service
Subject to coinsurance

General Care Management Services and Qualifying HCPCS/CPT Codes

CCM - 99487, 99490, 99491
PCM - 99424, 99426
CPM - G3002
BHI - 99484
RPM - 99453, 99454, 99457, 99091
RTM - 98975, 98976, 98977, 98980
CHI - G0019
PIN - G0023
PIN-PS - G0140
APCM - G0556, G0557, G0558

CHI (G0019)

CHI services provide tailored support and system navigation to help address unmet social needs that significantly limit a practitioner's ability to carry out a medically necessary treatment plan.
CHI services include person-centered planning, health system navigation, facilitating to community-based resources, practitioner, home and community-based care coordination, and patient self-advocacy promotion.
Requires an initiating visit where an unmet SDOH needs are identified
Incident to provisions apply under general supervision
Auxiliary personnel, including community health workers (CHWs) may perform the subsequent CHI services, and must meet applicable state requirements, including licensure
Advance patient consent (verbal or written) must be obtained by auxiliary personnel under supervision and documented in the patient's medical record
CPT code G0019 - First 60 minutes
CPT G0022 - Second 30 minutes (list in addition to G0022)
CHI services can be billed monthly as medically reasonable and necessary
Document the amount of time spent with the patient and the nature of the activities (i.e., health education, patient self-advocacy skills, health care access, etc.)
Document ICD-10 Z-codes Z55-Z65
Only one practitioner can bill for CHI services per month
Subject to coinsurance

PIN (G0023)

PIN services requires an initiating visit from a billing practitioner addressing a serious high-risk condition, illness, or disease that is expected to last at least three months, patient at significant risk of hospitalization, nursing home placement, acute exacerbation or decompensation, and functional decline or death
Some examples of a serious, high risk condition include, but are not limited to, cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dementia, HIV/AIDS, severe mental illness, and substance abuse disorder (SUD)
CPT code G0023 - First 60 minutes
CPT code G0024 - Second 30 minutes
PIN services may be performed by the auxiliary personnel, including patient care navigators or peer support specialists, incidental to the professional services of a physician or other billing practitioner, under general supervision
Auxiliary personnel must meet applicable state requirements and licensure
Must document the amount of time spent with the patient and the nature of activities in the medical record
Document ICD-10 Z codes
PIN services can be billed monthly as medically reasonable and necessary
Cannot be provided more than once per practitioner per month for any single serious high-risk condition
Cannot be billed concurrently for the same serious, high risk condition
Requires advance patient consent before providing PIN services, and obtained annually
Subject to coinsurance

PIN-PS (G0140)

PIN-PS services are for patient with high-risk behavioral health conditions.
PIN-PS CPT codes G0140 - First 60 minutes
CPT code G0146 - Second 30
Cannot be billed concurrently for the same serious, high-risk condition
Cannot be provided more than once per practitioner per month for any single serious high-risk condition
Requires advance patient consent
Subject to coinsurance

RPM (99453, 99454, 99457, 99091)

First 20 minutes minimum requirement that involve the collection, analysis, and interpretation of digitally collected physiological data, followed by the patient plan of care
RPM can only be furnished to an established FQHC patient with both acute and chronic conditions
Monthly remote monitoring services may be reported once during a 30-day period by one practitioner
RPM services may be furnished by physician, NPP, qualified health professional, or by clinical staff under general supervision
Can bill concurrently with other care management service codes, except for RTM

RTM (98975, 98976, 98977, 98980, 98981)

First 20 minutes minimum requirement that involve monitoring of respiratory system status, musculoskeletal status, therapy adherence or therapy response through scheduled recording or program alert, or interactive communication with patient or caregiver.
Data collection minimum apply (at least 16 days in a 30-day period) to existing RPM and RTM code families for CY 2024
Practitioners (psychiatrist, NPs, PTs, OTs, SLPs) may bill RPM or RTM, but not both RPM and RTM, concurrently with other care management services: CCM/TCM/BHI, PCM, and CPM, for the same patient, if time or effort is not counted twice and all requirements to report each service is met
Only one practitioner can bill RPM or RTM services associated with all medical devices, only once per patient, per 30-day period, and only when at least 16-day of date have been collected; and that the services must be reasonable and necessary
Practitioner may furnish separately RPM or RTM services during the global period, as long as the episode of care is separate from the global service, so long as other requirements for the global service and any other service during the global period are met; and as long as the remote monitoring services are unrelated to the diagnosis for which the global procedure is performed and the purpose of this episode of care is separate and distinct from the global procedure (remote monitoring service underlying condition is not linked to the global procedure or service)
When furnished by therapists, add appropriate therapy modifiers - GP, GO, or GN to reflect the specified plan of care under a physical therapy, occupational therapy, or speech-language pathology.

CMS waived face-to-face requirement for Chronic Care Management (CCM). CCM services furnished to patient with multiple chronic conditions CMS MLN909188

CCM can be billed with another billable visit on the same date of service
Billable by reporting CPT code G0511- General Management code
Primary care practitioners and some specialty practitioners may furnish and bill CCM services
Minimum of 20 minutes of qualifying CCM services per month
CPT code 99491 - only the practitioner time count toward the required reporting time threshold
CPT codes 99487, 99489, 99490 - clinical staff may furnish CCM services under general supervision of the billing practitioner and incident to provisions apply
Subject to coinsurance
Can bill TCM services with other care management services
G0511 General Care Management code can be billed either alone or with other payable services, starting January 01, 2024
G0511 can be billed multiple times in a calendar month

General Behavioral Health Integration (BHI) and Psychiatric Collaborative Care Model (CoCM) codes are billable FQHC services. Policy requirements can be found in CMS MLN909432, MLN1986542 and CMS MLN006397

Can be billed with another billable visit on the same date of service
G0511 general BHI
G0512 Psychiatric CoCM billable once per month
Face-to-face requirements waived
Services may be furnished by auxiliary personnel under general supervision
BHI involves integrative treatment of patients with primary care, mental health, and/or behavioral health conditions including substance use disorder
General BHI CPT code 99484 - First 20 minimum per calendar month
Psychiatric CoCM CPT code 99492 - First 70 minutes in the first calendar month
Psychiatric CoCM CPT code 99493 - Second 60 minutes in subsequent months
Coinsurances apply

PCM (99424, +99425, 99426, +99427)

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.
Single complex chronic condition lasting at least 3 months, which is focus of care plan
Condition is sufficient severity to place patient at risk of hospitalization or have been cause of recent hospitalization
Condition requires development or revision of disease-specific care plan
Condition requires frequent adjustments in medication regiment
Condition is unusually complex due to comorbidities

CPM (G3002, +G3003)

CPM services are furnished to patients with multiple chronic conditions that involve chronic pain, and may include a person-centered plan of care, care coordination, medication management, and other aspects of pain care
CPT G3002 - First 30 minutes of qualifying non-face-to-face CPM services per calendar month
CPT G3003 - Second 15 minutes - no frequency limit per month as medically necessary and G3002 requirement is met

APCM (G0056, G0057, G0558)

APCM services combine various care coordination and communication technology-based services into monthly bundle and not time-based
Primary care practitioners (e.g. physicians, NPPs) bill APCM once per patient per calendar month
Auxiliary personnel can provide APCM services under general supervision and incident-to rules apply
HCPCS code G0556 - patients with one chronic condition
HCPCS code G0557 - patients with two or more chronic conditions
HCPCS code G0558 - patients with two or more chronic condition and Qualified Medicare Beneficiary (QMB) status
If patient enrolled in APCM, they cannot participate in other Medicare care coordination services programs simultaneously to avoid duplication of services

Psychiatric Care Collaborative (CoCM)

CMS MLN006397

Offer specific model of care integrating primary health care services and psychiatric consultation with structured care management support to patients with mental health, behavioral health, or psychiatric conditions, including substance use disorders
Psychiatric CoCM CPT code 99492 - First 70 minutes in the first calendar month
Psychiatric CoCM CPT code 99493 - Second 60 minutes in subsequent months
Bill on HCPCS code G0512, either alone or with other FQHC payable services, once per month per patient
Only services furnished by FQHC practitioner or auxiliary personnel and within in scope of service can count towards the minimum 60 minutes time requirement
Requires an initiating visit within one year of furnishing psychiatric CoCM services
Requires advance patient consent (verbal or written)
Cost insurance apply
Psychiatric costs are reported in the non-reimbursable section of the cost report

Intensive Outpatient Program (IOP)

Note: This is an added row; insert after General Care Management and before Transitional Care Management (TCM).

Noridian Intensive Outpatient Program (IOP)

CMS MM 13264

CMS MM 13222

CMS MM 13222 - New Condition Code 92: Billing Requirements for Intensive Outpatient Program Services

Intensive Outpatient Program (IOP) services provide treatment at a level more intense than outpatient day treatment or psychosocial rehabilitation, but less intense than a partial hospitalization program.

FQHCs and Grandfathered tribal FQHCs must meet all FQHC certification and payment requirements
Caregiver training services CPT codes 97550 (first 30 minutes) and 97551 (each additional 15 minutes)
Report condition code 92 to identify claims for IOP services
Bill on revenue code 0905

IOP scope of benefits includes the following items and services:

Individual and group therapy with physicians or psychologists or other mental health professionals to the extent authorized under state law
Occupational therapy by a qualified occupational therapist or under appropriate supervision of a qualified occupational therapist by an occupational therapy assistant
Services of social workers, trained psychiatric nurses, and other staff trained to work with psychiatric patients
Drugs and biologicals provided for therapeutic purposes, which can't be self-administered
Individualized activity therapies that aren't primarily recreational or diversionary
Counseling, the primary purpose of which is treatment of the patient's condition
Patient training and education to the extent that training and educational activities are closely and clearly related to the patient's care and treatment
Diagnostic services CMS MM 13264

Transitional Care Management (TCM)

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 100.4

CMS MLN908628

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). CMS MLN908628

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.

Revenue code 0780
HCPCS code Q3014
Use appropriate revenue code 052X or 0900

Virtual Communications

CMS 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 communications-based technology or remote evaluation services 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 communications can be found in CMS MM 10843.

HCPCS code G0071
Revenue code 052X
Coinsurance and deductible apply

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:

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

Preventive Services

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 210.3

CR 13843

CMS MM 13937

Not an all-inclusive list.

Influenza (G0008) and Pneumococcal Vaccines (G0009)

Vaccines and administrations are paid at 100 percent of reasonable cost through the cost report
The cost is included in the cost report and no visit is billed
FQHCs must include these charges on the claim if furnished as part of an encounter
The beneficiary coinsurance is waived

Hepatitis B Vaccine (G0010)

Hepatitis B vaccine and its administration are separately billable with a qualifying visit
Practitioner's order is no longer necessary
The cost of the vaccine and its administration can be included in the line item for the otherwise qualifying visit
Include hepatitis B vaccine costs on the cost report from January 1, 2025, through June 30, 2025. Exclude these costs starting July 1, 2025
Starting July 1, 2025, billable with or without a qualifying visit at time of service and paid at 95 percent of their Average Wholesale Price (AWP)

Hepatitis C Screening (GO472)

Screening is included in a FQHC visit and is not separately billable
The cost of the professional component of the screening can be included in the line item for the otherwise qualifying visit
A visit cannot be billed if this is the only service the FQHC provides

Human Immunodeficiency Virus (HIV) Screening and Pre-Exposure (G0011, G0012)

PrEP for HIV Counseling HCPCS Code G0011 is considered a visit for FQHCs when furnished by an FQHC Practitioner
Frequency edits for eight counseling visits in 12 months are applicable for FQHCs
FQHCs do not need to enroll as a Medicare Part B pharmacy supplier or a DMEPOS pharmacy supplier to bill for PrEP for HIV drugs
Refer to Preventive Services - HIV Screening and Pre-exposure page for additional information

IPPE (G0402)

IPPE is a one-time exam that must occur within the first 12 months following the beneficiary's enrollment
IPPE can be billed as a stand-alone visit if it is the only medical service provided
If an IPPE visit is furnished on the same day as another billable visit may not bill for a separate visit if the IPPE is furnished on the same day as another billable visits
Coinsurance is waived

AWV (G0438 and G0439)

The AWV is a personalized prevention plan for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an IPPE or AWV within the past12 months
Can be billed as a stand-alone visit if it is the only medical service provided on date of service
If the AWV is furnished on the same day as another medical visit, it is not a separately billable visit
Coinsurance is waived
Added SDOH (G0136) as an optional element, covered once a year with cost sharing waived
Append modifier 33 (Preventive service) when SDOH is rendered on same day as an AWV to waive coinsurance

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
Separate encounter is not allowed to be billed on the same day as a medical or mental health encounter visit. Cannot be billed on same day as DSMT visit
Coinsurance is not waived
Must obtain written referrals for initial and subsequent DSMT visits from treating practitioner

MNT (97802 and 97803)

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
Separate encounter is not allowed to be billed on the same day as a medical or mental health encounter visit. Cannot be billed on same day as DSMT visit
Coinsurance is waived
Written referrals for initial and subsequent MNT visits must be obtained from physician, MD or DO
MNT furnished only by Registered Dietician (RD) or Nutrition professional

Screening Pelvic and Clinical Breast Examination (G0101)

Can be billed as a stand-alone visit if it is the only medical service provided on that day
If it is furnished on the 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 the only medical service provided on that day
If it is furnished on the 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 the only medical service provided on that day
If it is furnished on the same day as another medical visit, it is not a separately billable visit
Coinsurance is not waived

Glaucoma Screening (G0117 and G0118)

Glaucoma screening for high risk patients can be billed as a stand-alone visit if it is the only medical service provided on that day
If it is furnished on the same day as another medical visit, it is not a separately billable visit
Coinsurance is not waived

Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)

Can be billed as a stand-alone if it is the only medical service provided on that day
If it is furnished on the same day as another medical visit, it is not separately billable visit
Coinsurance is waived

Social Determinant of Health (SDOH) Risk Assessment

CMS MLN9201074 - Health Equity Services

CMS Health-Related Social Needs FAQ

CMS Improving Collection of SDoH Data Infographic

CMS Using Z-Codes Infographic

CMS Framework for Health Equity

CMS ICD-10 Codes

CMS AHC Health-Related Social Needs Screening Tool

Effective January 1, 2024, Social Determinants of Health (SDH) risk assessments, HCPCS code G0136, can be furnished using any standardized, evidence-based SDOH risk tool that has been tested and validated through research, includes the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties. One possible evidence-based tool includes the CMS Accountable Health Communities (AHC) tool. There are other standardized, evidence-based tools available that may be incorporated into the Electronic Health Record (EHR) or medical record.

SDOH risk assessment of one or more known or suspected SDOH needs that may interfere with the practitioner's diagnosis and treatment of a patient condition or illness
Stand-alone G code, 5-15 minutes for administering an SDOH risk assessment
SDOH can be performed by the treating physician or other practitioners (NPs, CNSs, CNMs, PAs)
SDOH may be furnished by auxiliary personnel under the general supervision of the billing practitioner incident to their professional services
Frequency of not more than once every six months per practitioner per beneficiary
SDOH should not be performed in advance of the associated E/M visit or behavioral health visit
It is not designed for routine screening
SDOH can be performed in both facility and non-facility settings
Collecting SDOH information from the patient before, during, or after the health care encounter would allow assignment of the appropriate ICD-10-CM diagnosis code(s).
It is not designed for routine screening
Part B deductible and coinsurance applies except when furnished as an optional element of the AWV
G0136 permanently added to the Medicare List of Telehealth Services

FQHCs may provide SDOH service with:

Evaluation and management (E/M) visit, which can include hospital discharge or transitional care management (TCM) services
Behavioral health office visit (CPT code 90791), such as psychiatric diagnostic evaluation and health behavioral assessment and intervention (HBAI codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168)
Annual Wellness Visit (AWV)

Important to check periodically with patients to follow-up on identified social risks to see if circumstances have changed.

Initiating Discussion with Patients

Respect the patient's privacy if they are uncomfortable discussing topics related to SDoH. Standard screening may not be accepted by all patients. The patient may ask why a provider needs to know if they are safe, have a place to live, access to food and transportation. Establishing a trusting patient-physician relationship is important when providing an explanation for the questions.

For example: A provider planning treatment may need to know if the patient can store medication, be able to follow-up, perform personalized care, and more.

Reporting SDoH diagnosis codes - Z55-Z65

ICD-10-CM includes a variety of classifications to code for persons with potential health hazards related to socioeconomic and psychosocial circumstances. Refer to the ICD-10-CM to code to the highest specificity in the following categories:

Z55 Problems related to education and literacy
Z65 Problems related to employment or unemployment
Z57 Occupational exposure to risk factors
Z58 Problems related to physical environment
Z59 Problems related to housing and economic circumstances
Z60 Problems related to social environment
Z62 Problems related to upbringing
Z63 Other problems related to primary support group, including family circumstances
Z64 Problems related to certain psychosocial circumstances
Z65 Problems related to other psychosocial circumstances

Claims Data

Top five diagnosis codes

Z59.00 - Homelessness, unspecified
Z63.4 - Disappearance and death of family member
Z59.6 - Low income
Z63.6 - Dependent relative needing care at home
Z63.0 - Problems in relationship with spouse or partner

Additional information on SDOH can be found on the CMS MLN9201074 - Health Equity Services

Caregiving Training Services (CTS)

CMS MLN9201074 - Health Equity Services

CMS Health-Related Social Needs FAQ

Effective January 1, 2024, CMS will pay FQHC practitioners to train caregivers to support patients with chronic illness or disabling condition (e.g., dementia) as part of the patient's individualized treatment plan or therapy plan of care.

CTS may be furnished by a physician or NPPs, or therapist - physical therapist (PT), occupational therapist (OT), or speech language pathologist (SLP)
CPT code 97550 - first 30 minutes
CPT code 97551 - second 15 minutes
Patient presence not required
CPT codes 97550, 97551 involves services performed with activities of daily living (ADL) billable by outpatient therapists
Report modifier KX as medically necessary
Report applicable plan of care modifiers - GP, GN, or GO
CPT codes 97550-97552 are not allowed via telehealth
Group behavioral training or therapy is not billable in FQHCs

Hospice Services

CMS MM 12357

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.

GV modifier on the claim line with the payment code (G0466 - G0470) each day a hospice attending physician service
This applies when a physician, Nurse Practitioner (NP), or Physician Assistant (PA)
Services are subject to only coinsurance
When the FQHC provides a hospice attending physician service that has a technical component (TC), the provider giving the TC would go to the hospice for payment

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

CMS Federally Qualified Health Centers (FQHC) Center

CR 13867

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
2025 PPS Base Rate - $202.65
2024 PPS Base Rate - $195.99
2023 PPS Base Rate - $187.19
2022 PPS Base Rate - $180.16

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 the FQHC bill
Commonly furnished in an outpatient clinic setting
Furnished under the physician's direct supervision
Furnished by a member of the 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 the supervision of the 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

CMS MLN1783722

CMS MM 13946

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 reporting unrelated services that occurred at separate times during the day (e.g., the patient left the FQHC and returned later in the day for an unscheduled visit for a condition that was not present during the first visit).
Append on FQHC Payment Code G0467.
Do not append to services when a patient sees more than one practitioner on the same day, or has multiple encounters with the same practitioner on the same day, unless the patient, subsequent to the first visit, leaves the FQHC and then suffers an illness or injury that requires additional diagnosis or treatment on the same day
Count as two separate and billable - IOP services on the same day with a medical visit
Count as two separate and billable - qualified medical and mental health visit on the same day
If a mental visit and IOP service occur on the same day, only the IOP service will be paid - the mental health visit included in IOP rate (packaged)
Count as two separate and billable - qualified dental and medical visit on the same day
Policy requirements are found on CMS MLN1783722

Supplemental PPS payment for FQHCs under contract with MA Plans

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.5

CMS MM 13264

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.