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
  • 071Q - 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.
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, 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 FQHC revenue codes listed belowand 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
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
  • 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)
  • Chronic Care Management (CCM)
  • 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 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
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 Medicare Learning Network (MLN) Matters (MM)9234
CMS Medicare Learning Network (MLN) Matters (MM)10175

CMS waived face-to-face requirement for Chronic Care Management (CCM). Policy requirements for CCM can be found in MLN 9234.

  • Can be billed with another billable visit on the same date of service
  • CPT code 99490
  • Subject to coinsurance
  • Cannot be billed in conjuction with a TCM service

Effective February 15, 2018, CCM services is 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.

  • Can be billed with another billable visit on the same date of service
  • G0511 General Care Management
  • G0512 Psychiatric CoCM
  • Coinsurance and deductible apply
  • Cannot be billed in conjunction with other care management services
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 CenterDirect contact, telephone or electronic communication with patient/caregiver must begin within two business days of dischargeFace-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)
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 Q0134
  • Use appropriate revenue code 052X or 0900
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.

  • HCPCS code G0071
  • Revenue code 052X
  • Coinsurnace 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

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 administration is included in the FQHC visit and is not separately billable
  • The cost of the vaccine and its administration can be included in the line item for the otherwise qualifying visit
  • A visit cannot be billed if vaccine administration is the only service the FQHC provides

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

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

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

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

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 is is furnished on the same day as another medical visit, it is not serparately billable visit
  • Coinsurance is waivedo
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

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
  • 2017 PPS Base Rate - $163.49
  • 2018 PPS Base Rate - $166.60
  • 2019 PPS Base Rate - $169.77
  • 2020 PPS Base Rate - $173.50

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 

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 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.
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 50
  • 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 16, Section 30.1.1

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
  • Coinsurance is 20% of the lesser of the FQHC’s charge for the specific payment code or the 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 Thu, 02 Jul 2020 17:20:38 +0000