(Medicare Claims Processing Manual)

Payment based on charges of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co- insurance  0521  G0468   10/01  150.00  150.00  150.00  0 0521  G0439 PS  10/01  155.00  155.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     330.00  330.00     Payment = (150.00 (charges) * 100% = 150.00   Since the charges for the preventive service, G0439 are greater than the providers actual charge for the specific payment code G0468, Medicare pays 100% of the providers actual charge for the specific payment code, G0468.  Reporting Multiple G -codes  When a FQHC reports multiple specific payment codes (G-codes) on the same day, the total payment amount will be determined by comparing the sum of the charges for all the G-codes reported to the PPS rate.  When a qualified mental health visit occurs on the same day as a qualified medical visit, the G -codes will be totaled separately (see example 8).  Listed below is the order in which payment will be applied when multiple G-code s are reported on the same day:  Medical visits:  G0468- IPPE or AWV   G0466- Medical, new patient   G0467-Established patient  Mental health visits:  G0469-Mental health, new patient  G0470- Mental health, established patient  When G0466 (Medical, new patient) and G0468 (IPPE or AWV) are reported together, the add -on payment will be applied to G0468.   Example:  Payment based on PPS rate with multiple G- codes and preventive services  Because this scenario does not qualify for an exception to a per diem payment, the system will calculate and apply a PPS rate to only one of the specific payment codes.  However, the FQHC may list its actual charges for both specific payment codes, and the comparison would be between the PPS rate and the total of the providers charges for the specific payment codes. Payment would be based on the lesser amount.  PPS RATE, refl ecting a 1.3416 adjustment for new patients or a visit including an IPPE or AWV = 215.00  Total of provider charges for the specific payment codes (170.00 + 65.00) = 235.00 Providers charge for the Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  170.00  170.00  0521  G0438  PS   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0521  G0466   10/01  65.00  65.00  0521  92004   10/01  45.00  45.00  0001     440.00  440.00   Payment based on adjusted PPS rate of 215.00 REV CODE  HCPC CODE  MODS SERV DATE  TOTAL CHARGE COV CHARGE Payment  Coinsurance  0521  G0468   10/01  170.00  170.00  199.00  16.00  0521  G0438 PS   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  25.00  25.00  CO 97  0 0521  G0466   10/01  65.00  65.00  CO 97  0 0521  92004   10/01  45.00  45.00  CO 97  0 0001     440.00  440.00     Payment = (215.00 (PPS rate)  135.00 (preventive service G0438) * 80% + 135.00 preventive service  Coinsurance = (215.00 (PPS rate)  135.00 (preventive service G0438)) * 20%    Reporting Multiple Preventive Services  When multiple preventive services are reported on the same day, the coinsurance will be determined by carving out the total preventive ser vices charges.    Example:  Payment based on PPS rate with multiple G- codes and multiple preventive services   PPS RATE =225.00  Total G code charges (140.00 + 75.00 + 55.00) = 270.00  Total Preventive Services (135.00 +60.00) =195.00  REV  CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  140.00  140.00  0521  G0439  PS   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0521  G0467   10/01  75.00  75.00  0521  97802  PS   10/01  60.00  60.00  0521  G0466   10/01  55.00  55.00  0521  92004   10/01  45.00  45.00  0001     535.00  535.00   Payment based on PPS rate of 225.00 REV CODE  HCPC CODE  MODS SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co-insurance  0521  G0468   10/01  140.00  140.00  219.00  6.00 0521  G0439 PS   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  25.00  25.00  CO 97  0 0521  G0467   10/01  75.00  75.00  CO 97  0 0521  97802 PS   10/01  60.00  60.00  CO 97  0 0521  G0466   10/01  55.00  55.00  CO 97  0 0521  92004   10/01  45.00  45.00  CO 97  0 0001     535.00  535.00     Payment = (225.00  (135.00 +60.00)) * 80% + 135.00 + 60.00  Coinsurance = (225.00 (PPS rate)  (135.00 + 60.00)) * 20%    Influenza and Pneumococcal Pneumonia Vaccination  (PPV ) Flu and PPV vaccines and their administration will continue to be paid through the cost report.  However, these services should be reported on the claim for information purposes only.  Flu and PPV vaccines and their administration codes will not be carved out of the coinsurance calculation.    Example:  Payment based on charges with Flu and Flu administration co de services   PPS rate = 160.00  Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0438 PS   10/01  135.00  135.00  0636  90655   10/01  15.00  15.00  771 G0008   10/01  5.00 5.00 0001     305.00  305.00   Payment based on charges of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co- insurance  0521  G0468   10/01  150.00  150.00  150.00  0 0521  G0438 PS   10/01  135.00  135.00  CO 97  0 0636  90655 ****   10/01  15.00  15.00  CO  246***  0 0771  G0008 ****   10/01  5.00 5.00 CO 246  0 0001     305.00  305.00     Because flu and PPV are reported on the claim for information purposes only, G0438 remains as the only service payable on this claim.  Because the claim consists solely of preventive services for which coinsurance is waived, the contractor will pay 100% of the providers actual charge for the specific payment code, G0468.  *** CARC 246- This non-payable code is for required reporting only.  **** Flu/PPV ar e reported on the claim for information purposes only, the payment and coinsurance are not impacted by the charges associated with the Flu/PPV vaccine and their administration code.   Hepatitis B  Hepatitis B should be reported on the claim and is included i n the claim payment.  These services will be carved out of the coinsurance calculation.   Example:  Payment based on charges with Hepatitis B   PPS rate= 160.00  Preventive Services = 20.00 (15.00 +5.00) REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0467   10/01  150.00  150.00  0521  99213   10/01  135.00  135.00  0300  36415   10/01  5.00 5.00 0636  90746 PS   10/01  15.00  15.00  771 G0010 PS   10/01  5.00 5.00 0001     310.00  310.00   Payment based on charges of 150.00 REV CODE  HCPC  CODE  MODS SERV DATE  TOTAL CHARGE COV CHARGE  Payment  Co-insurance  0521  G0467   10/01  150.00  150.00  124.00  26.00  0521  99213   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  5.00 5.00 CO 97  0 0636  90746 PS   10/01  15.00  15.00  CO 97  0 0771  G0010 PS   10/01  5.00 5.00 CO 97  0 0001     310.00  310.00     Payment = (150.00 (charges)  20.00 (preventive service 90746 + G0010)) * 80% + 20.00 preventive  Coinsurance = (150.00 (charges)  20.00 (preventive service 90746 + G0010)) * 20%  Mental Health Services  Qualified mental health visits billed under revenue code 0900 receive an additional payment when billed on the same day as a medical visit.   Example:  Mental Health Services   PPS RATE for G0468:  $225.00  PPS rate for G0470: $160  Total of providers actual charges for the specific payment codes representing medical visits (140.00 + 75.00 + 55.00) = 270.00-  This does not include charges for G0470