(Medicare Claims Processing Manual)

G0469  FQHC vi sit, mental health, new patient  A medically -necessary, face- to-face mental health encounter (one- on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving a mental health visit.   G0470  FQHC visit, men tal health, established p atient  A medically -necessary, face- to-face mental health encounter (one- on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient r eceiving a mental health visit.    Modifiers, FL 44  The FQHC reports modifier 59 when billing for a s ubsequent injury or illness.  This is not to be used when a patient sees more than one practitioner on the same d ay, 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.   Modifier 5 9 is the FQHCs attestation that the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day.  Modifier 59 should only be used when reporting unrelated services that occurred at separate times during the day (e.g., the patient had left the FQHC and returned later in the day for an unscheduled visit for a condition that was not present during the first visit).  For claims subject to the FQHC PPS, modifier 59 is only valid with FQHC Payment Code G0467.  Please see section 60.2 of this manual for more information on the FQHC Payment Codes.  Service Date, FL 45  Medicare requires a line item dates of service for all outpatient claims.  Medicare classifies RHC/FQHC claims as outpatient claims.  Non -payment service revenue codes  report dates as described in the table above under Revenue Codes.   Line items on outpatient claims under HIPAA require reporting of a line -item service date for each iteration of revenue code. A single date must be reported on a line item for the date the service was provided, not a range of dates.  For services that do not qualify as a billable visit, the usual charges for the services are added to those of the qualified visit.  RHCs/FQHCs use the date of the visit as the single date on the line item.  If there is no is billable visit associated with the services, then no claim is filed.   Service Units, FL 46  The RHC/FQHC enters  the number  of units  for each type  of service.  Units represent visits, which are paid based on the AIR or the FQHC PPS, no matter how many services are delivered.  Only one visit is billed per day unless the patient leaves and later returns with a different illness or in jury suffered later on the same day.   Total Charges, FL 47 The RHC/FQHC enters the total charge for the service descri bed on each revenue code line.  Payer Name, FL 50  The RHC/FQHC identifies the appropriate payer(s) for the claim.   National Provider Identifier (NPI)  Billing Provider, FL 56 The RHC/FQHC enters its own NPI.  When more than one encounter/visits is reported on the same claim i.e., medical and mental health visits, please choose the NPI of the provider that furnished the majorit y of the services.   Principal Diagnosis Code, FL 67 The RHC/FQHC enters diagnosis coding as required by ICD -9-CM o r ICD -10-CM Coding Guidelines.  Other Diagnosis Codes, FL 67A -Q The RHC/FQHC enters diagnosis coding as required by ICD -9-CM or ICD -10-CM Codi ng Guidelines.  Attending Provider Name and Identifiers, FL 76  The RHC/FQHC enters the NPI and name of the attending physician designated by the patient as having the most significant role in the determination and delivery of the patients medical care.   Other Provider Name and Identifiers, FL78 -79 The RHC/FQHC enters the NPI and name  NOTE:  For electronic claims using version 5010 or later, this information is reported in Loop ID 2310F  Referring Provider Name.   60 - Billing Requirements for RHCs and FQHCs  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  RHCs and FQHCs are institutional claims and are submitted to the MAC on TOB 71x and 77x.  Generally, only those services that are included in the RHC and FQHC benefits are billed on these claims.    The RHC and FQHC benefits are defined in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13 (http://www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf.)  All professional services in the RHC and FQHC benefit are paid through the AIR system or the FQHC PPS payment for each patient encounter or visit.  T echnical services (or technical components of services with both professional and technical components) are not billed on RHC/FQHC claims .  For FQHCs with cost reporting periods beginning on or after October 1, 2014, all services are paid according to the FQHC PPS methodology.  The visit rate includes: covered services provided by a FQHC practitioner and services and supplies furnished incident to the visit.  For additional information on FQHC services, see the Medicare Policy Manual, Chapter 13.  60.1 - Billing Guidelines for RHCs and FQHC Claims under the AIR System  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  When billing Medicare, FQHCs must report all services provided during the encounter/visit by listing the appropr iate HCPCS code.  The additional revenue lines with detailed HCPCS code(s) are for information and data gathering purposes.  RHCs are only required to report the appropriate revenue code for medical and mental health services.  Encounters with more than one health professional and multiple encounters with the same health professionals that take place on the same day and at a single location generally constitute a single visit.  For FQHCs, payment is applied to the service line wi th revenue code 052X and a valid evaluation and management (E&M) HCPCS code for medical visits and revenue code 0900 for mental health visits.  Since RHCs are not required to reported detailed HCPCS codes, the payment is applied to the service line with revenue code 052X for medical and revenue code 0900 for mental health visits.  However, an additional AIR payment may be made for IPPE, DSMT or MNT (FQHCs only), and a subsequent illness and injuries billed with modifier 59 (FQHCs only).  When reporting multiple services on FQHC claims, the 052X revenue line with the E&M HCPCS code must include the total charges for all of the services provided during the encounter, minus any charges for approved preventive services.   For approved preventive services with a g rade of A or B from the United States Preventive Services Task Force (USPSTF), the charges for these services must be deducted from the E&M HCPCS code for the purposes of calculating beneficiary coinsurance correctly.  For example, if the total charge for the visit is $350.00, and $50.00 of that is for a qualified preventive service, the beneficiary coinsurance is based on $300.00 of the total charge.   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  E&M code*   01/01  300.00  0771  Preventive Service code   01/01  50.00   * RHCs are not required to report a HCPCS code.   Medicare will make an additional AIR payment for IPPE, when billed on the same day with a qualified encounter/visit.  When reporting an additional encounter/visit for IPPE, the FQHC or RHC reports the appropriate HCPCS code for the service.  The revenue lines should be reflected as follows:   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  Office Visit   01/01  75.00  0419  Breathing Treatment   01/01  75.00  0521  IPPE   01/01  150.00   For FQHCs, Medicare will make an additional AIR payment for a subsequent illness or injury that occurs on the same day.  This is reported on the claim with an additional service line with revenue code 052X, a vali d HCPCS code and modifier 59.  Please see section 50 for more information on reporting modifier 59.   For Example:  Rev Code  HCPCS code  Modifier  Date of service  Charges  0521  Office Visit   01/01  150.00  0479  Removal of Wax From Ear   01/01  50.00  0521  Office Visit  59 01/01  135.00  0271  Wound Cleaning   01/01  25.00  0279  Bone Setting With Casting   01/01  95.00   Medicare will make an additional AIR payment to FQHCs when DSMT or MNT is reported on the same day with a qualified encounter/visit.  When reporting an additional encounter/visit for DSMT or MNT Report the appropriate HCPCS code for the service.  The reven ue lines should be reflected as follows:   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  Office Visit   01/01  75.00  0419  Breathing Treatment   01/01  75.00  0521  DSMT or MNT   01/01  150.00   FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim, the reporting of these codes are informational only.  MACs shall continue to pay for the influenza and pneumococcal vaccines and their administr ation through the cost report.   60.2 - Billing for FQHC Claims Paid under the PPS  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  FQHCs transitioning to the PPS must submit separate claims for services subject to the PPS an d services paid under the AIR.   CMS established five FQHC payment specific codes to be used by FQHCs submitting claims under the PPS.  When reporting an encounter/visit for payment, the FQHC must bill on the claim (77X TOB ) a FQHC specific payment code.   FQHC Specific Payment Codes   G0466  FQHC visit, new patient  A medically -necessary, face- to-face encounter (one- on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Me dicare- covered services that would be furnished per diem to a patient receiving a FQHC visit.   G0467  FQHC visit, established patient A medically -necessary, face- to-face encounter (one- on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving a FQHC visit.   G0468  FQHC visit, IPPE or AWV  A FQHC visit that includes an IPPE or AWV and includes a typical bundle of Medicare -covered services that would be furnished per diem to a pa tient receiving an IPPE or AWV.   G0469 FQHC visit, men tal health, new patient  A medically -necessary, face- to-face mental health encounter (one-on- one) between  a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient r eceiving a mental health visit.   G0470  FQHC visit, men tal health, established patient A medically -necessary, face- to-face mental health encounter (one-on- one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medi care- covered services that would be furnished per diem to a patient r eceiving a mental health visit.