(Medicare Benefit Policy Manual)

Hepatitis  B Vaccine (G0010)  Hepatitis B vaccine and its administration is included in the RHC 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 RHC provides. The beneficiary coinsurance and  deductible are waived.   Initial Preventive Physical  Exam (G0402)  The IPPE is a face- to-face one- time exam that must occur within the first 12 months  following the benefic iarys enrollment.  The IPPE can be billed as a stand -alone visit if it is the only medical  service provided on that day with an RHC practitioner.  If an IPPE  visit is furnished on the same day as another billable visit, two visits may be billed.  The beneficiary  coinsurance and deductible are waived.   Annual  Wellness  Visit  (G0438 and G0439)  The AWV is a face- to-face personalized prevention visit 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. The AWV can be billed as a stand -alone visit if  it is the only medical service provided on that day with an RHC practitioner. If the AWV  is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible are waived.   Diabetes Self -Management Training (G0108) and Medical Nutrition Therapy (97802 and 97803)  Diabetes self -management training or medical nutrition therapy provided by a regis tered  dietician or nutritional professional at an RHC may be considered incident to a visit with  an RHC  practitioner  provided all  applicable conditions are met. DSMT  and MNT  are not billable visits in an RHC, although the cost may be allowable on the cost report.  RHCs  cannot bill a visit for services furnished by registered dieticians or nutritional professionals. However, RHCs are permitted to become certified providers of DSMT services and report the cost of such services on their cost report for inclusion in the computation of their  AIR.  The beneficiary  coinsurance and deductible apply.  Screening  Pelvic  and Clinical Breast  Examination (G0101)  Screening pelvic and clinical breast examination can be billed as a stand -alone visit if it is  the only medical service provided on that day with an RHC practitioner. If it is furnished  on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible are waived.   Screening  Papanicolaou Smear  (Q0091)  Screen ing Papanicolaou  smear  can be billed  as a stand -alone visit if  it is the only medical  service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance  and deductible are waived.   Prostate  Cancer Screening  (G0102)  Prostate cancer screening can be billed as a stand -alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary coinsurance and deductible apply.  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 with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible apply.  Lung  Cancer Screening  Using  Low Dose  Computed  Tomography (LDCT)  (G0296)  LDCT  can be billed  as a stand -alone visit if  it is the  only medical  service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit,  it is not a separately billable visit.  The beneficiary coinsurance and deductible are waived.   NOTE : Hepatitis  C Screening  (GO472)  is a technical  service only and therefore  it is not  paid as part of  the RHC visit.   220.2 - Copayment and Deductible for RHC Preventive Health Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  When one or more qualified preventive service is provided as part of an RHC visit, charges for these services must be deducted from the total charge for purposes of calculating benef iciary copayment and deductible.  For example, if the total charge for the visit is $150, and $50 of that is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the total charge, and Medicare would pay 80 percen t of the $100, and 100 percent of the $50 (minus any deductible).  If no other RHC service took place along with the preventive service, there would be no copayment or deductible applied, and Medicare would pay 100 percent of the payment amount.  220.3 - Preventive Health Services in FQHCs  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  FQHCs must provide preventive health services on site or by arrangement with another provider. These services must be furnished by or under the direct supervision of a physician, NP, PA, CNM, CP, or CSW. Section 330(b)(1)(A)(i)(III) of the Public Health Service (PHS) Act required preventive health services can be found at http://bphc.hrsa.gov/policies regulations/legislation/index.html, and include:  prenatal and perinatal services;   appropriate cancer screening;   well-child services;   immunizations against vaccine -preventable diseases;   screenings for elevated blood lead levels, communicable diseases, and   cholesterol;   pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care;   voluntary family planning services; and  preventive denta l services.  NOTE: The cost of providing these services may be included in the FQHC cost report but they do not necessarily qualify as FQHC billable visits or for the waiver of the beneficiary coinsurance.   Influenza (G0008), Pneumococcal (G0009) and COVID -19 vaccines and certain COVID -19 monoclonal antibody products  Influenza, pneumococcal and COVID-19 vaccines and covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration 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 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. The beneficiary coinsurance is waived.   Initial Preventive Physical Exam (G0402)  The IPPE is a face- to-face one- time exam that must occur within the first 12 months following the beneficiarys  enrollment. The IPPE can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If an IPPE visit is furnished on the same day as another billable visit, FQHCs may not bill for a separate visit. T hese FQHCs will have an adjustment of 1.3416 to their PPS rate. The beneficiary coinsurance is waived.   Annual Wellness Visit (G0438 and G0439)  The AWV is a personalized face- to-face prevention visit 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. The AWV can be billed as a stand- alone visit if it is the only medical service provided on that day with an FQHC practitioner. If the AWV is furnish ed on the same day as another medical visit, it is not a separately billable visit. FQHCs that are authorized to bill under the FQHC PPS will have an adjustment of 1.3416 to their PPS rate. The beneficiary coinsurance is waived.  Diabetes Self -Management Training (G0108) and Medical Nutrition Therapy (97802 and 97803)  DSMT and MNT furnished by certified DSMT and MNT providers are billable visits in FQHCs when they are provided in a one-on- one, face- to-face encounter and all program requirements are met. Ot her diabetes counseling or medical nutrition services provided by a registered dietician at the FQHC may be considered incident to a visit with an FQHC provider. The beneficiary coinsurance is waived for MNT services and is applicable for DSMT.   DSMT must be furnished by a certified DSMT practitioner, and MNT must be furnished by a registered dietitian or nutrition professional. Program requirements for DSMT services are set forth in 42 CFR 410 Subpart H for DSMT and in Part 410, Subpart G for MNT services, and additional guidance can be found at Pub. 100-02, chapter 15, section 300.  Screening Pelvic and Cli nical Breast Examination (G0101)  Screening pelvic and clinical breast examination can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary coinsurance is waived.   Screening Papanicolaou Smear (Q0091)  Screening Papanicolaou smear can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance is waived.   Prostate Cancer Screening (G0102)  Prostate cancer screening can be billed as a stand -alone visit if  it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance applies.   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 with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance applies.  Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)  LDCT can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance is waived.   NOTE:  Hepatitis C Screening (GO472) is a technical service only and therefore not paid as part of the FQHC visit.   220.4 - Copayment  for FQHC Preventive Health Services (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Under the FQHC PPS, coinsurance will generally be 20 percent of the lesser of the FQHCs charge or the PPS rate.  When one or more qualified preventive services are provided as part of an FQHC visit, the A/B MAC will use the lesser of the FQHCs charge for the specific FQHC payment code or the PPS rate to determine the total payment amount.  To determine the amount of Medicare payment and the a mount of coinsurance that should be waived, the A/B MAC  will use the FQHCs reported line -item charges and subtract the dollar value of the FQHC's reported line -item charge for the preventive services from the full payment amount. For FQHC claims that con sist solely of preventive services that are exempt from beneficiary coinsurance, Medicare pays 100 percent of the lesser of the FQHCs charge or the FQHC PPS rate, and no beneficiary coinsurance is assessed.  230  Care Management Services                                                                      (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)