(Medicare Claims Processing Manual)

Base payment rate x FQHC  GAF = PPS rate   Updates to the FQHC GAFs will be made in conjunction with updates to the Physician Fee Schedule Geographic Practice Cost Indices for the same period and will be posted on CMSs FQHC PPS webpage at http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/FQHCPPS/index.html .  The PPS per -diem rate will be adjusted by a factor of 1.3416 when a FQHC furnishes care to a patient who  is new to the FQHC (has not been a patient at any site that is part of the FQHC organization within the previous 3 years) or to a beneficiary receiving an IPPE or an annual wellness visit (AWV).  This is a composite adjustment factor and only one adjustme nt per day can be applied.  If the patient is new to the FQHC, or the FQHC furnishes an Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV), the FQHC PPS rate for a covered visit will be calculated as follows:   Base payment rate x FQHC GAF x 1.3416 = PPS rate  For more information on the FQHC PPS, please see the FQHC PPS Final Rule located at: https://www.cms.gov/Center/Provider- Type/Federally -Qualified -Health -Centers -FQHC -Center.html  40 - Deductible and Coinsurance  (Rev. 3434, I ssued: 12 -31-15, Effective: 03-31-16, Implementation: 03-31-16)  40.1 - Part B Deductible  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  RHC services are subject to an annual deductible of twenty percent of charges for covered services.  Effective for dates of service on or after January 1, 2011, the deductible is not applicable for certain preventive services.  Please see section 80 for more information on how to bill for preventive services.  RHCs collect the patients deductible or the portion of the patients deductible that has not already been met. Once RHCs have billed the MAC for services, they do not collect or accept any additional  money from the patient for their deductible until the MAC notifies the RHC of how much of the deductible has been met.   The Part B deductible does not apply to FQHC services.  40.2 - Part B Coinsurance  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Im plementation: 03 -31-16)  After any applicable deductibles have been satisfied, RHCs and FQHCs paid under the AIR system will be paid 80 percent of their AIR.  The patient is responsible for a coinsurance amount of 20 percent of the charges after deduction of the  deductible, where applicable.   Effective for dates of service on or after January 1, 2011, coinsurance is not applicable for certain preventive services.  See section 80 of this manual for information on how to bill for preventive services on a RHC and FQHC claims.   FQHCs paid under the PPS will be paid 80 percent of the lesser of the FQHCs actual charge for the specific payment code or the adjusted PPS rate.  The patient is responsible for a coinsurance amount of 20 percent of the lesser of the  FQHCs actual charge for the specific payment code or the adjusted PPS rate.  See section 60.2 for more information on the FQHC specific payment codes.   50 - General Requirements for RHC and FQHC Claims  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, I mplementation: 03 -31-16)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 13 for coverage requirements for RHCs and FQHCs.  This section addresses requirement s for claim submission only.   Section 1862 (a)(22) of the Act requires that all claims f or Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic format required for billing RHC and FQHC services is the ASC X12 837 institutional claim transaction.  Instructions relative to the data element names on the Form CMS -1450 hardcopy form are described below.  Each data element name is shown in bold type.  Information regarding the form locator numbers that correspond to these data element names is found in Chapter 25.  Not all data elements are required or utilized by all payers.  Detailed information is given only for items required for Medicare RHC and FQHC claims.  Only the items listed below are required for RHCs and FQHCs.   Provider Name, Address, and Telephone Number, Form Locator (FL) 01  The RHC/FQHC enters this information for their agency.   Type of Bill, FL 4   This four -digit alphanumeric code gives three specific pieces of information.  The first digit is a leading ze ro.   CMS ignores the first digit.  The second digit identifies the type of facility.  The third classifies the type of care.  The fourth indicates the sequence of this bill in this particular benefit period. It is referred to as a frequency code.   Code Structure  1st Digit  Leading Zero  CMS ignores the first digit    2nd Digit - Type of Facility  7 - Special  facility (Clinic)   3rdDigit - Classification (Special Facility Only)  1  Rural Health Clinic  7  Federally Qualified Health Centers   4th Digit  Frequency  Definition  0 - Nonpayment/Zero Claims  Used when no payment from Medicare is anticipated.  l - Admit  Through  Discharge  Claim  This code  is used for a billing for a confined treatment.  7 - Replacement  of Prior  Claim  This code  is used by the provider  when  it wants  to correct  a previously submitted  bill.  This  is the code  used  on the  corrected  or new bill.   For additional information on replacement bills see Chapter 3.  8 - Void/Cancel  of a Prior  Claim  This code is used to cancel a previously processed claim.   For additional information on void/cancel bills see Chapter 3.   Statement Covers Period (From -Through),  FL 06  The RHC/FQHC shows  the beginning and  ending dates  of the period covered  by this  bill in numeric  fields  (MM -DD-YY).   Patient Name/Identifier, FL 08  The RHC/FQHC enters the beneficiarys name exactly as it appears on the Medicare card.   Patient Address, FL 09  The RHC/FQHC enters the mailing address of the patient.  Ente r the complete mailing address.   Patient Birth date, FL10 The RHC/FQHC enters the date of birth of the patient.  Patient Sex, FL 11 The RHC/FQHC enters the sex of the patient as recorded at the start of care.   Priority (Type) of Admission or Visit, FL14  The RHC/FQHC enters the most appropriate NUBC approved code indicating the priority of the visit.   Point of Origin for Admission or Visit, FL 15  The RHC/FQHC enters the most appropriate NUBC approved code indicating the point of origin for this admission or visit.  Patient Discharge Status, FL 16 The RHC /FQHC enters the most appropriate NUBC approved code indicating the  patients  status  as of the Through date of  the billing  period.  Condition Codes, FL 18 -28 The RHC/FQHC enters any appropriate NUBC approved code(s) identifying conditions related to this bill that may affect processing.   Value Codes and Amounts, FL 39- 41 The RHC/FQHC enters any appropriate NUBC approved code(s) and the associated value amounts identifying numeric information related to this bill that may affect processing.   Revenue Co des, FL42  The RHC/FQHC assigns a revenue code for each type of service provided and enters the appropriate four -digit numeric revenue code to explain each charge.   For FQHC claims with dates of service on or after January 1, 2010, FQHCs may report additional revenue codes when describing services rendered during an encounter.  However, Medicare payment will continue to be reflected only on claim lines with the revenue codes in the following table:   Code  Description  0521  Clinic visit by member to RHC/FQHC   0522  Home visit by RHC/FQHC practitioner   Code  Description  0524  Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF   0525  Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility   0527  RHC/FQHC Visiting Nurse Service(s) to a members home when in a home health shortage area  0528  Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)   0519  Clinic, Other Clinic (only for the  FQHC supplemental payment)   0900  Mental Health Treatment/Services   When billing for additional services rendered during the FQHCs encounter, any valid revenue codes may be used with a HCPCS code.  However, the following revenue codes are not allowed on FQHC claims:  002x- 024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x- 072x, 080x- 088x, 093x, or 096-310x.  HCPCS/Accommodation Rates/HIPPS Rate Codes, FL 44 For all services provided in a FQHC on or after January 1, 2010 and for approved preventive services provided in a RHC, HCPCS codes are required to be reported on the service lines.   The following HCPCS codes must be reported on FQHC PPS claims:   HCPCS Code  Definition  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 Medicare -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 inclu des 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 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.