(Medicare Claims Processing Manual)

Hepatitis B vaccine is included in the RHC all -inclusive and the FQHC /PPS rate.  The charges 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 and its administration is the only service the RHC/FQHC provides.  Additional information on vaccine s can be found in Chapter 18, section 10 of this manual. Additional coverage requirements for pneumococcal vaccine, hepatitis B vaccine, and influenza virus vaccine can be found in Publication 100- 02, the Medicare Benefit Policy Manual, Chapter 13.   70.5 - Diabetes Self Management Training (DSMT) and Medical Nutrition Services (MNT)  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  FQHCs billing under the AIR system   Payment is made at the all- inclusive encounter rate to the FQHC  for DSMT or MNT.  This payment can be in addition to payment for another qualifying visit on the same date of service as the beneficiary received qualifying DSMT services.   For FQHCs to qualify for a separate visit payment for DSMT or MNT services, the services must be a one- on-one face- to-face encounter.  Group sessions do not constitute a billable visit for any FQHC services.  To receive separate payment for DSMT or MNT services, the services must be billed on TOB 77x with HCPCS code G0108 (DSMT) or HCPC S code 97802, 97803, or G0270 (MNT) and the appropriate site of service revenue code in the 052X revenue code series.  This payment can be in addition to payment for any other qualifying visit on the same date of service that the beneficiary received quali fying DSMT /MNT services as long as the claim for DSMT/MNT services contains the appropriate coding specified above. Additional information on DSMT can be found in Chapter 18, section 120 of Pub. 100- 04.  Additional information on MNT can be found in Chapt er 4, section 300 of Pub. 100- 04.  Group services (G0109, 97804 and G0271) do not meet the criteria for a separate qualifying encounter. A  ll line items billed on TOBs 77x with group services will be denied.   DSMT and MNT services are subject to the frequency edits described in Pub. 100- 04, Chapter 18, and should not be reported on the same day.   FQHCs billing under the PPS   DSMT and MNT are qualifying visits when billed under G0466 or G0467.  For additional information on the payment specific codes and qua lifying visits, see  section 60.2 of this manual.  Under the FQHC PPS, DSMT and MNT do not qualify for a separate payment when billed on the same day with another qualified visit.   RHCs   RHCs are not paid separately for DSMT and MNT services.  All line items billed on TOB 71x with HCPCS codes for DSMT and MNT services will be denied.  70.6 - Initial Preventive Physical Examination ( IPPE)  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  FQHCs and RHCs billing under the AIR system   Medicare provides for coverage for one  IPPE for new beneficiaries only, subject to certain elig ibility and other limitations.   Payment for the professional service s will be made under the AIR.  However, RHCs/FQHCs can receive a separate payment for  an encounter in addition to the payment for the IPPE when they are performed on the same day.   When IPPE is provided in an RHC or FQHC, the professional portion of the service is billed on TOBs 71X and 77X, respectively, and the appropriate site of servic e revenue code in the 052X revenue code series, and must include HCPCS code G0402.  Additional information on IPPE can be found in Chapter  18, section 80 of Pub. 100- 04.  EKGs  The professional component is included in the AIR or FQHC PPS and is not separat ely billable.   The technical component of an EKG performed at a RHC/FQHC billed to Medicare on professional claims (Form CMS -1500 or 837P) under the practitioners ID following instructions for submitting practitioner claims for independent/freestanding cl inics.  Practitioners at provider -based clinics bill the applicable TOB to the A/B MAC  using the base providers ID.   FQHCs billing under the PPS:   IPPE is qualifying visits when billed under G0468, for additional information on the payment specific codes and qualifying visits, please refer to section 60.2 of this manual.  Under the FQHC PPS, IPPE does not qualify for a separate payment when billed on the same day with another encounter/visit.  70.7 - Virtual Communication Services                                                    (Rev. 10357, Issued: 09- 18-2020, Effective: 10 -19-2020, Implementation: 10- 19-2020)   In the CY 2019 PFS final rule, CMS finalized a policy for payment to RHCs and FQHCs for communication technology- based services (virtual check -in) or remote evaluation services, effective January 1, 2019. CMS created a new Virtual Communications G Code, G0071 for use by RHCs and FQHCs only, with the payment rate set at the average of the PFS non- facility payment rate for communication technology- based services and remote evaluation services.   RHCs and FQHCs receive an additional payment for the costs of communication technology- based services or remote evaluation services that are not alre ady captured in the RHC AIR or the FQHC PPS payment when the requirements for these services are met.  Coinsurance and deductibles apply to RHC claims, and coinsurance applies to FQHC claims for these services.   RHCs and FQHCs can bill HCPCS code G0071 al one or with other payable services on an RHC or FQHC claim.  The services should be billed with a revenue code 052x and should not be billed with modifier CG for payment on RHC claims. HCPCS codes G0071 are paid based on the lesser of the charges or the ra te from the Medicare Physician Fee Schedule (MPFS).    70.8- General Care Management Services  Chronic Care or Psychiatric Collaborative Care Model  (CoCM ) Services                                             (Rev. 10357, Issued: 09- 18-2020, Effective: 10 -19-2020, Implementation: 10- 19-2020)   Effective for services furnished on or after January 1, 2018, RHCs and FQHCs are paid for General Care Management or  Psychiatric CoCM services when G0511 or G0512 is billed alone or with other payable services on an RHC or FQHC claim.  HCPCS code G0511 or G0512 can only be billed once per month per beneficiary, and cannot be billed if other care management services are billed for the same time period.   HCPCS codes G0511 and G0512 are subject to coinsurance and deductibles on RHC claims.  Only coinsurance applies on FQHC claims. Coinsurance is 20 percent of the lesser of the RHC or FQHCs charge for HCPCS codes G0511 and G0512, or the corresponding rate.   The allowable revenue code is 052X. These HCPCS codes of G0511 or G0512 should not be billed with modifier CG for payment on RHC claims.   80 - Telehealth Services  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implem entation: 03 -31-16)  RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and HCPCS code Q3014.  Telehealth services are the only services billed on FQHC claims that are subject to the Part B d eductible.   Additionally, a FQHC payment code and qualifying visit HCPCS code are not required when the only service reported on the claim is for Telehealth services.  RHCs and FQHCs are not authorized to serve as distant practitioners for Telehealth services.   For more information on Telehealth services please see Pub 100-04, chapter 12, section 190: http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf   90 - Services non -Covered on RHC and FQHC Claims  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  Technical Services  RHCs/FQHCs do not bill using TOBs 71x or 77x for technical components of services because they are not within the scope of Medicare- covered RHC/FQHC services.  The associated technical components of services furnished by the RHC/FQHC are billed on other types of claims that are subject to appl icable frequency limits edits.   For services that can be split into professional and technical components, RHCs and FQHCs bill for the professional component as part of the AIR or the FQHC PPS payment and bill the MAC separately for the technical component.  See Chapter 17, section 30.1.1, for more information on how RHCs and FQHCs can bill the MAC for laboratory services.  See Chapter 13 for more information on how to bill the MAC for technical components of diagnostic services.  o Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are submitted to the MAC in the designated claim format (837P or Form CMS-1500.)  See chapters 12 (http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) and 26 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf ) of this manual for billing instructions.  o Technical services/components associated with professional services/components performed by provider- based RHCs or FQHCs  are submitted by the base-provider on the appropriate TOB to the MAC in the designated claim format (837I or the UB- 04 claim form); see the applicable chapter of this manual based on the base-provider type, such as (http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf ) for outpatient hospital services, chapter 6 (http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf ) for inpatient SNF services chapter 7 for Outpatient SNF services, etc.   Laboratory Services   RHCs  must furnish the following lab services to be approved as an RHC.  However, these and other lab services that may be furnished are not included in the encounter rate and must be billed separately.   Chemical examinations of urine by stick or tablet method or both;   Hemoglobin or hematocrit;   Blood sugar;   Examination of stool specimens for occult blood;   Pregnancy tests; and    Primary culturing for transmittal to a certified laboratory (No CPT code available).   RHCs/FQHCs bill all laboratory services to their MAC under the host providers bill type and payment is made under the fee schedule.  HCPCS codes are required for lab services.   Venipuncture is included in the AIR and the PPS per diem payment and is not separately billable.   Refer to Chapter 16 for general billing instructions.   Durable Medical Equipment (DME), ambulance services, hospital-based services, group services, and non- face-to-face services are also non -covered and are billed separately.   When billing these services on FQHC PPS claims, a FQHC payment code and qualifying visit HCPCS code is not  required.  100 - Frequency of Billing and Same Day Billing  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  RHC and FQHC claims cannot overlap calendar years.  Therefore, the statement dates, or from and through dates of the claim, must always be in the same calendar year.   RHCs and FQHCs billing under the FQHC PPS may submit claims that span multiple days of service.  FQHCs billing under the PPS must submit all services that are rendered on the same day on one claim.  General information on basic Medicare claims processing can be found in this manual in:  Chapter 1, General Billing Requirements, (http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf) for general claims processing information;   Chapter 2, Admission and Registration Requirements, (http://www.cms.hhs.gov/manuals/downloads/clm104c02.pdf) for general filing requirements applicable to all providers.