(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers   Table of Contents  (Rev. 1 2070, 06-07-23)  Transmittals for Chapter 9   10 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) General Information  10.1 - RHC General Information  10.2 - FQHC General Information  20 - RHC and FQHC All -Inclusive Rate (AIR) Payment System  20.1 - Per Visit Payment and Exceptions under the AIR  20.2 - Payment Limit under the AIR  30 - FQHC Prospective Payment System (PPS) Payment System  30.1 - Per -Diem Payment and Exceptions under the PPS  30.2 - Adjustments under the PPS  40 - Deductible and Coinsurance  40.1 - Part B Deductible  40.2 - Part B Coinsurance  50 - General Requirements for RHC and FQHC Claims  60 - Billing and Payment Requirements for RHCs and FQHCs  60.1 - Billing Guidelines for RHC and FQHC Claims under the AIR System  60.2 - Billing for  FQHC Claims Paid under the PPS  60.3 - Payments for FQHC PPS Claims  60.4 - Billing for Supplemental Payments to FQHCs  under Contract wit h Medicare Advantage (MA) Plans  60.5 - PPS Payments to FQHCs under Contract with MA Plans  60.6 - RHCs and FQHCs for Billing Hospice Attending Physician Services  70 - General Billing Requirements for Preventive Services  70.1 - RHCs Billing Approved Preventive Services  70.2 - FQHCs Billing Approved Preventive Services under the AIR  70.3 - FQHCs Billing Approved Preventive Services under the PPS  70.4 - Vaccines  70.5 - Diabetes Self  Management Traini ng (DSMT) and Medical Nutrition Services (MNT)  70.6 -  Initial Preventive Physical Examination (IPPE)   70.7  Virtual Communication Services  70.8  General Care Management Services  Chronic Care and Psychiatric Collaborative Care Model (CoCM) Services  80 - Telehealth Services  90 - Services Non -covered on RHC and FQHC Claims  100 -  Frequency of Bill ing and Same Day Billing    10 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) General Information  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  10.1 - RHC  General Information  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  RHCs are facilities that provide services that are typically furnished in an outpatient clinic setting.  The statutory requirements that RHCs must meet to qu alify for the Medicare benefit are in 1861(aa) (2) of the Social Security Act (the Act).   A RHC visit is defined as a medically -necessary, face -to-face (one-on-one) medical or mental health visit, or a qualified preventive health visit, with a RHC practitioner during which time one or more RHC services are rendered.  A RHC practitioner is a physician, nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW). A Transitiona l Care Management (TCM) service can also be a RHC visit.  A RHC visit can also be a visit between a home-bound patient and an RN or LPN under certain conditions.  RHCs can be either independent or provider-based.  Independent RHCs are stand- alone or freest anding clinics and submit claims to a Medicare Administrative Contractor (MAC).  They are assigned a CMS Certification Number (CCN) in the range of XX3800-XX3974 or XX8900-XX8999.  Provider-based RHCs are an integral and subordinate part of a hospital (including a critical access hospital (CAH), skilled nursing facility (SNF), or a home health agency (HHA)).   Information on RHC covered services, visits, payment policies, and other information can be found in Pub. 100- 02, Medicare Benefit Policy Manual, chap ter 13, http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downloads/ bp102c13.pdf .  Information on certifica tion requirements can be found in Pub. 100- 07, Medicare State Operations Manual, Chapter 2, http://www.cms.gov/Regulations- and-Guidance/ Guidance/ Manuals/ Downloads/ som107c02.pdf .  10.2 - FQHC General Information  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  FQHCs are facilities that provide services that are typically furnished in an outpatient clinic setting.  FQHC services consist of services that are similar to those furnished in RHCs.  The statutory requirements that FQHCs must meet to qualify for the Medicare benefit are in 1861(aa)(4) of the Act.  An entity that qualifies as a FQHC is assigned a CCN in the range of XX1000-XX1199 or XX1800-XX1989.  NOTE:   Information in this chapter applies to FQHCs that are Health Center Program Grantees and Health Center Program Look- Alikes.  It does not necessarily apply to tribal or urban Indian FQHCs or grandfathered tribal (GFT) FQHCs.   20 - RHC and FQHC All -Inclusive Rate (AIR) Payment System  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03 -31-16)  20.1 - Per Visit Payment and Exceptions under the AIR  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  RHCs and FQHCs are paid an AIR per visit, except for FQHCs that have transitioned to the Medicare Pros pective Payment System (PPS).  For RHCs and FQHCs billing under the AIR, more than one medically- necessary face -to-face visit with a RHC or FQHC practitioner on the same day is payable as one visit, except for the following circumstances:    The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day, (for example, a patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the RHC/FQHC);    The patient has a medical visit and a mental health visit on the same day;   The patient has an Initial Preventive Physical Examination (IPPE) and a separate qualified medical and/or mental health visit on the same day;    The pat ient has a Diabetes Self -Management Training (DSMT) or Medical Nutrition Therapy (MNT) visit on the same day as an otherwise payable medical visit.   DSMT and MNT apply to FQHCs only.  20.2 - Payment Limit under the AIR (Rev. 3434, Issued: 12- 31-15, Effecti ve: 03 -31-16, Implementation: 03- 31-16)  For RHCs and FQHCs that bill under the AIR, Medicare pays 80 percent of the RHC or FQHCs AIR, subject to a payment limit, except for RHCs that have an exception to the payment limit.  An interim rate for newly certified RHCs, and for FQHCs certified prior to October, 1, 2014, is established based on the RHCs or FQHCs anticipated average cost for direct and supporting services.  At the end of the cost reporting period, the MAC determines the total payment due and r econciles payments made during the period with the total payments due.   For FQHCs paid under the AIR, there is a payment limit for FQHCs located in an urban area and a payment limit for FQHCs located in a rural area.  Urban FQHCs are those located within a  Metropolitan Statistical Area (MSA). Rural FQHCs cannot be reclassified into an urban area (as determined by the Bureau of Census) for FQHC payment limit purposes.  If the FQHC organization includes both urban and rural sites and the FQHC organization files a consolidated cost report, the FQHC is paid the lower of the FQHC organizations AIR or a single weighted payment limit calculated for the entire FQHC organization.  The payment limit is weighted by the percentage of urban and rural visits as a percentage of total visits for the entire FQHC organization.  RHCs and FQHCs paid under the AIR are required to file a cost report annually in order to determine their payment rate.  If a RHC or FQHC is in its initial reporting period, the MAC calculates an interim rate based on a percentage of the per -visit limit, which is then adjusted when the cost report is filed.  For information on cost reporting requirements, see the Medicare Provider Reimbursement Manual (PRM), at http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Paper -Based -Manuals.html   30 - FQHC PPS Payment System  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03-31-16)  30.1 - Per-Diem Payment and Exceptions under the PPS  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-152) added section 1834(o) of the Social Security Act to establish a Me dicare PPS for FQHC services.  FQHCs transition to the Medicare PPS beginning on October 1, 2014, based on their cost-reporting period.  All FQHCs are expected to be transitioned to the PPS by December 31, 2015.  For FQHCs paid under the PPS, Medicare payment is based on the lesser of the FQHCs actual charge or the PPS rate, as determined by the MAC.  The FQHC PPS rate will be updated annually beginning January 1, 2016.  For FQHCs billing under the PPS, more than one medically- necessary face -to-face visit with a FQHC practitioner on the same day is payable as one visit, except for the following circumstances:   The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day, (for example, a patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the FQHC),    The patient has a medical visit and a mental health visit on the same day.   Separate payment is not made to FQHCs under the PPS for an IPPE or DSMT/MNT visit that is furnished on the same day as another FQHC medical visit.  30.2 - Adjustments under the PPS  (Rev. 3434, Issued: 12- 31-15, Effec tive: 03 -31-16, Implementation: 03-31-16)  The FQHC PPS rate will be adjusted to account for geographic differences in costs by the FQHC geographic adjustment factor (FQHC GAF).  In calculating the PPS rate, the FQHC GAF will be based on the locality of the site where the services are furnished.  For FQHC organizations with multiple sites, the FQHC GAF may vary depending on the location of the FQHC delivery site.  The FQHC PPS rate for a covered visit will be calculated as follows:   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.