(Medicare Claims Processing Manual)

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.   FQHCs must use the specific payment code that corresponds to the type of visit that qualifies the encounter for Medicare payment, and these codes will correspond to the appropriate PPS rates.  Each FQHC shall report a charge for the FQHC visit code that would reflect the sum of regular rates charged to both beneficiaries and other paying patients for a typical bundle of services that would be furnished per diem to a Medicare beneficiary.   FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or 0519.  NOTE:   Revenue code 0519 is used for Medicare Advantage (MA) Supplemental claims only.   FQHC specific payment codes G0469 and G0470 must be reported under revenue code 0900 or 0519.  FQHCs must report HCPCS coding on the claim to describe all services that occurred during the encounter.  All service lines must be reported with their associa ted charges.  The additional services reported on the claim that are part of the FQHC encounter, will not be paid.  The payment for these services is included in the payment under the FQHC payment code.  Payment for a FQHC encounter requires a medically necessary face- to-face visit.  Each FQHC specific payment code (G0466-G0470) must have a corresponding service line with a HCPCS code that describes the qualifying visit.  The link below contains the list of the qualifying visits for each payment specific code:  https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC -PPS- Specific- Payment -Codes.pdf   For example:  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0467  FQHC Payment code   10/01  0521  99213  Qualifying visit   10/01   When submitting a claim for a mental health visit furnished on the same day as a medical visit, FQHCs must report a specific payment code for a medical visit (G0466, G0467, or G0468) and a specific payment code for a mental health visit (G0470), and each specific payment code must be accompanied by a service line with a qualifying visi t.  For example:  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0468  FQHC Payment code   10/01  0521  G0439  Qualifying visit   10/01  0900  G0470  FQHC Payment code   10/01  0900  90832 -Qualifying visit   10/01   When submitting a claim for a subsequent illness or injury, the FQHCs reports G0467 for a med ical visit), with modifier 59.  A qualifying visit is still required when reporting modifier 59 with G0467.  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0468  FQHC Payment code   10/01  0521  G0439  Qualifying visit   10/01  0521  G0467  FQHC Payment code  59 10/01  0900  99211 -Qualifying visit   10/01   FQHCs must report all services that occurred on the same day on one claim.  FQHC may submit claims that span multiple days of service.  However, for FQHCs transitioning to the PPS, a separate claim must be submitted for services subject to the PPS and serv ices paid based on the AIR.  MACs will reject claims with multiple dates of service that include both PPS and non- PPS dates, as determined based on the individua l FQHCs cost reporting period.   FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim, and these HCPCS codes will be considered informational only.  MACs shall continue to pay for the influenza and pneumococcal vaccines through the cost report.   60.3 - Payments for FQHC PPS Claims (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  Payment for FQHC PPS claims is made by comparing the adjusted FQHC PPS rate to the total submitted covered charges reported for the specific payment codes G0466, G 0467, G0468, G0469, a nd G0470.  To calculate payment, follow the steps below:   Step 1:  Determine the lesser of the providers submitted charges for the specific payment code(s) and the fully- adjusted PPS rate.   Step 2:  Determine if preventive services for which the coi nsurance is waived are present.   Step 3:  Subtract the charges for the preventive services from the lesser of the providers charge for the specific payment code(s) or the PPS Rate.  (Lesser of the providers charge for the specifi c payment code or the PPS rate) -  (Preventive services charges) = Step 3 total   Note:   If no preventive services are present, use the lesser of the providers charge for the specific payment code(s) or the PPS rate as the Step 3 total.    Step 4:  Multiply the total from Step 3 by 80%. Step 3 total * 80% = Step 4 total   Note:   If no preventi ve services are present, contractors will p ay this amount and skip step 5.  Step 5:  Add the charges for the approved preventive service s to the total from step 4.  Contractors will pay this amount. Step 4 total + preventive services  charges = Medicare Paym ent  Note:  If the charges for the approved preventive services are greater than the total payment amount identified in Step 1 (i.e., the lesser of the charges for the specific payment code or the PPS rate), pay 100% of the total payment amount determined in Step 1 and do not apply coinsurance.  (Please see example 3)   To calculate coinsurance, follow the steps below:  Step 1:  Determine the lesser of the submitted charges for the G -code (s) and the PPS rate.  Step 2:  Determine if approved preventive servi ces (i.e., preventive services for which coinsurance is waived) are present.   Step 3:  Subtract the charges for the preventive services from the lesser of the providers charge for the specific payment code(s) or the PPS Rate.  (Lesser of the providers cha rge for the specific payment code or the PPS rate) -  (Preventive services charges) = Step 3 total   Note:   If no approved preventive services are present, use the lesser the providers charge for the specific payment code(s) or th e PPS rate as the Step 3 total.   Step 4:  Multiply the total from Step 3 by 20%. Step 3 total * 20% = Coinsurance    Example :  Paymen t based on the charges  PPS rate = 160.00  Providers actual charge for the specific payment code, G0467 = $150  REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0467   10/01  150.00  150.00  0521  99213   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0001     310.00  310.00   The comparison is between the PPS rate and the providers $150 actual charge for the specific payment code, G0467.  In this case, the sum of the line items exceeds the providers actual charge for the payment code.   Payment based on the providers charge of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Coinsurance  0521  G0467   10/01  150.00  150.00  120.00  30.00  0521  99213   10/01  135.00  135.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     310.00  310.00    Payment = 150.00 (charges) * 80%   Coinsurance = 150.00 (charges) * 20%   For service lines that do not receive payment, group code CO - contractual obligation and the appropriate claim adjustment reason code (CARC) will be used.  * CARC 97  the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.    Example:  Payment based on the charges w ith approved preventive service  PPS rate = 160.00  Providers actual charge for the specific payment code, G0468 = $150   Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0439 PS**   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0001     310.00  310.00   Payment based on the providers actual charge of 150.00 for the specific payment code, G0468.  REV CODE  HCPC CODE  MODS SERV DATE  TOTAL CHARGE  COV  CHARGE  Payment  Co-insurance  0521  G0468   10/01  150.00  150.00  147.00  3.00 0521  G0439 PS   10/01  135.00  135.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     310.00  310.00     Payment = (150.00 (charges)  135.00 (preventive service G0439)) * 80% + 135.00 preventive service   Coinsurance = (150.00 (charges)  135.00 (preventive service G0439)) * 20%    ** PS  Preventive Service - These are approved preventive services where the coinsurance is waived based on the USPSTF recommendation. Example:  Payment based on the charges when preventive service is greater than G -code  PPS rate = 160.00   Providers actual charge for the specific payment code, G0468 = $150 Preventive Service = 155.00 REV CODE  HCPC  MODS  SERV DATE  TOTAL CHARGE  COV  CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0439 PS   10/01  155.00  155.00  0300  36415   10/01  25.00  25.00  0001     330.00  330.00   Payment based on charges of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co- insurance  0521  G0468   10/01  150.00  150.00  150.00  0 0521  G0439 PS  10/01  155.00  155.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     330.00  330.00     Payment = (150.00 (charges) * 100% = 150.00