(Medicare Benefit Policy Manual)

Exceptions are for the following circumstances  only:  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 or FQHC). In this situation only , the FQHC would  use modifier 59 on the claim and the RHC would use modifier 59 or 25 to attest that the conditions being treated qualify as 2 billable  visits;    The patient has a medical visit and a mental health visit on the same day (2 billable visits ); or   For RHCs only, the patient has an initial preventive physical exam (IPPE) and a separate medical and/or mental health  visit on  the same day (2 or 3 billable  visits).   NOTE:  These exceptions  do not apply to grandfathered  tribal FQHCs.   40.4 - Global Billing  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Surgical procedures furnished in an RHC or FQHC by an RHC or FQHC practitioner are considered RHC or FQHC services.  Procedures are included in the payment of an otherwise qualified visit and are not separately billable.  If a procedure is associated with a qualified visit, the charges for the procedure go on the claim with the visit.  Payment is included in the AIR when the procedure is furnished in an RHC, and payment is included in the PPS methodology when furnished in an FQHC.  The Medicare global billing requirements do not apply to RHCs and FQHCs, and global billing codes are not accepted for RHC or FQHC billing or payment. Surgical procedures furnished at locations other than RHCs or FQHCs may be subject to Medicare global billing requirements.  If an RHC or FQHC furnishes services to a patient who has had surgery elsewhere and is still in the global billing period, the RHC or FQHC must determine if these serv ices have been included in the surgical global billing.  RHCs and FQHCs may bill for a visit during the global surgical period if the visit is for a service not included in the global billing package.  If the service furnished by the RHC or FQHC was included in the global payment for the surgery, the RHC or FQHC may not also bill for the same service.  Services not included in the global surgical package are listed in Pub. 100- 04, Medicare Claims Processing Manual, chapter 12, section 40.1.B, and include, but are not limited to: initial consultation by the surgeon to determine the need for major surgery; visits unrelated to the diagnosis for which the surgical procedure is performed (unless the visit occurs due to complications of the surgery); treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery; etc.  For additional information on global billing, see http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf   40.5 - 3-Day Payment Window  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicares 3 -day payment window applies to outpatient services furnished by a hospital (or an entity that is wholly owned or wholly operated by the hospital).  The statute requires that hospitals bundle the technical component of all outpatient diagnostic services and related non-diagnostic services (e.g., t herapeutic) with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1- day) preceding an inpatient admission in compliance with  section 1886 of the Act. RHCs and FQHC services are not subject to the Medicare 3 - day payment window requirements.  For additional information on the 3 day payment window, see http://www.cms.gov/Outreach -and-Education/Medicare- Learning -Network -MLN/MLNMattersArticles/downloads/MM7502.pdf   50 - RHC and FQHC Services (Rev. 166, Issued: 01-31-13, Effective: 03-01- 13, Implementation: 0 3-01-13)   50.1 - RHC Services (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  RHC  services  include:  Physicians'  services,  as described  in section  110;  Services  and supplies incident to a physicians  services,  as described  in section  120;  Services  of NPs,  PAs,  and CNMs,  as described  in section  130;  Services and supplies incident to the services of NPs, PAs, and CNMs, as described  in section 140;  CP and CSW services,  as described  in section  150;  Services and supplies incident to the services of CPs, as described in section 160; and  Visiting nurse services to patients confined to the home, as described in section 190.  Certain  care management  services,  as described  in section  230.  Certain  virtual communication  services,  as described  in section  240.   RHC  services  also include certain  preventive services  when  specified  in statute  or when  established  through the National  Coverage Determination  (NCD)  process  and not specifically  excluded  (see section  220  Preventive  Health  Services).  These services  include:   Influenza,  Pneumococcal,  Hepatitis  B, COVID -19 vaccinations , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19;  IPPE;   Annual  Wellness  Visit  (AWV);  and  Medicare- covered  preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) with a grade of A or B, as appropriate for the  09individual. Influenza , pneumococcal and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure p rophylaxis prevention of COVID -19 and  their administration are paid through the cost         report, and payment for the hepatitis B vaccine and its administration is included in an otherwise billable visit.  The professional component of the IPPE, AWV, and other  qualified  preventive  services is paid  based on the AIR.  Note: Monoclonal antibody products used for the treatment or for post -exposure prophylaxis of COVID -19 (when they are not purchased by the government) and their administration are paid through t he cost report until the end of the calendar year in which the Emergency Use Authorization declaration for drugs and biological products with respect to COVID -19 ends.  50.2 - FQHC Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23) FQHC services include all of the RHC services listed in section 50.1 of this chapter.  While the following services may also be furnished in an RHC, the statute specifically  lists certain services  as FQHC  services, including  but not  limited to:   Screening  mammography;    Screening  pap smear  and screening  pelvic  exam;    Prostate  cancer  screening  tests;    Colorectal  cancer  screening  tests;    DSMT  services;    Diabetes  screening  tests;    MNT  services;    Bone  mass  measurement;    Screening  for glaucoma;    Cardiovascular  screening  blood tests;  and   Ultrasound screening  for abdominal  aortic  aneurysm.  Influenza , pneumococcal  and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19 their administration are paid through the cost  report, and payment for the hepatitis B vaccine and its administration is included in an  otherwise billable visit.  The professional component of the IPPE, AWV, and other  qualified preventive services is paid based on the lesser of the FQHCs charge or the PPS  rate for the specific payment  code,  with  an adjustment  for IPPE  and AWV  (see section 70.4  FQHC  Payment  Codes).   Note: Monoclonal antibody products used for the treatment or for post -exposure prophylaxi s of COVID -19 (when they are not purchased by the government) and their administration are paid through the cost report until the end of the calendar year in which the Emergency Use Authorization declaration for drugs and biological products with respect t o COVID -19 ends.   50.3 - Emergency Services  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs provide outpatient services that are typically furnished in a physicians office or outpatient clinic and generally provide only limited emergency care.  Neither independent nor hospital -based RHCs are subject to Emergency Medical Treatment and Active Labor Act regulations.  However, RHC practitioners are required to provide medical emergency procedures as a first response to common life threatening injuries and acute illnesses and to have available the drugs and biologicals commonly used in life -saving procedures.  The definition of a first response is a service that is commonly provided in a physicians office.  If a patient presents at the RHC with an emergency when the RHC is not open for patient care because a physician, NP, PA, CNM, CP, or CSW is not present, other staff may attend to the patient until care of the individual can be transferred.  Any care provided in this situat ion must be within the individuals ability, training, and scope of practice, and in accordance with state laws, and would not be considered an RHC service. During their regular hours of operations, FQHC practitioners are required to provide medical proced ures as a first response to common life threatening injuries and acute illnesses and to have available the drugs and biologicals commonly used in life -saving procedures.  After their operating hours, FQHCs must provide telephone access to an individual who has the qualifications and training to exercise professional judgment in assessing a patients need for emergency medical care, and if appropriate, to refer the patient to an appropriate provider or facility that is open.  Additional information on emergen cy preparedness requirements for RHCs and FQHCs can be found 42 CFR 491.12.   60 - Non RHC/FQHC Services (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs and FQHCs must be primarily engaged in furnishing primary care services, but may also furnish certain services that are beyond the scope of the RHC or FQHC benefit, such as laboratory services or the technical component of an RHC or FQHC service.  If these services are authorized to be furnished by the RHC or FQHC and are cover ed under a separate Medicare benefit category, the services must be billed separately (not by the RHC or FQHC) to the appropriate A/B MAC under the payment rules that apply to the service.  RHCs and FQHCs must identify and remove from allowable costs on the Medicare cost report all costs associated with the provision of non-RHC/FQHC services such as space, equipment, supplies, facility overhead, and personnel.  60.1 - Description of Non RHC/FQHC Services (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Certain services are not considered RHC or FQHC services either because they 1) are not  included in the RHC or FQHC benefit, or 2) are not a Medicare benefit. Non- RHC/FQHC  services include, but are not limited to:   Medicare excluded services  - Includes routine physical checkups, dental care, hearing tests, routine eye exams, etc.  For additional information, see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, at http://www.cms.gov/Regulations- a nd-Guidance/Guidance/Manuals/downloads/bp102c16.pdf   Technical component of an RHC or FQHC service - Includes diagnostic te sts such as x - rays, electrocardiograms (EKGs), and other tests authorized by Medicare statute or the NCD process.  These services may  be billed  separately  to the A/B MAC  by the facility).  (The professional component is an RHC or FQHC service if performed by an RHC or FQHC  practitioner  or furnished incident to an RHC or  FQHC  visit).