(Medicare Claims Processing Manual)

For services of plan years beginning on and a fter January 1, 2006 and before, an interim supplemental rate can be determined by the MAC based on cost report data, MACs shall calculate an interim supplemental payment for each MA plan the FQHC has contracted with using the documented estimate provided by the FQHC of their average MA payment (per visit basis) under each MA plan they contract with.  Once an interim supplemental rate is determined for a previous plan year based on cost report data, use that interim rate until the MAC receives information t hat changes in service patterns that will result in a different interim rate.  MACs shall calculate an interim supplemental payment rate for each MA plan the FQHC has contracted with.  Reconcile all interim payments at cost settlement.   Do not apply the Me dicare deductible when calculating the FQHC interim supplemental payment.  Do not apply the original Medicare co -insurance (20%) to the FQHC all inclusive rate when calculating the FQHC interim supplemental payment.  Any beneficiary cost sharing under the MA plan is included in the calculation of the FQHC interim supplemental payment rate.   MACs shall submit all claims to CWF for approval.  CWF will verify each beneficiarys enrollment in an MA plan for the line item date of service (LIDOS) on the claim.  C WF shall reject all claims for the FQHC interim supplemental payment for beneficiaries who are not MA enrollees on the same date as the LIDOS on the claim.  MACs shall RTP such claims to the FQHCs.  MACs shall accept TOB 77x with revenue code 0519 and pay the interim supplemental payment rate for each qualified visit billed.   Billing for Supplemental Payments u nder the AIR   When billing for supplemental payment to the MAC, the encounter is reported on type of bill (TOB) 77x with revenue code 0519 for the am ount of the interim supplemental payment rate (FQHC interim all- inclusive rate  estimated average payment from the MA plan plus any beneficiary cost sharing = billed amount > 0).  Do not submit revenue codes 0520 and/or 0900 on the same claim as revenue c ode 0519.  HCPCS coding is not required.   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0519  blank   01/01  150.00   Billing for Supplemental Payments under the PPS   When billing for supplemental payment to the MAC under the PPS, a FQHC payment specific code and a qualifying visit must be reported under revenue code 0519.  For example:  Revenue Code  HCPCS code  Modifier  Service Date  0519  G0467  FQHC Payment code   10/01  0519  99213  Qualifying visit   10/01   60.5 - PPS Payments to FQHCs  under Contract with MA Plans  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  For claims with the 0519 revenue code, the wraparound payment is based on the PPS rate without compari son to the providers charge.  The rate is also NOT adjusted for coinsurance or preventive services as the MA plan would have already assessed any applicable coinsurance and related waivers of coinsurance.   Medicare will compare the PPS rate with the MA contract rate for a FQHC visit.   When the MA contract rate is lower than the applicable PPS rate that would otherwise have been paid by traditional Medicare had the beneficiary not been covered by the MA plan, the contractor will pay the difference as a supplemental wraparound payment.  The FQHC does not qualify for a supplemental wraparound payment when the MA contract rate is higher than the applicable PPS rate that would otherwise have been paid by traditional Medicare had the beneficiary not be covered by the MA plan.    Example:  MA Claim that Qualifies for a S upplemental Wraparound Payment   PPS Rate = $225  Rev HCPC  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0519  G0468   10/01  170.00  170.00  0519  G0439 PS   10/01  150.00  150.00  0001     320.00  320.00   If the MA contract rate is lower than the applicable PPS rate  e.g., $200:   Wraparound payment = PPS rate  MA contract rate = $225 -  $200 = $25   Note that the charge of $170 would reflect the FQHCs typical charge for G0468, but would not be used to calculate the supplemental payment.   Example :  MA Claim that Does Not Qualify for a Supplemental Wraparound Payment   PPS Rate = $225  Rev HCPC  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0519  G0468   10/01  170.00  170.00  0519  G0439 PS   10/01  150.00  150.00  0001     320.00  320.00   If the MA contract rate was higher than the applicable PPS rate  e.g., the MA contract rate was $250 - no wraparound payment is due to the FQHC.   60.6 - RHCs and FQHCs for billing Hospice Attending Physician Services   (Rev. 11200, Issued :01 -12-22, Effective: 01 -01-22, Implementation: 01- 03-22)  Effective for services furnished on or after January 1, 2022, RHCs or FQHCs can bill and receive payment under the RHC All -Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS), when  a designated attending physician employed by or working under contract with the RHC or FQHC furnishes hospice attending physician services during a patients hospice election.   RHCs must report a GV modifier on the claim line for payment (that is, along with the CG modifier) each day a hospice attending physician service is furnished.  FQHCs must report a GV modifier on the claim line with the payment code (G0466  G0470) each day a hospice attending physician service is furnished.    The hospice attending physician services are subject to coinsurance and deductibles on RHC claims and only coinsurance on FQHC claims.    70 - General Billing Requirements for Preventive Services  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  Professional components of preventive services are covered under the RHC and FQHC benefit.  The payment for most preventive services is included with a qualified visit as part of the overall encounter/visit.  To ensure coinsurance and deductible (deductible applies to RHC claims only) are applied correctly, detailed HCPCS coding is required for approved preventive services recommended by the USPSTF with a grade of  A or B  for TOBs 71x or 77x.  Additionally, RHCs/FQHCs are required to report HCPCS codes for certain preventive services subject to frequency limits.   70.1 - RHCs Billing Approved Preventive Services  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  An additional line with the appropriate site of service revenue code in the 052X series should be submitted with the approved preventive service HCPCS code and the associated charges.  For example, if the total charge for the visit is $150.00, and $50.00 of that is a qualified preventive service, the service lines should be code d as follows:   Revenue Code  HCPCS code  Modifier  Service Date  Charges  0521  Encounter = Blank or valid HCPCS code   10/01  100.00  0521  Preventive Service Code   10/01  50.00   In the example above, the encounter service line will receive the AIR payment.  The charges reported on this line should not include the charges for the  approved preventive service.  Coinsurance and deductible will be accessed based on the charges reported on this service line.  The qualified preventive service reported on the additional service line will not receive payment, as payment is made under the AIR for the services reported under the encounter service line.  Coinsurance and deductible are accessed based on the charges reported on the preventive services line.   70.2 - FQHCs Billing Approved Preventive Services under the AIR  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  Detailed HCPCS codes are required for all  service lines.  When reporting the encounter/visit, revenue code 052X for medical and revenue code 0900 for mental health visits must be used.  For additional services, the most appropriate revenue code for the service rendered should be used.   Revenue Co de HCPCS code  Modifier  Service Date  Charges  0521  Encounter = E&M HCPCS code   10/01  100.00  0771  Preventive Service Code   10/01  50.00   In the example above, the services reported under the encounter/visit service line will receive the AIR payment.  The charges reported on this line should not include the charges for the approved preventive service.  Since deductible does not apply to FQHC claims, only coinsurance will be applied to the charges reported on the encounter service line.  The qualified preventive service reported on the second revenue line will not receive payment.  Coinsurance and deductible are not accessed to the services reported under the preventive services line.  70.3 - FQHC Billing Approved Preventive Services under the P PS (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  An additional line with the appropriate site of service revenue code in the 052X series should be submitted with the approved preventive service HCPCS code and the associated charges.  For example, if the total charge for the visit is $150.00, report the total charges for the encounter.  NOTE:   Do not carve out the charges for the approved preventive services.  The service lines should be coded as follows:   Revenue Code  HCPCS c ode  Modifier  Service Date  Charges  0521  Encounter = FQHC Payment Code (G -code) code   10/01  150.00  0771  Preventive Service code   10/01  75.00   In the example above, the services reported under the encounter/visit service line will receive the PPS payment.  The charges reported on this line should  include the charges for the approved preventive service.  The coinsurance will be applied to the char ges reported on the encounter service line.  Coinsurance will not be applied to the charges reported for the approved preventive service.  The qualified preventive service reported on the second revenue line will not r eceive payment.  NOTE:   A qualified HC PCS code visit must be reported if the preventive service is not a qualified visit.   70.4 - Vaccines  (Rev. 12070; Issued: 06- 07-23; Effective: 07 -10-23; Implementation: 07- 10-23)  Influenza virus, pneumococcal and COVID -19 vaccines do not count as RHC/FQHC  visits.   The cost for these vaccines is included in the cost report and a visit is not billed for these services.  RHCs do not report vaccines on the claim, TOB 71x.  However, for FQHCs,  if there was another reason for the visit, the vaccine and the admin istration code should be reported on the claim, TOB 77x, for informational and data collection purposes only.  Coinsurance and deductible do not apply to these vaccines.  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 the 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.   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