(Medicare Claims Processing Manual)

Payment = (150.00 (charges)  20.00 (preventive service 90746 + G0010)) * 80% + 20.00 preventive  Coinsurance = (150.00 (charges)  20.00 (preventive service 90746 + G0010)) * 20%  Mental Health Services  Qualified mental health visits billed under revenue code 0900 receive an additional payment when billed on the same day as a medical visit.   Example:  Mental Health Services   PPS RATE for G0468:  $225.00  PPS rate for G0470: $160  Total of providers actual charges for the specific payment codes representing medical visits (140.00 + 75.00 + 55.00) = 270.00-  This does not include charges for G0470   Providers charge for the specific payment code representing mental health services = 159.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV  CHARGE  0521  G0468   10/01  140.00  140.00  0521  G0439  PS   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0521  G0467   10/01  75.00  75.00  0521  97802  PS   10/01  60.00  60.00  0521  G0466   10/01  55.00  55.00  0521  92004   10/01  45.00  45.00  0900  G0470   10/01  159.00  159.00  0900  90832   10/01  139.00  139.00  0636  J3490   10/01  15.00  15.00  0001     848.00  848.00   Payment based on PPS rate of 225.00 for the specific payment codes describing the medical visits and based on the providers actual charges for the specific payment code describing the mental health visit.  REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co-insurance  0521  G0468   10/01  140.00  140.00  219.00  6.00 0521  G0439 PS   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  25.00  25.00  CO 97  0 0521  G0467   10/01  75.00  75.00  CO 97  0 0521  97802 PS   10/01  60.00  60.00  CO 97  0 0521  G0466   10/01  55.00  55.00  CO 97  0 0521  92004   10/01  45.00  45.00  CO 97  0 0900  G0470   10/01  159.00  159.00  127.20  31.80  0900  90832   10/01  139.00  139.00  CO 97  0 0636  J3490   10/01  15.00  15.00  CO 97  0 0001     848.00  848.00     For Medical visit with revenue code 052X  Payment = (225.00  (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate)  (135.00 + 60.00)) * 20%    For Mental Health visit with revenue code 0900  Payment = 159.00 *80% = 127.20 Coinsurance =159.00 * 20% = 31.80  Modifier 59  Medicare allows for an additional payment when an illness or injury occurs subsequent to the initial visit, and the FQHC bills these visits with the specific payment codes and modifier 59. Services billed with a modifier 59 will be paid an additional per diem rate    Example:  Modifier 59   PPS rate for G0468 = 225.00  Total G code charges (140.00 + 75.00 + 55.00) = 270.00  This does not include charges for G0470 and G- code charges for modifier 59   Total mental Health Services = 159.00   PPS rate for G0467 (billed with Modifier 59) = 160.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  140.00  140.00  0521  G0438  PS   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0521  G0467   10/01  75.00  75.00  0521  97802  PS   10/01  60.00  60.00  0521  G0466   10/01  55.00  55.00  0521  92004   10/01  45.00  45.00  0900  G0470   10/01  159.00  159.00  0900  90832   10/01  139.00  139.00  0636  J3490   10/01  15.00  15.00  0521  G0467  59 10/01  165.00  165.00  0521  99211   10/01  105.00  105.00  0001     1118.00  1118.00   Payment based on PPS rate of 225.00 for the G-codes, based on the charges for the mental health visit and based on the PPS rate for G0467 billed with modifier 59. REV CODE  HCPC  CODE  MODS SERV DATE  TOTAL CHARGE COV CHARGE Payment  Coinsurance  0521  G0468   10/01  140.00  140.00  219.00  6.00 0521  G0438 PS   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  25.00  25.00  CO 97  0 0521  G0467   10/01  75.00  75.00  CO 97  0 0521  97802 PS   10/01  60.00  60.00  CO 97  0 0521  G0466   10/01  55.00  55.00  CO 97  0 0521  92004   10/01  45.00  45.00  CO 97  0 0900  G0470   10/01  159.00  159.00  127.20  31.80  0900  90832   10/01  139.00  139.00  CO 97  0 0636  J3490   10/01  15.00  15.00  CO 97  0 0521  G0467  59 10/01  165.00  165.00  128.00  32.00  0521  99211   10/01  105.00  105.00  CO 97  0 0001     1118.00  1118.00     For Medical visit with revenue code 052X  Payment = (225.00  (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate)  (135.00 + 60.00)) * 20%    For Mental Health visit with revenue code 0900  Payment = 159.00 *80% = 127.20 Coinsurance =159.00 * 20% = 31.80   For G0467 billed with modifier 59  Payment = 160.00 * 80% = 128.00 Coinsurance = 160.00 * 20% = 32.00   60.4 - Billing for Supplemental Payments to FQHCs under Contract with Medicare Advantage (MA) Plans (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  Section 237 of the Medicare Modernization Act (MMA) requires CMS to provide supplemental payments to FQHCs that contract with MA organizations to cover the difference, if any, between the payment received by the FQHC fo r treating MA enrollees and the payment to which the FQHC would be entitled to receive under the cost -based all-inclusive payment rate as set forth in 42 CFR, Part 405, Subpart X.  This supplemental payment for covered FQHC services furnished to MA enrolle es augments the direct payments made by the MA organization to FQHCs for all covered FQHC services.  The Medicare per diem payment, which continues to be made for all covered FQHC services furnished to Medicare beneficiaries participating in the original Medicare program, is based on the FQHC's unique cost -per-visit as calculated by the MAC.  The MAC determines if the Medicare payments that the FQHC would be entitled to exceed the amount of payments received by the FQHC from the MA organization and, if so, pay the difference to the FQHC.   FQHCs seeking the supplemental payment are required to submit (for the first two rate years) to the MAC an estimate of the average MA payments (per visit basis) for covered FQHC services.  They are required to submit a doc umented estimate of their average per visit payment for their MA enrollees, for each MA plan they contract with, and any other information as may be required to enable the MAC to accurately establish an interim supplemental payment.   Expected payments from  the MA organization would only be used until actual MA revenue and visits collected on the FQHCs cost report can be used to establish the amount of the supplemental payment.  Effective January 1, 2006, eligible FQHCs will report actual MA revenue and vis its on their cost reports.  At the end of each cost reporting period the MAC shall use actual MA revenue and visit data along with the FQHCs final all -inclusive payment rate, to determine the FQHCs final actual supplemental per visit payment.  Once this amount (per visit basis) is determined it will serve as the interim rate for the next full rate year. Actual aggregated supplemental payments will then be reconciled with aggregated interim supplemental payments, and any underpayment or overpayment thereon will then be accounted for in determining final Medicare FQHC program liability at cost settlement.   An FQHC is only eligible to receive this supplemental payment when FQHC services are provided during a face -to-face encounter between an MA enrollee and o ne or more of the following FQHC covered core practitioners:  physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, or clinical social workers.  The supplemental payment is made directly to each qualified FQHC through the MAC.  Each FQHC seeking the supplemental payment is responsible for submitting a claim for each qualifying visit to the MAC on type of bill (TOB) 77x with revenue code 0519 for the amount of the interim supplemental payment rate (FQHC inte rim all- inclusive rate  estimated average payment from the MA plan plus any beneficiary cost sharing = billed amount > 0).  Do not submit revenue codes 052X and/or 0900 on the same claim as revenue code 0519.   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.