evekhm/cms_iom_500 huggingface dataset:
(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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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   Payment is made at the all- inclusive encounter rate to the FQHC  for DSMT or MNT.  This payment can be in addition to payment for another qualifying visit on the same date of service as the beneficiary received qualifying DSMT services.   For FQHCs to qualify for a separate visit payment for DSMT or MNT services, the services must be a one- on-one face- to-face encounter.  Group sessions do not constitute a billable visit for any FQHC services.  To receive separate payment for DSMT or MNT services, the services must be billed on TOB 77x with HCPCS code G0108 (DSMT) or HCPC S code 97802, 97803, or G0270 (MNT) and the appropriate site of service revenue code in the 052X revenue code series.  This payment can be in addition to payment for any other qualifying visit on the same date of service that the beneficiary received quali fying DSMT /MNT services as long as the claim for DSMT/MNT services contains the appropriate coding specified above. Additional information on DSMT can be found in Chapter 18, section 120 of Pub. 100- 04.  Additional information on MNT can be found in Chapt er 4, section 300 of Pub. 100- 04.
(Medicare Claims Processing Manual)
Additional information on MNT can be found in Chapt er 4, section 300 of Pub. 100- 04.  Group services (G0109, 97804 and G0271) do not meet the criteria for a separate qualifying encounter. A  ll line items billed on TOBs 77x with group services will be denied.   DSMT and MNT services are subject to the frequency edits described in Pub. 100- 04, Chapter 18, and should not be reported on the same day.   FQHCs billing under the PPS   DSMT and MNT are qualifying visits when billed under G0466 or G0467.  For additional information on the payment specific codes and qua lifying visits, see  section 60.2 of this manual.  Under the FQHC PPS, DSMT and MNT do not qualify for a separate payment when billed on the same day with another qualified visit.   RHCs   RHCs are not paid separately for DSMT and MNT services.  All line items billed on TOB 71x with HCPCS codes for DSMT and MNT services will be denied.  70.6 - Initial Preventive Physical Examination ( IPPE)  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  FQHCs and RHCs billing under the AIR system   Medicare provides for coverage for one  IPPE for new beneficiaries only, subject to certain elig ibility and other limitations.   Payment for the professional service s will be made under the AIR.  However, RHCs/FQHCs can receive a separate payment for  an encounter in addition to the payment for the IPPE when they are performed on the same day.   When IPPE is provided in an RHC or FQHC, the professional portion of the service is billed on TOBs 71X and 77X, respectively, and the appropriate site of servic e revenue code in the 052X revenue code series, and must include HCPCS code G0402.  Additional information on IPPE can be found in Chapter  18, section 80 of Pub. 100- 04.  EKGs  The professional component is included in the AIR or FQHC PPS and is not separat ely billable.
(Medicare Claims Processing Manual)
EKGs  The professional component is included in the AIR or FQHC PPS and is not separat ely billable.   The technical component of an EKG performed at a RHC/FQHC billed to Medicare on professional claims (Form CMS -1500 or 837P) under the practitioners ID following instructions for submitting practitioner claims for independent/freestanding cl inics.  Practitioners at provider -based clinics bill the applicable TOB to the A/B MAC  using the base providers ID.   FQHCs billing under the PPS:   IPPE is qualifying visits when billed under G0468, for additional information on the payment specific codes and qualifying visits, please refer to section 60.2 of this manual.  Under the FQHC PPS, IPPE does not qualify for a separate payment when billed on the same day with another encounter/visit.  70.7 - Virtual Communication Services                                                    (Rev. 10357, Issued: 09- 18-2020, Effective: 10 -19-2020, Implementation: 10- 19-2020)   In the CY 2019 PFS final rule, CMS finalized a policy for payment to RHCs and FQHCs for communication technology- based services (virtual check -in) or remote evaluation services, effective January 1, 2019. CMS created a new Virtual Communications G Code, G0071 for use by RHCs and FQHCs only, with the payment rate set at the average of the PFS non- facility payment rate for communication technology- based services and remote evaluation services.   RHCs and FQHCs receive an additional payment for the costs of communication technology- based services or remote evaluation services that are not alre ady captured in the RHC AIR or the FQHC PPS payment when the requirements for these services are met.  Coinsurance and deductibles apply to RHC claims, and coinsurance applies to FQHC claims for these services.
(Medicare Claims Processing Manual)
RHCs and FQHCs can bill HCPCS code G0071 al one or with other payable services on an RHC or FQHC claim.  The services should be billed with a revenue code 052x and should not be billed with modifier CG for payment on RHC claims. HCPCS codes G0071 are paid based on the lesser of the charges or the ra te from the Medicare Physician Fee Schedule (MPFS).    70.8- General Care Management Services  Chronic Care or Psychiatric Collaborative Care Model  (CoCM ) Services                                             (Rev. 10357, Issued: 09- 18-2020, Effective: 10 -19-2020, Implementation: 10- 19-2020)   Effective for services furnished on or after January 1, 2018, RHCs and FQHCs are paid for General Care Management or  Psychiatric CoCM services when G0511 or G0512 is billed alone or with other payable services on an RHC or FQHC claim.  HCPCS code G0511 or G0512 can only be billed once per month per beneficiary, and cannot be billed if other care management services are billed for the same time period.   HCPCS codes G0511 and G0512 are subject to coinsurance and deductibles on RHC claims.  Only coinsurance applies on FQHC claims. Coinsurance is 20 percent of the lesser of the RHC or FQHCs charge for HCPCS codes G0511 and G0512, or the corresponding rate.   The allowable revenue code is 052X. These HCPCS codes of G0511 or G0512 should not be billed with modifier CG for payment on RHC claims.   80 - Telehealth Services  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implem entation: 03 -31-16)
(Medicare Claims Processing Manual)
80 - Telehealth Services  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implem entation: 03 -31-16)  RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and HCPCS code Q3014.  Telehealth services are the only services billed on FQHC claims that are subject to the Part B d eductible.   Additionally, a FQHC payment code and qualifying visit HCPCS code are not required when the only service reported on the claim is for Telehealth services.  RHCs and FQHCs are not authorized to serve as distant practitioners for Telehealth services.   For more information on Telehealth services please see Pub 100-04, chapter 12, section 190: http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf   90 - Services non -Covered on RHC and FQHC Claims  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  Technical Services  RHCs/FQHCs do not bill using TOBs 71x or 77x for technical components of services because they are not within the scope of Medicare- covered RHC/FQHC services.  The associated technical components of services furnished by the RHC/FQHC are billed on other types of claims that are subject to appl icable frequency limits edits.
(Medicare Claims Processing Manual)
For services that can be split into professional and technical components, RHCs and FQHCs bill for the professional component as part of the AIR or the FQHC PPS payment and bill the MAC separately for the technical component.  See Chapter 17, section 30.1.1, for more information on how RHCs and FQHCs can bill the MAC for laboratory services.  See Chapter 13 for more information on how to bill the MAC for technical components of diagnostic services.  o Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are submitted to the MAC in the designated claim format (837P or Form CMS-1500.)  See chapters 12 (http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) and 26 (http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf ) of this manual for billing instructions.  o Technical services/components associated with professional services/components performed by provider- based RHCs or FQHCs  are submitted by the base-provider on the appropriate TOB to the MAC in the designated claim format (837I or the UB- 04 claim form); see the applicable chapter of this manual based on the base-provider type, such as (http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf ) for outpatient hospital services, chapter 6 (http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf ) for inpatient SNF services chapter 7 for Outpatient SNF services, etc.   Laboratory Services   RHCs  must furnish the following lab services to be approved as an RHC.  However, these and other lab services that may be furnished are not included in the encounter rate and must be billed separately.   Chemical examinations of urine by stick or tablet method or both;   Hemoglobin or hematocrit;   Blood sugar;   Examination of stool specimens for occult blood;   Pregnancy tests; and    Primary culturing for transmittal to a certified laboratory (No CPT code available).