evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
For more information on the FQHC PPS, please see the FQHC PPS Final Rule located at: https://www.cms.gov/Center/Provider- Type/Federally -Qualified -Health -Centers -FQHC -Center.html  40 - Deductible and Coinsurance  (Rev. 3434, I ssued: 12 -31-15, Effective: 03-31-16, Implementation: 03-31-16)  40.1 - Part B Deductible  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)  RHC services are subject to an annual deductible of twenty percent of charges for covered services.  Effective for dates of service on or after January 1, 2011, the deductible is not applicable for certain preventive services.  Please see section 80 for more information on how to bill for preventive services.  RHCs collect the patients deductible or the portion of the patients deductible that has not already been met. Once RHCs have billed the MAC for services, they do not collect or accept any additional  money from the patient for their deductible until the MAC notifies the RHC of how much of the deductible has been met.   The Part B deductible does not apply to FQHC services.  40.2 - Part B Coinsurance  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Im plementation: 03 -31-16)  After any applicable deductibles have been satisfied, RHCs and FQHCs paid under the AIR system will be paid 80 percent of their AIR.  The patient is responsible for a coinsurance amount of 20 percent of the charges after deduction of the  deductible, where applicable.   Effective for dates of service on or after January 1, 2011, coinsurance is not applicable for certain preventive services.  See section 80 of this manual for information on how to bill for preventive services on a RHC and FQHC claims.
(Medicare Claims Processing Manual)
Effective for dates of service on or after January 1, 2011, coinsurance is not applicable for certain preventive services.  See section 80 of this manual for information on how to bill for preventive services on a RHC and FQHC claims.   FQHCs paid under the PPS will be paid 80 percent of the lesser of the FQHCs actual charge for the specific payment code or the adjusted PPS rate.  The patient is responsible for a coinsurance amount of 20 percent of the lesser of the  FQHCs actual charge for the specific payment code or the adjusted PPS rate.  See section 60.2 for more information on the FQHC specific payment codes.   50 - General Requirements for RHC and FQHC Claims  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, I mplementation: 03 -31-16)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 13 for coverage requirements for RHCs and FQHCs.  This section addresses requirement s for claim submission only.   Section 1862 (a)(22) of the Act requires that all claims f or Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic format required for billing RHC and FQHC services is the ASC X12 837 institutional claim transaction.  Instructions relative to the data element names on the Form CMS -1450 hardcopy form are described below.  Each data element name is shown in bold type.  Information regarding the form locator numbers that correspond to these data element names is found in Chapter 25.  Not all data elements are required or utilized by all payers.  Detailed information is given only for items required for Medicare RHC and FQHC claims.  Only the items listed below are required for RHCs and FQHCs.   Provider Name, Address, and Telephone Number, Form Locator (FL) 01  The RHC/FQHC enters this information for their agency.   Type of Bill, FL 4
(Medicare Claims Processing Manual)
Provider Name, Address, and Telephone Number, Form Locator (FL) 01  The RHC/FQHC enters this information for their agency.   Type of Bill, FL 4   This four -digit alphanumeric code gives three specific pieces of information.  The first digit is a leading ze ro.   CMS ignores the first digit.  The second digit identifies the type of facility.  The third classifies the type of care.  The fourth indicates the sequence of this bill in this particular benefit period. It is referred to as a frequency code.   Code Structure  1st Digit  Leading Zero  CMS ignores the first digit    2nd Digit - Type of Facility  7 - Special  facility (Clinic)   3rdDigit - Classification (Special Facility Only)  1  Rural Health Clinic  7  Federally Qualified Health Centers   4th Digit  Frequency  Definition  0 - Nonpayment/Zero Claims  Used when no payment from Medicare is anticipated.  l - Admit  Through  Discharge  Claim  This code  is used for a billing for a confined treatment.  7 - Replacement  of Prior  Claim  This code  is used by the provider  when  it wants  to correct  a previously submitted  bill.  This  is the code  used  on the  corrected  or new bill.   For additional information on replacement bills see Chapter 3.  8 - Void/Cancel  of a Prior  Claim  This code is used to cancel a previously processed claim.   For additional information on void/cancel bills see Chapter 3.   Statement Covers Period (From -Through),  FL 06  The RHC/FQHC shows  the beginning and  ending dates  of the period covered  by this  bill in numeric  fields  (MM -DD-YY).   Patient Name/Identifier, FL 08  The RHC/FQHC enters the beneficiarys name exactly as it appears on the Medicare card.   Patient Address, FL 09  The RHC/FQHC enters the mailing address of the patient.  Ente r the complete mailing address.   Patient Birth date, FL10 The RHC/FQHC enters the date of birth of the patient.  Patient Sex, FL 11 The RHC/FQHC enters the sex of the patient as recorded at the start of care.   Priority (Type) of Admission or Visit, FL14  The RHC/FQHC enters the most appropriate NUBC approved code indicating the priority of the visit.
(Medicare Claims Processing Manual)
Priority (Type) of Admission or Visit, FL14  The RHC/FQHC enters the most appropriate NUBC approved code indicating the priority of the visit.   Point of Origin for Admission or Visit, FL 15  The RHC/FQHC enters the most appropriate NUBC approved code indicating the point of origin for this admission or visit.  Patient Discharge Status, FL 16 The RHC /FQHC enters the most appropriate NUBC approved code indicating the  patients  status  as of the Through date of  the billing  period.  Condition Codes, FL 18 -28 The RHC/FQHC enters any appropriate NUBC approved code(s) identifying conditions related to this bill that may affect processing.   Value Codes and Amounts, FL 39- 41 The RHC/FQHC enters any appropriate NUBC approved code(s) and the associated value amounts identifying numeric information related to this bill that may affect processing.   Revenue Co des, FL42  The RHC/FQHC assigns a revenue code for each type of service provided and enters the appropriate four -digit numeric revenue code to explain each charge.   For FQHC claims with dates of service on or after January 1, 2010, FQHCs may report additional revenue codes when describing services rendered during an encounter.  However, Medicare payment will continue to be reflected only on claim lines with the revenue codes in the following table:   Code  Description  0521  Clinic visit by member to RHC/FQHC   0522  Home visit by RHC/FQHC practitioner   Code  Description  0524  Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF   0525  Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility   0527  RHC/FQHC Visiting Nurse Service(s) to a members home when in a home health shortage area  0528  Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)   0519  Clinic, Other Clinic (only for the  FQHC supplemental payment)   0900  Mental Health Treatment/Services
(Medicare Claims Processing Manual)
0519  Clinic, Other Clinic (only for the  FQHC supplemental payment)   0900  Mental Health Treatment/Services   When billing for additional services rendered during the FQHCs encounter, any valid revenue codes may be used with a HCPCS code.  However, the following revenue codes are not allowed on FQHC claims:  002x- 024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x- 072x, 080x- 088x, 093x, or 096-310x.  HCPCS/Accommodation Rates/HIPPS Rate Codes, FL 44 For all services provided in a FQHC on or after January 1, 2010 and for approved preventive services provided in a RHC, HCPCS codes are required to be reported on the service lines.   The following HCPCS codes must be reported on FQHC PPS claims:   HCPCS Code  Definition  G0466  FQHC visit, new patient  A medically -necessary, face- to-face 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 receiving a FQHC visit.   G0467  FQHC visit, established patient  A medically -necessary, face- to-face encounter (one- on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and inclu des a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving a FQHC visit.   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.
(Medicare Claims Processing Manual)
G0469  FQHC vi sit, mental 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 receiving a mental health visit.   G0470  FQHC visit, men tal health, established p atient  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 Medicare-covered services that would be furnished per diem to a patient r eceiving a mental health visit.    Modifiers, FL 44  The FQHC reports modifier 59 when billing for a s ubsequent injury or illness.  This is not to be used when a patient sees more than one practitioner on the same d ay, or has multiple encounters with the same practitioner on the same day, unless the patient, subsequent to the first visit, leaves the FQHC and then suffers an illness or injury that requires additional diagnosis  or treatment on the same day.   Modifier 5 9 is the FQHCs attestation that the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day.  Modifier 59 should only be used when reporting unrelated services that occurred at separate times during the day (e.g., the patient had left the FQHC and returned later in the day for an unscheduled visit for a condition that was not present during the first visit).  For claims subject to the FQHC PPS, modifier 59 is only valid with FQHC Payment Code G0467.  Please see section 60.2 of this manual for more information on the FQHC Payment Codes.  Service Date, FL 45  Medicare requires a line item dates of service for all outpatient claims.  Medicare classifies RHC/FQHC claims as outpatient claims.  Non -payment service revenue codes  report dates as described in the table above under Revenue Codes.
(Medicare Claims Processing Manual)
Line items on outpatient claims under HIPAA require reporting of a line -item service date for each iteration of revenue code. A single date must be reported on a line item for the date the service was provided, not a range of dates.  For services that do not qualify as a billable visit, the usual charges for the services are added to those of the qualified visit.  RHCs/FQHCs use the date of the visit as the single date on the line item.  If there is no is billable visit associated with the services, then no claim is filed.   Service Units, FL 46  The RHC/FQHC enters  the number  of units  for each type  of service.  Units represent visits, which are paid based on the AIR or the FQHC PPS, no matter how many services are delivered.  Only one visit is billed per day unless the patient leaves and later returns with a different illness or in jury suffered later on the same day.   Total Charges, FL 47 The RHC/FQHC enters the total charge for the service descri bed on each revenue code line.  Payer Name, FL 50  The RHC/FQHC identifies the appropriate payer(s) for the claim.   National Provider Identifier (NPI)  Billing Provider, FL 56 The RHC/FQHC enters its own NPI.  When more than one encounter/visits is reported on the same claim i.e., medical and mental health visits, please choose the NPI of the provider that furnished the majorit y of the services.   Principal Diagnosis Code, FL 67 The RHC/FQHC enters diagnosis coding as required by ICD -9-CM o r ICD -10-CM Coding Guidelines.  Other Diagnosis Codes, FL 67A -Q The RHC/FQHC enters diagnosis coding as required by ICD -9-CM or ICD -10-CM Codi ng Guidelines.  Attending Provider Name and Identifiers, FL 76  The RHC/FQHC enters the NPI and name of the attending physician designated by the patient as having the most significant role in the determination and delivery of the patients medical care.   Other Provider Name and Identifiers, FL78 -79 The RHC/FQHC enters the NPI and name  NOTE:  For electronic claims using version 5010 or later, this information is reported in Loop ID 2310F  Referring Provider Name.
(Medicare Claims Processing Manual)
60 - Billing Requirements for RHCs and FQHCs  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  RHCs and FQHCs are institutional claims and are submitted to the MAC on TOB 71x and 77x.  Generally, only those services that are included in the RHC and FQHC benefits are billed on these claims.    The RHC and FQHC benefits are defined in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13 (http://www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf.)  All professional services in the RHC and FQHC benefit are paid through the AIR system or the FQHC PPS payment for each patient encounter or visit.  T echnical services (or technical components of services with both professional and technical components) are not billed on RHC/FQHC claims .  For FQHCs with cost reporting periods beginning on or after October 1, 2014, all services are paid according to the FQHC PPS methodology.  The visit rate includes: covered services provided by a FQHC practitioner and services and supplies furnished incident to the visit.  For additional information on FQHC services, see the Medicare Policy Manual, Chapter 13.  60.1 - Billing Guidelines for RHCs and FQHC Claims under the AIR System  (Rev. 3434, Issued: 12- 31-15, Effective: 03-31-16, Implementation: 03-31-16)
(Medicare Claims Processing Manual)
When billing Medicare, FQHCs must report all services provided during the encounter/visit by listing the appropr iate HCPCS code.  The additional revenue lines with detailed HCPCS code(s) are for information and data gathering purposes.  RHCs are only required to report the appropriate revenue code for medical and mental health services.  Encounters with more than one health professional and multiple encounters with the same health professionals that take place on the same day and at a single location generally constitute a single visit.  For FQHCs, payment is applied to the service line wi th revenue code 052X and a valid evaluation and management (E&M) HCPCS code for medical visits and revenue code 0900 for mental health visits.  Since RHCs are not required to reported detailed HCPCS codes, the payment is applied to the service line with revenue code 052X for medical and revenue code 0900 for mental health visits.  However, an additional AIR payment may be made for IPPE, DSMT or MNT (FQHCs only), and a subsequent illness and injuries billed with modifier 59 (FQHCs only).  When reporting multiple services on FQHC claims, the 052X revenue line with the E&M HCPCS code must include the total charges for all of the services provided during the encounter, minus any charges for approved preventive services.   For approved preventive services with a g rade of A or B from the United States Preventive Services Task Force (USPSTF), the charges for these services must be deducted from the E&M HCPCS code for the purposes of calculating beneficiary coinsurance correctly.  For example, if the total charge for the visit is $350.00, and $50.00 of that is for a qualified preventive service, the beneficiary coinsurance is based on $300.00 of the total charge.   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  E&M code*   01/01  300.00  0771  Preventive Service code   01/01  50.00   * RHCs are not required to report a HCPCS code.
(Medicare Claims Processing Manual)
* RHCs are not required to report a HCPCS code.   Medicare will make an additional AIR payment for IPPE, when billed on the same day with a qualified encounter/visit.  When reporting an additional encounter/visit for IPPE, the FQHC or RHC reports the appropriate HCPCS code for the service.  The revenue lines should be reflected as follows:   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  Office Visit   01/01  75.00  0419  Breathing Treatment   01/01  75.00  0521  IPPE   01/01  150.00   For FQHCs, Medicare will make an additional AIR payment for a subsequent illness or injury that occurs on the same day.  This is reported on the claim with an additional service line with revenue code 052X, a vali d HCPCS code and modifier 59.  Please see section 50 for more information on reporting modifier 59.   For Example:  Rev Code  HCPCS code  Modifier  Date of service  Charges  0521  Office Visit   01/01  150.00  0479  Removal of Wax From Ear   01/01  50.00  0521  Office Visit  59 01/01  135.00  0271  Wound Cleaning   01/01  25.00  0279  Bone Setting With Casting   01/01  95.00   Medicare will make an additional AIR payment to FQHCs when DSMT or MNT is reported on the same day with a qualified encounter/visit.  When reporting an additional encounter/visit for DSMT or MNT Report the appropriate HCPCS code for the service.  The reven ue lines should be reflected as follows:   For Example:  Rev Code  HCPCS code  Modifier  Date of Service  Charges  0521  Office Visit   01/01  75.00  0419  Breathing Treatment   01/01  75.00  0521  DSMT or MNT   01/01  150.00   FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim, the reporting of these codes are informational only.  MACs shall continue to pay for the influenza and pneumococcal vaccines and their administr ation through the cost report.   60.2 - Billing for FQHC Claims Paid under the PPS  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)
(Medicare Claims Processing Manual)
60.2 - Billing for FQHC Claims Paid under the PPS  (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  FQHCs transitioning to the PPS must submit separate claims for services subject to the PPS an d services paid under the AIR.   CMS established five FQHC payment specific codes to be used by FQHCs submitting claims under the PPS.  When reporting an encounter/visit for payment, the FQHC must bill on the claim (77X TOB ) a FQHC specific payment code.   FQHC Specific Payment Codes   G0466  FQHC visit, new patient  A medically -necessary, face- to-face 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 Me dicare- covered services that would be furnished per diem to a patient receiving a FQHC visit.   G0467  FQHC visit, established patient A medically -necessary, face- to-face 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 Medicare -covered services that would be furnished per diem to a patient receiving a FQHC visit.   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.
(Medicare Claims Processing Manual)
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