evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
For example:  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0467  FQHC Payment code   10/01  0521  99213  Qualifying visit   10/01   When submitting a claim for a mental health visit furnished on the same day as a medical visit, FQHCs must report a specific payment code for a medical visit (G0466, G0467, or G0468) and a specific payment code for a mental health visit (G0470), and each specific payment code must be accompanied by a service line with a qualifying visi t.  For example:  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0468  FQHC Payment code   10/01  0521  G0439  Qualifying visit   10/01  0900  G0470  FQHC Payment code   10/01  0900  90832 -Qualifying visit   10/01   When submitting a claim for a subsequent illness or injury, the FQHCs reports G0467 for a med ical visit), with modifier 59.  A qualifying visit is still required when reporting modifier 59 with G0467.  Revenue Code  HCPCS code  Modifier  Service Date  0521  G0468  FQHC Payment code   10/01  0521  G0439  Qualifying visit   10/01  0521  G0467  FQHC Payment code  59 10/01  0900  99211 -Qualifying visit   10/01   FQHCs must report all services that occurred on the same day on one claim.  FQHC may submit claims that span multiple days of service.  However, for FQHCs transitioning to the PPS, a separate claim must be submitted for services subject to the PPS and serv ices paid based on the AIR.  MACs will reject claims with multiple dates of service that include both PPS and non- PPS dates, as determined based on the individua l FQHCs cost reporting period.   FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim, and these HCPCS codes will be considered informational only.  MACs shall continue to pay for the influenza and pneumococcal vaccines through the cost report.
(Medicare Claims Processing Manual)
60.3 - Payments for FQHC PPS Claims (Rev. 3434, Issued: 12- 31-15, Effective: 03 -31-16, Implementation: 03- 31-16)  Payment for FQHC PPS claims is made by comparing the adjusted FQHC PPS rate to the total submitted covered charges reported for the specific payment codes G0466, G 0467, G0468, G0469, a nd G0470.  To calculate payment, follow the steps below:   Step 1:  Determine the lesser of the providers submitted charges for the specific payment code(s) and the fully- adjusted PPS rate.   Step 2:  Determine if preventive services for which the coi nsurance is waived are present.   Step 3:  Subtract the charges for the preventive services from the lesser of the providers charge for the specific payment code(s) or the PPS Rate.  (Lesser of the providers charge for the specifi c payment code or the PPS rate) -  (Preventive services charges) = Step 3 total   Note:   If no preventive services are present, use the lesser of the providers charge for the specific payment code(s) or the PPS rate as the Step 3 total.    Step 4:  Multiply the total from Step 3 by 80%. Step 3 total * 80% = Step 4 total   Note:   If no preventi ve services are present, contractors will p ay this amount and skip step 5.  Step 5:  Add the charges for the approved preventive service s to the total from step 4.  Contractors will pay this amount. Step 4 total + preventive services  charges = Medicare Paym ent  Note:  If the charges for the approved preventive services are greater than the total payment amount identified in Step 1 (i.e., the lesser of the charges for the specific payment code or the PPS rate), pay 100% of the total payment amount determined in Step 1 and do not apply coinsurance.  (Please see example 3)   To calculate coinsurance, follow the steps below:  Step 1:  Determine the lesser of the submitted charges for the G -code (s) and the PPS rate.  Step 2:  Determine if approved preventive servi ces (i.e., preventive services for which coinsurance is waived) are present.
(Medicare Claims Processing Manual)
Step 2:  Determine if approved preventive servi ces (i.e., preventive services for which coinsurance is waived) are present.   Step 3:  Subtract the charges for the preventive services from the lesser of the providers charge for the specific payment code(s) or the PPS Rate.  (Lesser of the providers cha rge for the specific payment code or the PPS rate) -  (Preventive services charges) = Step 3 total   Note:   If no approved preventive services are present, use the lesser the providers charge for the specific payment code(s) or th e PPS rate as the Step 3 total.   Step 4:  Multiply the total from Step 3 by 20%. Step 3 total * 20% = Coinsurance    Example :  Paymen t based on the charges  PPS rate = 160.00  Providers actual charge for the specific payment code, G0467 = $150  REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0467   10/01  150.00  150.00  0521  99213   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0001     310.00  310.00   The comparison is between the PPS rate and the providers $150 actual charge for the specific payment code, G0467.  In this case, the sum of the line items exceeds the providers actual charge for the payment code.   Payment based on the providers charge of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Coinsurance  0521  G0467   10/01  150.00  150.00  120.00  30.00  0521  99213   10/01  135.00  135.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     310.00  310.00    Payment = 150.00 (charges) * 80%   Coinsurance = 150.00 (charges) * 20%   For service lines that do not receive payment, group code CO - contractual obligation and the appropriate claim adjustment reason code (CARC) will be used.  * CARC 97  the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
(Medicare Claims Processing Manual)
* CARC 97  the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.    Example:  Payment based on the charges w ith approved preventive service  PPS rate = 160.00  Providers actual charge for the specific payment code, G0468 = $150   Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0439 PS**   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0001     310.00  310.00   Payment based on the providers actual charge of 150.00 for the specific payment code, G0468.  REV CODE  HCPC CODE  MODS SERV DATE  TOTAL CHARGE  COV  CHARGE  Payment  Co-insurance  0521  G0468   10/01  150.00  150.00  147.00  3.00 0521  G0439 PS   10/01  135.00  135.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     310.00  310.00     Payment = (150.00 (charges)  135.00 (preventive service G0439)) * 80% + 135.00 preventive service   Coinsurance = (150.00 (charges)  135.00 (preventive service G0439)) * 20%    ** PS  Preventive Service - These are approved preventive services where the coinsurance is waived based on the USPSTF recommendation. Example:  Payment based on the charges when preventive service is greater than G -code  PPS rate = 160.00   Providers actual charge for the specific payment code, G0468 = $150 Preventive Service = 155.00 REV CODE  HCPC  MODS  SERV DATE  TOTAL CHARGE  COV  CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0439 PS   10/01  155.00  155.00  0300  36415   10/01  25.00  25.00  0001     330.00  330.00
(Medicare Claims Processing Manual)
Payment based on charges of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co- insurance  0521  G0468   10/01  150.00  150.00  150.00  0 0521  G0439 PS  10/01  155.00  155.00  CO 97*  0 0300  36415   10/01  25.00  25.00  CO 97  0 0001     330.00  330.00     Payment = (150.00 (charges) * 100% = 150.00   Since the charges for the preventive service, G0439 are greater than the providers actual charge for the specific payment code G0468, Medicare pays 100% of the providers actual charge for the specific payment code, G0468.  Reporting Multiple G -codes  When a FQHC reports multiple specific payment codes (G-codes) on the same day, the total payment amount will be determined by comparing the sum of the charges for all the G-codes reported to the PPS rate.  When a qualified mental health visit occurs on the same day as a qualified medical visit, the G -codes will be totaled separately (see example 8).  Listed below is the order in which payment will be applied when multiple G-code s are reported on the same day:  Medical visits:  G0468- IPPE or AWV   G0466- Medical, new patient   G0467-Established patient  Mental health visits:  G0469-Mental health, new patient  G0470- Mental health, established patient  When G0466 (Medical, new patient) and G0468 (IPPE or AWV) are reported together, the add -on payment will be applied to G0468.
(Medicare Claims Processing Manual)
When G0466 (Medical, new patient) and G0468 (IPPE or AWV) are reported together, the add -on payment will be applied to G0468.   Example:  Payment based on PPS rate with multiple G- codes and preventive services  Because this scenario does not qualify for an exception to a per diem payment, the system will calculate and apply a PPS rate to only one of the specific payment codes.  However, the FQHC may list its actual charges for both specific payment codes, and the comparison would be between the PPS rate and the total of the providers charges for the specific payment codes. Payment would be based on the lesser amount.  PPS RATE, refl ecting a 1.3416 adjustment for new patients or a visit including an IPPE or AWV = 215.00  Total of provider charges for the specific payment codes (170.00 + 65.00) = 235.00 Providers charge for the Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  170.00  170.00  0521  G0438  PS   10/01  135.00  135.00  0300  36415   10/01  25.00  25.00  0521  G0466   10/01  65.00  65.00  0521  92004   10/01  45.00  45.00  0001     440.00  440.00   Payment based on adjusted PPS rate of 215.00 REV CODE  HCPC CODE  MODS SERV DATE  TOTAL CHARGE COV CHARGE Payment  Coinsurance  0521  G0468   10/01  170.00  170.00  199.00  16.00  0521  G0438 PS   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  25.00  25.00  CO 97  0 0521  G0466   10/01  65.00  65.00  CO 97  0 0521  92004   10/01  45.00  45.00  CO 97  0 0001     440.00  440.00
(Medicare Claims Processing Manual)
Payment = (215.00 (PPS rate)  135.00 (preventive service G0438) * 80% + 135.00 preventive service  Coinsurance = (215.00 (PPS rate)  135.00 (preventive service G0438)) * 20%    Reporting Multiple Preventive Services  When multiple preventive services are reported on the same day, the coinsurance will be determined by carving out the total preventive ser vices charges.    Example:  Payment based on PPS rate with multiple G- codes and multiple preventive services   PPS RATE =225.00  Total G code charges (140.00 + 75.00 + 55.00) = 270.00  Total Preventive Services (135.00 +60.00) =195.00  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  0001     535.00  535.00   Payment based on PPS rate of 225.00 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 0001     535.00  535.00
(Medicare Claims Processing Manual)
Payment = (225.00  (135.00 +60.00)) * 80% + 135.00 + 60.00  Coinsurance = (225.00 (PPS rate)  (135.00 + 60.00)) * 20%    Influenza and Pneumococcal Pneumonia Vaccination  (PPV ) Flu and PPV vaccines and their administration will continue to be paid through the cost report.  However, these services should be reported on the claim for information purposes only.  Flu and PPV vaccines and their administration codes will not be carved out of the coinsurance calculation.    Example:  Payment based on charges with Flu and Flu administration co de services   PPS rate = 160.00  Preventive Service = 135.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0468   10/01  150.00  150.00  0521  G0438 PS   10/01  135.00  135.00  0636  90655   10/01  15.00  15.00  771 G0008   10/01  5.00 5.00 0001     305.00  305.00   Payment based on charges of 150.00 REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  Payment  Co- insurance  0521  G0468   10/01  150.00  150.00  150.00  0 0521  G0438 PS   10/01  135.00  135.00  CO 97  0 0636  90655 ****   10/01  15.00  15.00  CO  246***  0 0771  G0008 ****   10/01  5.00 5.00 CO 246  0 0001     305.00  305.00     Because flu and PPV are reported on the claim for information purposes only, G0438 remains as the only service payable on this claim.  Because the claim consists solely of preventive services for which coinsurance is waived, the contractor will pay 100% of the providers actual charge for the specific payment code, G0468.  *** CARC 246- This non-payable code is for required reporting only.  **** Flu/PPV ar e reported on the claim for information purposes only, the payment and coinsurance are not impacted by the charges associated with the Flu/PPV vaccine and their administration code.
(Medicare Claims Processing Manual)
**** Flu/PPV ar e reported on the claim for information purposes only, the payment and coinsurance are not impacted by the charges associated with the Flu/PPV vaccine and their administration code.   Hepatitis B  Hepatitis B should be reported on the claim and is included i n the claim payment.  These services will be carved out of the coinsurance calculation.   Example:  Payment based on charges with Hepatitis B   PPS rate= 160.00  Preventive Services = 20.00 (15.00 +5.00) REV CODE  HCPC CODE  MODS  SERV DATE  TOTAL CHARGE  COV CHARGE  0521  G0467   10/01  150.00  150.00  0521  99213   10/01  135.00  135.00  0300  36415   10/01  5.00 5.00 0636  90746 PS   10/01  15.00  15.00  771 G0010 PS   10/01  5.00 5.00 0001     310.00  310.00   Payment based on charges of 150.00 REV CODE  HCPC  CODE  MODS SERV DATE  TOTAL CHARGE COV CHARGE  Payment  Co-insurance  0521  G0467   10/01  150.00  150.00  124.00  26.00  0521  99213   10/01  135.00  135.00  CO 97  0 0300  36415   10/01  5.00 5.00 CO 97  0 0636  90746 PS   10/01  15.00  15.00  CO 97  0 0771  G0010 PS   10/01  5.00 5.00 CO 97  0 0001     310.00  310.00     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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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
(Medicare Claims Processing Manual)
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)
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.