Federally Qualified Health Centers (FQHC) Center
MLN Matters® Special Edition Article #SE1508 on Physician Quality Reporting System 2013 Reporting Year and 2015 Payment Adjustment for RHCs, FQHCs, and CAHs Released
On March 6, 2015, MLN Matters® Special Edition Article #SE1508, “Guidance on the Physician Quality Reporting System (PQRS) 2013 Reporting Year and 2015 Payment Adjustment for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs),” was released. This article is designed to provide education on the PQRS 2013 reporting year and 2015 payment adjustment for RHCs, FQHCs, and CAHs.
CMS Finalizes a Medicare Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs)
On May 2, 2014, CMS published a final rule that establishes methodology and payment rates for a PPS for FQHC services under Medicare Part B beginning on October 1, 2014, in compliance with the statutory requirements of Section 10501 of the Patient Protection and Affordable Care Act of 2010. Medicare will pay FQHCs a national encounter-based rate per beneficiary per day, with some adjustments. Payment will be 80 percent of either the PPS rate of $158.85, or the total charges for services furnished, whichever is less. FQHCs will be able to bill for separate visits when a mental health visit occurs on the same day as a medical visit. The FQHC PPS rate will be adjusted for geographic differences in the cost of services. In addition, the rate will be increased by 34 percent when a FQHC furnishes care to a patient that is new to the FQHC or to a beneficiary receiving a comprehensive initial Medicare visit or an annual wellness visit. FQHCs will transition into the PPS beginning October 1, 2014, based on their cost reporting periods.
2015 Medicare Benefit Policy Manual, Chapter 13
The Medicare Benefit Policy Manual, Chapter 13, has been updated, effective January 1, 2015. Updates include new and clarifying information on the new FQHC PPS rate, adjustments, payment codes, and qualifying visits; RHC employment requirements; RHC and FQHC preventive health services; and other issues related to RHC and FQHC billing and services. See MM8981 [PDF, 174KB] for a summary of the updates.
- 2015 RHC and FQHC Payment Rate Increases for RHCs and FQHCs Billing Under the All-Inclusive Rate System (AIR) and Urban and Rural Designations for FQHCs Billing Under the AIR. See MM8980 [PDF, 86KB] .
Sample Billing for Screening Pelvic and Clinical Breast Examination (HCPCS) Code G0101 for FQHCs Billing Under the AIR
Until further notice, claims for which G0101 is the only service furnished shall be paid based on a FQHC’s AIR when submitted as shown in the following example on a 77X TOB with revenue code 052X:
42 Rev Code 44 HCPCS/RATES 45 SERV DATE 46 SERV UNITS 47 Total Charges 0521 E&M code, 99XXX 10/01 1 $00.01 0521 G0101 10/01 1 $XX.XX
FQHC PPS Specific Payment Codes
When submitting a claim for FQHC services for payment under the FQHC PPS, FQHCs must use specific payment codes. See FQHC PPS Specific Payment Codes [PDF, 186KB] .
FQHC PPS Geographic Adjustment Factors (GAFs) for Services Furnished 1/01/2015 – 12/31/2015
See FQHC GAFs effective 01/01/2015 – 12/31/2015 [ZIP, 20KB] .
Medicare FQHC PPS Frequently Asked Questions (FAQs)
Updated FAQs on the new FQHC PPS are now available. See FQHC PPS FAQs [PDF, 221KB] .
- Questions on the FQHC PPS? Email FQHC-PPS@cms.hhs.gov
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- Medicare Benefit Policy Internet Only Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 249KB]
- FQHC Preventive Services [PDF, 301KB] – Information on preventive services in FQHCs including HCPCS coding, same day billing, and waivers of co-insurance
- FQHC PPS Specific Payment Codes [PDF, 186KB]
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide ( SE1039 [PDF, 108KB] )
- Medicare Claims Processing Manual: Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers [PDF, 217KB]
- Chapter 29-(T11) -- Independent Rural Health Clinic and Freestanding Federally Qualified Health Center cost Report Form CMS 222-92 (Instructions) [ZIP, 344KB]
- FQHC PPS in the Physician Fee Schedule (PFS) Final Rule with Comment Period
The PFS Final Rule with Comment Period was published in the Federal Register on November 13, 2014. In this final rule with comment period, we addressed comments that we received in response to the FQHC PPS Final Rule with Comment Period and finalized policies on specific aspects of the FQHC PPS. The CY 2015 PFS Final Rule is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
- FQHC PPS Final Rule with Comment Period
The FQHC PPS final rule with comment period was published in the Federal Register on May 2, 2014. This rule finalized a methodology and payment rates for the new FQHC PPS. CMS-1443-F (PDF Version) - Opens in a new window and CMS-1443-F (Text Version) - Opens in a new window
- FQHC PPS Proposed Rule
The FQHC PPS proposed rule with comment period was published in the Federal Register on September 23, 2013. This rule proposed a methodology and payment rates for the new FQHC PPS. CMS-1443-P (PDF Version) - Opens in a new window and CMS-1443-P (Text Version) - Opens in a new window
- Supporting Files Available for the Final Rule with Comment Period
FQHC Summary Data (CMS-1443-F) [ZIP, 577KB] : This file contains data summarized by the CMS Certification Number (CCN) assigned to the FQHC. The data can be used to model the final methodology and calculate projected payments and impacts under the final FQHC PPS.
- Supporting Files Available for the Proposed Rule
FQHC Summary Data (CMS-1443-P) [ZIP, 549KB] : This file contains data summarized by the CMS Certification Number (CCN) assigned to the FQHC. The data can be used to model the proposed methodology and calculate projected payments and impacts under the proposed PPS.
- PPS Structure Design Document
PPS Structure Design Document [PDF, 1MB] : A report prepared by Arbor Research Collaborative for Health that describes analyses performed and options modeled to support the development and implementation of the PPS.
- Change Request 8743
R1383OTN : Implementation of a Prospective Payment System for FQHCs
FQHC PPS Geographic Adjustment Factors (GAFs)
FQHC PPS Training and Information
- June 25, 2014, National Provider Call - Operational requirements for the new Medicare PPS for FQHCs. See http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-06-25-FQHC-NPC.html.
- May 21, 2014, National Provider Call- Final policies for the new Medicare PPS for FQHCs. See http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-05-21-FQHC.html.
- November 4, 2013 - Special Open Door Forum - Medicare Prospective Payment System for Federally Qualified Health Centers. See http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html.
- Medicare FQHC PPS Frequently Asked Questions (FAQs) - See FQHC PPS FAQs [PDF, 221KB] .
- Medicare Provider-Supplier Enrollment
- Enrollment Applications
- Conditions for Coverage (CfCs) & Conditions of Participations (CoPs)
- CfC and CoP: Rural Health Clinic/Federally Qualified Health Center
- Survey & Certification - General Information
- National Provider Identifier Standard (NPI)
- Section 10501 of the Patient Protection and Affordable Care Act of 2010, as consolidated and amended through May 10, 2010.
CMS Manuals & Transmittals
Additional CMS Information
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