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Federally Qualified Health Centers (FQHC) Center

  • 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

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Important Links

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FQHC PPS Geographic Adjustment Factors (GAFs)

FQHC PPS Training and Information



CMS Manuals & Transmittals

Additional CMS Information

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