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Federally Qualified Health Centers (FQHC) Center

Spotlights
  • Frequently Asked Questions (FAQs)
    FAQs on the new FQHC PPS are now available.  Please visit the FQHC PPS Webpage at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Index.html and see FQHC PPS FAQs in the Downloads section.
  • MLN Connects™ National Provider Call - Review of the New Medicare PPS for Federally Qualified Health Centers

    CMS hosted a National Provider Call on Wednesday, May 21, 12:30 – 2:30 p.m. ET, to review the final policies for the new Medicare PPS for FQHCs. The slide presentation is available at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-05-21-FQHC.html

    CMS hosted a second National Provider Call on Wednesday, June 25, 1:30 - 3:00 pm ET, to review the operational requirements for the new Medicare PPS for FQHCs.  The slide presentation is available at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-06-25-FQHC-NPC.html

  • CMS Finalizes a Medicare Prospective Payment System for Federally Qualified Health Centers

    On May 2, 2014, CMS published a final rule that establishes methodology and payment rates for a prospective payment system (PPS) for Federally Qualified Health Center (FQHC) services under Medicare Part B beginning on October 1, 2014, in compliance with the statutory requirements of the Affordable Care Act. Medicare will pay FQHCs a single 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 by using an adaptation of the Geographic Practice Cost Indices used to adjust payment under the physician fee schedule. In addition, the rate will be increased by 34 percent to account for greater intensity and resource use when an 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.

  • Preventive Services

    Payments to RHCs and FQHCs for covered RHC and FQHC services furnished to Medicare beneficiaries are made on the basis of an all-inclusive rate (AIR) per covered visit.  Information on preventive services payable under the AIR is available in CMS Pub 100-04, Chapters 9 and 18. 

    The chart below lists preventive services that are eligible to be paid based on the provider’s AIR when billed without another covered visit.

     

    Service

    HCPCS Code

    Long Descriptor

    Eligible service paid at the AIR

    Coinsurance/Deductible

    CMS Pub 100-04

    Initial Preventive Physical Examination (IPPE)

    G0402*

    Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment

    Yes

    Waived

    Ch 9 §150

    Ch 18 §80

    Diabetes Self-Management Training (DSMT)

    G0108*

    Diabetes outpatient self-management training services, individual, per 30 minutes

    Yes

    (FQHCs only)

    Not

    Waived

    Ch 9 §181

    Ch 18 §120

    Medical Nutrition Therapy (MNT)

    97802*

    Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes

    Yes

    (FQHCs only)

    Waived

    Ch 9 §182

    97803*

    Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes

    Yes

    (FQHCs only)

    Waived

    G0270*

    Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes

    Yes

    (FQHCs only)

    Waived

    Annual Wellness Visit

    G0438

    Annual wellness visit, including PPPS, first visit

    Yes

    Waived

    Ch 18 §140

    G0439

    Annual wellness visit, including PPPS, subsequent visit

    Yes

    Waived

     

    * This service is payable with another encounter/visit on the same day at the provider’s AIR.

  • Special Open Door Forum

    On November 4, 2013, CMS held a Special Open Door Forum on Proposed Rule CMS-1443-P: Medicare Prospective Payment System for Federally Qualified Health Centers The transcript and audio files are posted in the Downloads section of CMS's Special Open Door Forum webpage at: http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html

  • CMS Proposes a Medicare Prospective Payment System for Federally Qualified Health Centers
    Health Centers will Transition to a New Medicare Payment System and Higher Medicare Reimbursements

    On September 18, CMS issued a proposed rule that would establish methodology and payment rates for a prospective payment system (PPS) for Federally Qualified Health Center (FQHC) services under Medicare Part B beginning on October 1, 2014, in compliance with the statutory requirements of the Affordable Care Act.  CMS is proposing payment to FQHCs based on a single encounter-based per diem rate per Medicare beneficiary. The encounter-based per-diem rate would be calculated based on an average cost per encounter and is estimated to be $155.90, subject to change in the final rule based on more current data. The rate would be adjusted for geographic differences in the cost of services by adopting the Geographic Practice Cost Indices (GPCI) used to adjust payment under the physician fee schedule (PFS). In addition, the rate would be adjusted (increased by approximately 33 percent) for greater intensity and resource use when an FQHC furnishes care to a patient that is new to the FQHC or to a beneficiary receiving a comprehensive initial Medicare visit (i.e., an initial preventive physical examination or an initial annual wellness visit).  FQHCs would transition into the PPS beginning October 1, 2014, based on their cost reporting periods.

    This proposed rule also amends the Clinical Laboratory Improvement Amendments (CLIA) of 1988 to be in alignment with the Taking Essential Steps for Testing (TEST) Act of 2012, proposing the regulatory changes needed to fully implement the TEST Act. This proposed rule outlines the framework for the application of sanctions in proficiency testing (PT) referral cases.

    The proposed rule will be published in the September 23 Federal Register. CMS will accept comments on the proposed rule until November 18, 2013, and will respond to them in a final rule to be issued in 2014.

    Additional information is available in the CMS press release , fact sheet  and proposed rule.  

  • Vaccination is the Best Protection Against the Flu [PDF, 414KB]
  • SE1039Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide

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