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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.

  • FQHC Preventive Services

    FQHCs are paid an all-inclusive rate (AIR) per visit for qualified primary and preventive health services. Except for IPPE and DSMT/MNT, all preventive services furnished on the same day as another medical visit constitute a single billable visit.  If an IPPE or DSMT/MNT visit occurs on the same day as another billable visit, two visits may be billed.  All of the preventive services listed below may be billed as a stand-alone visit if no other service is furnished on the same day. 

    Additional information on payment and claims processing for FQHC preventive services is available in the Medicare Claims Processing Manual, Pub 100-04, Chapters 9 and 18. Additional information on FQHC policy for preventive services is available in the Medicare Benefit Policy Manual, Pub 100-02, Chapter 13. These manuals are available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf.  

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

    Service

    HCPCS Code

    Long Descriptor

    Paid at the AIR

    Eligible for Same Day Billing

    Coinsurance

    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

    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

    Yes

    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

    Yes

    Waived

    Ch 9 §182

    97803

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

    Yes

    Yes

    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

    Yes

    Waived

    Annual Wellness Visit

    G0438

    Annual wellness visit, including PPPS, first visit

    Yes

    No

    Waived

    Ch 18 §140

    G0439

    Annual wellness visit, including PPPS, subsequent visit

    Yes

    No

    Waived

    Screening Pelvic Exam

    G0101

    Cervical or vaginal cancer screening; pelvic and clinical breast examination

    Yes

    No

    Waived

    Ch 18 §40

    Prostate Cancer Screening

    G0102

    Prostate cancer screening; digital rectal examination

    Yes

    No

    Not Waived

    Ch 18 §50

    Glaucoma Screening

    G0117

    Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist

    Yes

    No

    Not Waived

    Ch 18 §70

    G0118

    Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

    Yes

    No

    Not Waived

    Note:  Separate instructions will be available for FQHCs billing under the PPS on or after October 1, 2014. 

    Sample Billing for Preventive Services

    Eligible preventive services (identified above) 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 $XX.XX
    0521 G0101 10/01 1 $XX.XX

(Updated 8/1/14)

  • 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.  

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