FQHC Policies Addressed in the CY 2023 Physician Fee Schedule Final Rule
CMS issued the CY2023 Medicare Physician Fee Schedule Final Rule which included several provisions that impacted FQHCs. A list of provisions effective January 1, 2023 is outlined below. Information regarding each of these policies is available in the CY 2023 Medicare Physician Fee Schedule Final Rule Fact Sheet.
New Care Management Codes for Chronic Pain Management (CPM) and General Behavioral Health Integration (GBHI)
Conforming Technical Changes to 42 CFR 405.2463 and 42 CFR 405.246
The following HCPCS codes have been revised to reflect the updates in the Consolidated Appropriations Act (CAA), 2023:
CY 2023 Payment Rate
COVID-19 Public Health Emergency (PHE) - Updates for FQHCs
To provide as much support as possible to FQHCs and their patients during the COVID-19 (PHE), we have made several changes to FQHC requirements and payments. These changes are for the duration of the COVID-19 PHE, and we will continue to review our policies as the situation evolves. For additional information and other flexibilities, please see the link: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf (PDF)
COVID-19 Vaccines in FQHCs
COVID-19 vaccines and their administration will be paid the same way influenza and pneumococcal vaccines and their administration are paid in FQHCs. Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through the cost report. The beneficiary coinsurance and deductible are waived. For Medicare Advantage patients, RHCs and FQHCs should submit COVID-19 vaccine administration claims to the Medicare Advantage Plan for dates of service on or after January 1, 2022. Original Medicare won’t pay for these claims beginning in January 2022. For dates of service in 2021, RHCs and FQHCs should use the cost report to bill for administering COVID-19 vaccines. For additional information, please see https://www.cms.gov/covidvax.
Payment for Telehealth Services for FQHCs During the COVID-19 PHE
On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was signed into law. Section 3704 of the CARES Act authorizes FQHCs to furnish distant site telehealth services to Medicare beneficiaries during the COVID-19 PHE. Medicare telehealth services generally require an interactive audio and video telecommunications system that permits real-time communication between the practitioner and the patient. FQHCs with this capability can provide and be paid for telehealth services to patients covered by Medicare for the duration of the COVID-19 PHE.
Section 4113 of the CAA, 2023 extends the telehealth policies enacted in the CAA, 2022 through December 31, 2024 if the PHE ends prior to that date.
Distant site telehealth services can be furnished by any health care practitioner working for the FQHC within their scope of practice. Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the FQHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS). A list of these services can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
Payment for Mental Health Visits Furnished by FQHCs via Telecommunications
Beginning January 1, 2022, FQHC mental health visits will include visits furnished using interactive, real-time telecommunications technology. This change will allow FQHCs to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the beneficiary is not capable of, or does not consent to, the use of video technology. Therefore, we are finalizing that there must be an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that in general, there must be an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders. However, exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record) and more frequent visits are also allowed under our policy, as driven by clinical needs on a case-by-case basis.
Section 4113 of the CAA, 2023 delayed the in-person requirements under Medicare for mental health services furnished through telehealth under the PFS and for mental health visits furnished by FQHCs via telecommunications technology. For FQHCs, in-person visits will not be required until January 1, 2025 if the PHE ends prior to that date.
In order to bill for mental health visits furnished via telecommunications for dates of service on or after January 1, 2022, FQHCs should bill Revenue code 0900, along with the applicable FQHC Specific Payment Code and the FQHC PPS Qualifying Payment code for mental health visits. Use modifier 95 for services furnished via audio and video telecommunications and use modifier FQ for services that were furnished audio-only.
For additional information on payment, billing, and claims processing, see https://www.cms.gov/files/document/se20016.pdf (PDF)
Expansion of Virtual Communication Services for FQHCs During the COVID-19 PHE
During the COVID-19 PHE, payment for virtual communication services include digital assessment services. Digital assessment services are non-face-to-face, patient-initiated, digital communications using a secure online patient portal. The digital assessment codes that are billable during the COVID-19 PHE are CPT code 99421 (5-10 minutes over a 7-day period), CPT code 99422 (11-20 minutes over a 7-day period), and CPT code 99423 (21 minutes or more over a 7-day period).
To receive payment for the new digital assessment service or virtual communication services (HCPCS codes G2012 and G2010), FQHCs must submit an FQHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. For claims submitted with HCPCS code G0071 on or after March 1, 2020, and for the duration of the COVID-19 PHE, payment for HCPCS code G0071 is set at the average of the national non-facility PFS payment rates for these 5 codes. See Virtual Communication Services Frequently Asked Questions (PDF)
Care Management Services
Effective January 1, 2023, care management services furnished in FQHCs include transitional care management (TCM), chronic care management (CCM), principal care management (PCM), chronic pain management (CPM), and general behavioral health integration (BHI) services. CCM services are paid at the average of the national non-facility PFS payment rates, either alone or with other payable services, using general care management HCPCS code G0511 which is updated annually. At least 20 minutes of qualifying CCM services must be furnished in a calendar month to bill for this service.
Effective January 1, 2022, RHCs and FQHCs can bill TCM services and general care management services provided for the same patient during the same service period if the RHC and FQHC meet the requirements for billing each code.
Psychiatric CoCM services furnished on or after January 1, 2019, are paid at the average of the national non-facility PFS payment rate, either alone or with other payable services, using HCPCS code G0512. This rate is updated annually. At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months, of psychiatric CoCM services must be furnished in order to bill for this service.
Revision of FQHC Home Health Agency Shortage Requirement for Visiting Nursing Services During the COVID-19 PHE
FQHCs can bill for visiting nursing services furnished by an RN or LPN to homebound individuals under a written plan of treatment in areas with a shortage of home health agencies (HHAs). Effective March 1, 2020 and for the duration of the COVID-19 PHE, the area included in the FQHC service area plan is determined to have a shortage of home health agencies, and no request for this determination is required. FQHCs must check the HIPAA Eligibility Transaction System (HETS) before providing visiting nurse services to ensure that the patient is not already under a home health plan of care.
Grandfathered Tribal FQHCs
Effective 1/1/16, a clinic that is operated by a tribe or tribal organization under the Indian Self-Determination Education and Assistance Act, and was billing as if it were provider-based to an IHS hospital on or before 4/7/00, and is no longer operating as a provider-based department of an IHS hospital, may be certified as a grandfathered tribal FQHC. See the Grandfathered Tribal FQHCs page.
Questions on the FQHC PPS? Email FQHC-PPS@cms.hhs.gov
- CY 2023 Payment Rate Update to the FQHC PPS
- CY 2022 Payment Rate Update to the FQHC PPS
- CY 2021 Payment Rate Update to the FQHC PPS
- CY 2020 Payment Rate Update to the FQHC PPS
- Chronic Care Management Services (PDF) booklet
- SE22001 (PDF) - Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers (PDF)
- Communication Technology Based Services and Payment for Rural Health Clinic (RHCs) and Federally Qualified Health Centers (FQHCs) [January 2019]: MM10843 (PDF)
- CY 2019 Payment Rate Update to the FQHC PPS. See MM10990.
- Medicare Claims Processing Manual: Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers (PDF)
- Medicare Benefit Policy Internet Only Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (PDF) See MM11019 (PDF)
- FQHC Preventive Services (PDF) – Information on preventive services in FQHCs including HCPCS coding, same day billing, and waivers of co-insurance.
- FQHC PPS Specific Payment Codes (PDF) (Updated 12/7/2017)
- SE1606 (PDF) - Guidance on the Physician Quality Reporting System (PQRS) 2014 Reporting Year and 2016 Payment Adjustment for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs)
- Chapter 29-(T14) -- Independent Rural Health Clinic and Freestanding Federally Qualified Health Center cost Report Form CMS 222-92 (Instructions) (ZIP)
- Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 - See Section III. Other Provisions of the Final Rule - C. Payment for Care Management Services and Communication Technology-Based Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 - See Section III. Other Provisions of the Proposed Rule - A. New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)
- Previous FQHC Regulations and Other Supporting Information (PDF)
FQHC PPS Geographic Adjustment Factors (GAFs)
- FQHC GAFs - 01/01/2023 - 12/31/2023
- FQHC GAFs - 01/01/2022 - 12/31/2022 Revised (ZIP)
- FQHC GAFs - 01/01/2021 - 12/31/2021 (ZIP)
- FQHC GAFs - 01/01/2020 - 12/31/2020 (ZIP)
- FQHC GAFs - 01/01/2019 – 12/31/2019 (ZIP)
- FQHC GAFs - 01/01/2018 – 12/31/2018 (ZIP)
- Previous FQHC PPS Geographic Adjustment Factors (PDF)
Frequently Asked Questions
- CY 2022 Physician Fee Schedule Final Rule Frequently Asked Questions (PDF)
- FQHC PPS Frequently Asked Questions (PDF) - updated 11/21/19
- COVID-19 Frequently Asked Questions (FAQs) for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) (PDF)
- Virtual Communication Services in RHCs and FQHCs Frequently Asked Questions (PDF)