Federally Qualified Health Centers (FQHC) Center
- New Virtual Communication Services
Effective January 1, 2019, FQHCs can receive payment for Virtual Communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an FQHC practitioner to a patient who has had an FQHC billable visit within the previous year, and both of the following requirements are met:
- The medical discussion or remote evaluation is for a condition not related to an FQHC service provided within the previous 7 days, and
- The medical discussion or remote evaluation does not lead to an FQHC visit within the next 24 hours or at the soonest available appointment.
To receive payment for Virtual Communication services, FQHCs must submit an FQHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. Payment for G0071 is set at the average of the national non-facility PFS payment rates for HCPCS code G2012 (communication technology-based services) and HCPCS code G2010 (remote evaluation services) and is updated annually based on the PFS national non-facility payment rate for these codes.
RHC face-to-face requirements are waived when these services are furnished to an FQHC patient, and coinsurance applies.
2019 Update - Medicare Benefit Policy Manual, Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 120KB] and MM11019 [PDF, 208KB] .
New FQHC Care Management Services
Effective January 1, 2018, FQHCs can receive payment for Chronic Care Management (CCM) or general Behavioral Health Integration (BHI) services when 20 minutes or more of CCM or general BHI services are furnished and G0511 is billed either alone or with other payable services on an FQHC claim.
Effective January 1, 2018, FQHCs can receive payment for psychiatric Collaborative Care Model (CoCM) services when 70 minutes or more of initial psychiatric CoCM services or 60 minutes or more of subsequent psychiatric CoCM services are furnished and G0512 is billed either alone or with other payable services on an FQHC claim.
CCM services furnished on or before December 31, 2017 will continue to be processed and paid when CPT code 99490 is billed alone or with other payable services on an FQHC claim. Service lines reported with CPT code 99490 will be denied for dates of service on or after January 1, 2018.
Additional Information - MM10175 [PDF, 332KB] and Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program.
- 2018 FQHC Booklet
- FQHC PPS Geographic Adjustment Factors (GAFs) for Services Furnished 1/1/18 – 12/31/18
- FQHC PPS Specific Payment Codes [PDF, 323KB] – (Updated on 12/7/17)
- FQHC Preventive Services [PDF, 450KB] - (Updated on 8/10/16)
- 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 MM9267 [PDF, 50KB] and the Grandfathered Tribal FQHCs page.
- Questions on the FQHC PPS? Email FQHC-PPS@cms.hhs.gov
MLN Connects Newsletter
- Communication Technology Based Services and Payment for Rural Health Clinic (RHCs) and Federally Qualified Health Centers (FQHCs): MM10843
- CY 2019 Payment Rate Update to the FQHC PPS. See MM10990.
- Medicare Benefit Policy Internet Only Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 120KB]
- FQHC Preventive Services [PDF, 450KB] – Information on preventive services in FQHCs including HCPCS coding, same day billing, and waivers of co-insurance.
- FQHC PPS Specific Payment Codes [PDF, 323KB] (Updated 12/7/2017)
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide ( SE1039 [PDF, 92KB] )
- Medicare Claims Processing Manual: Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers [PDF, 241KB]
- Chapter 29-(T14) -- Independent Rural Health Clinic and Freestanding Federally Qualified Health Center cost Report Form CMS 222-92 (Instructions) [ZIP, 403KB]
- MLN Matters® Article SE1606 – 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)
- 2016 Physician Fee Schedule Final Rule with Comment
Information on CCM, ACP, and Grandfathered Tribal FQHCs. See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
- 2015 Physician Fee Schedule Final Rule with Comment
Final 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
Final methodology and payment rates for the new FQHC PPS. CMS-1443-F (PDF 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, 460KB] .
- FQHC Location Identifier - Opens in a new window
- Medicare Provider-Supplier Enrollment
- Enrollment Applications
- Conditions for Coverage (CfCs) & Conditions of Participations (CoPs)
- CfC and CoP: Rural Health Clinic/Federally Qualified Health Center
- Quality, Safety & Oversight - 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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