Federally Qualified Health Centers (FQHC) Center

Spotlight

End of the COVID-19 Public Health Emergency (PHE) - Updates for RHCs & FQHCs

The COVID-19 PHE ended on May 11, 2023. At the beginning of the COVID-19 PHE, CMS used emergency waiver authorities and various regulatory authorities to allow flexibilities so providers could quickly respond to their Medicare patients affected by COVID-19. View RHCs and FQHCs: CMS Flexibilities to Fight COVID-19 for information about the changes to the RHC and FQHC flexibilities.

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:

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 via Telecommunications for FQHCs

Starting January 1, 2022, FQHCs can provide mental health visits using interactive, real-time telecommunications technology. You can provide telecommunications for mental health visits using audio-video technology and audio-only technology. This change lets you report and get paid in the same way as in-person visits. You may use audio-only technology in situations when your patient can’t access or doesn’t consent to use audio-video technology. 

View MLN Matters Article SE22001: Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers for coding and in-person mental health visit requirements.

Expansion of Virtual Communication Services for FQHCs During the COVID-19 PHE

The COVID-19 PHE ended on May 11, 2023. Starting May 12, 2023, digital assessment services are no longer included in virtual communication services. So, don’t submit claims for digital assessments with dates of service on or after May 12, 2023, using HCPCS code G0071.

During the COVID-19 PHE, payment for virtual communication services included online digital assessment services. Digital assessment services are non-face-to-face, patient-initiated, digital visits using a secure online patient portal.  

Use the following CPT codes for billing digital assessments provided from March 1, 2020 – May 11, 2023:

• 99421 (5-10 minutes over a 7-day period)
• 99422 (11-20 minutes over a 7-day period)
• 99423 (21 minutes or more over a 7-day period)

You must submit an FQHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services to get paid for the digital assessment service or virtual communication services (HCPCS codes G2012 and G2010).

For claims submitted with HCPCS code G0071, with dates of service from March 1, 2020 – May 11, 2023, payment for HCPCS code G0071 is set at the average of the national non-facility PFS payment rates. See Virtual Communication Services FAQs. 

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. 

Once the COVID-19 PHE ends, RHCs and FQHCs, located in an area that has not been determined to have a current HHA shortage and seeking to provide visiting nurse services will have to make a written request along with written justification that the area it serves meets the required conditions.

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