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, please see the link: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf (PDF)
COVID-19 Vaccines in RHCs and FQHCs
COVID-19 vaccines and their administration will be paid the same way influenza and pneumococcal vaccines and their administration are paid in RHCs and 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. RHCs and FQHCs should include COVID-19 vaccines and their administration costs for patients enrolled in Medicare Advantage on the cost report as well. For additional information, please see https://www.cms.gov/covidvax.
- New Payment for Telehealth Services for RHCs and FQHCs
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 RHCs and 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. RHCs and FQHCs with this capability can immediately provide and be paid for telehealth services to patients covered by Medicare for the duration of the COVID-19 PHE.
Distant site telehealth services can be furnished by any health care practitioner working for the RHC or 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 RHC or 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 to RHCs and FQHCs for distant site telehealth services is set at $92.
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
Payment for virtual communication services now 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. Claims for G0071 will be paid at the CY 2020 rate of $13.53 and later reprocessed with the new rate of $24.76.
- Revision of FQHC Home Health Agency Shortage Requirement for Visiting Nursing Services
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 typically served by the FQHC 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.
Principal Care Management (PCM) Services in RHCs and FQHCs
PCM services describe comprehensive care management services of a single high-risk disease or complex condition. HCPCS code G2064 is for at least 30 minutes of PCM services furnished by physicians or non-physician during a calendar month. HCPCS code G2065 is for at least 30 minutes of PCM services furnished by clinical staff under the direct supervision of a physician or non-physician during a calendar month.
Beginning January 1, 2021, RHCs and FQHCs that furnish PCM services will bill the general care management HCPCS code G0511, either alone or with other payable services on an RHC or FQHC claim. The payment rate for HCPCS code G0511 is the average of the national non-facility physician fee schedule (PFS) payment rate for care management and general behavioral health codes (CPT codes 99484, 99487, 99490, and 99491) now includes PCM HCPCS codes G2064 and G2065. The payment rate for HCPCS code G0511 will be updated annually based on the PFS amounts for these codes.
New Virtual Communication Services
Effective January 1, 2019, RHCs can receive payment for Virtual Communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC practitioner to a patient who has had an RHC 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 RHC service provided within the previous 7 days, and
- The medical discussion or remote evaluation does not lead to an RHC 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.
Face-to-face requirements are waived when these services are furnished to an FQHC patient, and coinsurance applies. See Virtual Communication Services Frequently Asked Questions (PDF)
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 MM9267 (PDF) and the Grandfathered Tribal FQHCs page.
Questions on the FQHC PPS? Email FQHC-PPS@cms.hhs.gov