by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 21st, 2015
Basic Billing Requirements
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under revenue code 0519. NOTE: Revenue code 0519 is only used for Medicare Advantage (MA) Supplemental claims.
FQHCs must continue to report detailed HCPCS coding on the claim to describe all services that occurred during the encounter. All service lines must be reported with their associated charges.
Payment for a FQHC encounter requires a medically necessary face-to-face visit. Each FQHC specific payment code (G0466-G0470) must have a corresponding service line with a HCPCS code that describes the qualifying visit. See Attachment A of CR8743 for a list of qualifying visits that correspond to the specific payment codes. (NOTE: A link to CR8743 is available in the "Additional Information" section at the end of this article.)
When submitting a claim for a mental health visit furnished on the same day as a medical visit, FQHCs must report a specific payment code for a medical visit (G0466, G0467, or G0468) and a specific payment code for a mental health visit (G0470), and each specific payment code must be accompanied by a service line with a qualifying visit.
When submitting a claim for a subsequent illness or injury, FQHCs must report the appropriate specific payment code (G0467 for a medical visit or G0470 for a mental health visit) with modifier 59. Modifier 59 is the FQHC's attestation that the patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day. Modifier 59 should only be used when reporting unrelated services that occurred at separate times during the day (e.g., the patient had left the FQHC and returned later in the day for an unscheduled visit for a condition that was not present during the first visit). NOTE: A qualifying visit is still required when reporting modifier 59 with G0467 or G0470.
FQHCs must report all services that occurred on the same day on one claim.
FQHC may submit claims that span multiple days of service. However, FQHCs transitioning to the PPS must submit separate claims for services subject to the PPS and services paid based on the AIR. MACs shall reject claims with multiple dates of service that include both PPS and non-PPS dates, as determined based on the individual FQHC's cost reporting period.
Durable Medical Equipment (DME), laboratory services (excluding 36415), ambulance services, hospital-based services, group services, and non-face-to-face services will be rejected.
Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (MNT) services are subject to the frequency edits described in Pub 100-04, Chapter 18, and should not be reported on the same day.
FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their administration on a FQHC claim, and these HCPCS codes will be considered informational only. MACs shall continue to pay for the influenza and pneumococcal vaccines through the cost report.
Please refer to the examples in Attachment B of CR8743 for additional billing guidance.
The total payment amount for a FQHC visit shall be the lesser of the FQHC's reported charge for the FQHC payment code or the fully adjusted FQHC PPS rate for the specific payment code. Under the FQHC PPS, MACs shall generally pay 80 percent of the lesser of the FQHC's charge for the FQHC payment code or the corresponding FQHC PPS rate. Coinsurance will generally be 20 percent of the lesser of the actual charge or the FQHC PPS rate.
Medicare waives coinsurance for certain preventive services. For FQHC claims that consist solely of preventive services that are exempt from beneficiary coinsurance, MACs shall pay 100 percent of the lesser of the provider's charge for the FQHC payment code or the FQHC PPS rate, and no beneficiary coinsurance would be assessed.
For FQHC claims that include a mix of preventive and non-preventive services, MACs shall use the lesser of the provider's charge for the specific FQHC payment code or the corresponding FQHC PPS rate to determine the total payment amount. To determine the amount of Medicare payment and the amount of coinsurance that should be waived, MACs shall use the FQHC's reported line-item charges and subtract the dollar value of the FQHC's reported line-item charge for the preventive services from the full payment amount. (See the "Medicare Claims Processing Manual," Pub. 100-04, chapter 18, section 1.2, for a table of preventive services that are exempt from beneficiary coinsurance. That manual chapter is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf on the CMS website.)
Claims for Medicare Advantage (MA) Supplemental Payments
FQHCs that have a written contract with a MA organization that furnishes care to beneficiaries covered by the MA plan are paid by the MA organization at the rate that is specified in their contract. If the MA contract rate is less than the Medicare PPS rate, Medicare will pay the FQHC the difference, less any cost sharing amounts owed by the beneficiary. The supplemental payment is only paid if the contracted rate is less than the fully adjusted PPS rate. To facilitate accurate payment, claims for MA supplemental payments under the FQHC PPS must include the specific payment codes that correspond to the appropriate PPS rates and the detailed HCPCS coding required for all FQHC PPS claims.
The official instruction, CR 8743, issued to your MAC regarding this change is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1383OTN.pdf on the CMS website.