Implementation of a Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs)

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 21st, 2015

CMS is establishing five specific payment codes to be used by FQHCs submitting claims under the PPS:

1. G0466 – FQHC visit, new patient

A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit

2. G0467 – FQHC visit, established patient

A medically-necessary, face to face encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit

3. G0468 – FQHC visit, IPPE or AWV

A FQHC visit that includes an Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV

4. G0469 – FQHC visit, mental health, new patient

A medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit

5. G0470 – FQHC visit, mental health, established patient

A medically-necessary, face-to-face mental health encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare covered services that would be furnished per diem to a patient receiving a mental health visit

Reference: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8743.pdf

When reporting an encounter/visit for payment, the claim (77X TOB) must contain a
FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds
to the type of visit.
 
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under revenue code 0519. NOTE: Reveue code 0519 is only used
for Medicare Advantage (MA) Supplemental claims.
 
FQHC specific payment codes G0469 and G0470 must be reported under revenue code
0900 or 0519.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.

References:

Implementation of a Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs). (2015, February 21). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/implementation-of-a-prospective-payment-system-pps-for-federally-qualified-health-centers-fqhcs-2509.html

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