New G-Codes Released by CMS for FQHC PPS (Federally Qualified Health Centers)

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Dec 4th, 2014 - Reviewed/Updated Mar 1st

Medicare has established 5 new codes for reporting FQHC (Federally Qualified Health Center) services effective Oct 01, 2014. Very specific guidelines are to be followed for proper reimbursement.

G0466 — 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.

G0467 — 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

G0468 — 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.

G0469 — 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.

G0470 — 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.

• Each specific payment code must be submitted with a qualifying visit on a separate line. The use of these specific payment codes, and the crosswalk to the corresponding line item HCPCS code, may be subject to the following conditions, which are flagged by number in the following tables:

See (CODING TIPS in Find-A-Code) for specific coding information on encounters and qualifying visits that must be submitted on a separate line for proper reimbursement.  Qualifying visits may also be subject to certain conditions, these conditions are flagged 1-5 (see specific condition flags)

Conditions:

1) A new patient is one who has not received any professional medical or mental health services from any sites within the FQHC organization within the past three years.

The qualifying visit does not specify whether the service was furnished to a new or established patient.

Use G0466 only if the beneficiary is new to the FQHC or any of its sites for any professional services. Otherwise, use G0467.

2) A new patient is one who has not received any professional medical or mental health services from any sites within the FQHC organization within the past three years.

The qualifying visit does not specify whether the service was furnished to a new or established patient.

Use G0469 only if the beneficiary is new to the FQHC or any of its sites for any professional services. Otherwise, use G0470.

3) A FQHC that furnishes an IPPE or AWV would include all medical services in G0468.

FQHCs would not bill G0466 or G0467 on the same day, unless there was a subsequent illness or injury that would qualify for additional payment which the FQHC would attest to by submitting the claim with modifier 59.

4) The related evaluation and management service must be listed as a line item but is not billable as a separate FQHC visit.

5) Preventive primary services, as defined in 42 CFR405.2448, are statutorily authorized for FQHCs and not excluded by the provisions of section 1862(a) of the Act.