Medicare Claims Processing Manual
Chapter 9 - Rural Health Clinics/
Federally Qualified Health Centers
Table of Contents
(Rev. 12070, 06-07-23)
Transmittals for Chapter 9
10 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) General
Information
10.1 - RHC General Information
10.2 - FQHC General Information
20 - RHC and FQHC All-Inclusive Rate (AIR) Payment System
20.1 - Per Visit Payment and Exceptions under the AIR
20.2 - Payment Limit under the AIR
30 - FQHC Prospective Payment System (PPS) Payment System
30.1 - Per-Diem Payment and Exceptions under the PPS
30.2 - Adjustments under the PPS
40 - Deductible and Coinsurance
40.1 - Part B Deductible
40.2 - Part B Coinsurance
50 - General Requirements for RHC and FQHC Claims
60 - Billing and Payment Requirements for RHCs and FQHCs
60.1 - Billing Guidelines for RHC and FQHC Claims under the AIR System
60.2 - Billing for FQHC Claims Paid under the PPS
60.3 - Payments for FQHC PPS Claims
60.4 - Billing for Supplemental Payments to FQHCs under Contract with Medicare
Advantage (MA) Plans
60.5 - PPS Payments to FQHCs under Contract with MA Plans
60.6 - RHCs and FQHCs for Billing Hospice Attending Physician Services
70 - General Billing Requirements for Preventive Services
70.1 - RHCs Billing Approved Preventive Services
70.2 - FQHCs Billing Approved Preventive Services under the AIR
70.3 - FQHCs Billing Approved Preventive Services under the PPS
70.4 - Vaccines
70.5 - Diabetes Self Management Training (DSMT) and Medical Nutrition
Services (MNT)
70.6 - Initial Preventive Physical Examination (IPPE)
70.7 – Virtual Communication Services
70.8 – General Care Management Services – Chronic Care and Psychiatric
Collaborative Care Model (CoCM) Services
80 - Telehealth Services
90 - Services Non-covered on RHC and FQHC Claims
100 - Frequency of Billing and Same Day Billing
10 - Rural Health Clinic (RHC) and Federally Qualified Health Center
(FQHC) General Information
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
10.1 - RHC General Information
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHCs are facilities that provide services that are typically furnished in an outpatient
clinic setting. The statutory requirements that RHCs must meet to qualify for the
Medicare benefit are in §1861(aa) (2) of the Social Security Act (the Act).
A RHC visit is defined as a medically-necessary, face-to-face (one-on-one) medical or
mental health visit, or a qualified preventive health visit, with a RHC practitioner during
which time one or more RHC services are rendered. A RHC practitioner is a physician,
nurse practitioner (NP), physician assistant (PA), certified nurse midwife (CNM), clinical
psychologist (CP), and clinical social worker (CSW). A Transitional Care Management
(TCM) service can also be a RHC visit. A RHC visit can also be a visit between a home-
bound patient and an RN or LPN under certain conditions.
RHCs can be either independent or provider-based. Independent RHCs are stand-alone
or freestanding clinics and submit claims to a Medicare Administrative Contractor
(MAC). They are assigned a CMS Certification Number (CCN) in the range of XX3800-
XX3974 or XX8900-XX8999. Provider-based RHCs are an integral and subordinate part
of a hospital (including a critical access hospital (CAH), skilled nursing facility (SNF), or
a home health agency (HHA)).
Information on RHC covered services, visits, payment policies, and other information can
be found in Pub. 100-02, Medicare Benefit Policy Manual, chapter 13,
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/
bp102c13.pdf.
Information on certification requirements can be found in Pub. 100-07, Medicare State
Operations Manual, Chapter 2, http://www.cms.gov/Regulations-and-Guidance/
Guidance/ Manuals/ Downloads/ som107c02.pdf.
10.2 - FQHC General Information
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
FQHCs are facilities that provide services that are typically furnished in an outpatient
clinic setting. FQHC services consist of services that are similar to those furnished in
RHCs. The statutory requirements that FQHCs must meet to qualify for the Medicare
benefit are in §1861(aa)(4) of the Act. An entity that qualifies as a FQHC is assigned a
CCN in the range of XX1000-XX1199 or XX1800-XX1989.
NOTE: Information in this chapter applies to FQHCs that are Health Center Program
Grantees and Health Center Program Look-Alikes. It does not necessarily apply to tribal
or urban Indian FQHCs or grandfathered tribal (GFT) FQHCs.
20 - RHC and FQHC All-Inclusive Rate (AIR) Payment System
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
20.1 - Per Visit Payment and Exceptions under the AIR
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHCs and FQHCs are paid an AIR per visit, except for FQHCs that have transitioned to
the Medicare Prospective Payment System (PPS). For RHCs and FQHCs billing under
the AIR, more than one medically-necessary face-to-face visit with a RHC or FQHC
practitioner on the same day is payable as one visit, except for the following
circumstances:
• The patient, subsequent to the first visit, suffers an illness or injury that requires
additional diagnosis or treatment on the same day, (for example, a patient sees
their practitioner in the morning for a medical condition and later in the day has a
fall and returns to the RHC/FQHC);
• The patient has a medical visit and a mental health visit on the same day;
• The patient has an Initial Preventive Physical Examination (IPPE) and a separate
qualified medical and/or mental health visit on the same day;
• The patient has a Diabetes Self-Management Training (DSMT) or Medical
Nutrition Therapy (MNT) visit on the same day as an otherwise payable medical
visit. DSMT and MNT apply to FQHCs only.
20.2 - Payment Limit under the AIR
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
For RHCs and FQHCs that bill under the AIR, Medicare pays 80 percent of the RHC or
FQHC’s AIR, subject to a payment limit, except for RHCs that have an exception to the
payment limit. An interim rate for newly certified RHCs, and for FQHCs certified prior
to October, 1, 2014, is established based on the RHC’s or FQHC’s anticipated average
cost for direct and supporting services. At the end of the cost reporting period, the MAC
determines the total payment due and reconciles payments made during the period with
the total payments due.
For FQHCs paid under the AIR, there is a payment limit for FQHCs located in an urban
area and a payment limit for FQHCs located in a rural area. Urban FQHCs are those
located within a Metropolitan Statistical Area (MSA). Rural FQHCs cannot be
reclassified into an urban area (as determined by the Bureau of Census) for FQHC
payment limit purposes. If the FQHC organization includes both urban and rural sites
and the FQHC organization files a consolidated cost report, the FQHC is paid the lower
of the FQHC organization’s AIR or a single weighted payment limit calculated for the
entire FQHC organization. The payment limit is weighted by the percentage of urban
and rural visits as a percentage of total visits for the entire FQHC organization.
RHCs and FQHCs paid under the AIR are required to file a cost report annually in order
to determine their payment rate. If a RHC or FQHC is in its initial reporting period, the
MAC calculates an interim rate based on a percentage of the per-visit limit, which is then
adjusted when the cost report is filed.
For information on cost reporting requirements, see the Medicare Provider
Reimbursement Manual (PRM), at http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Paper-Based-Manuals.html
30 - FQHC PPS Payment System
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
30.1 - Per-Diem Payment and Exceptions under the PPS
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Section 10501(i)(3)(A) of the Affordable Care Act (Pub. L. 111-148 and Pub. L. 111-
152) added section 1834(o) of the Social Security Act to establish a Medicare PPS for
FQHC services. FQHCs transition to the Medicare PPS beginning on October 1, 2014,
based on their cost-reporting period. All FQHCs are expected to be transitioned to the
PPS by December 31, 2015.
For FQHCs paid under the PPS, Medicare payment is based on the lesser of the FQHC’s
actual charge or the PPS rate, as determined by the MAC. The FQHC PPS rate will be
updated annually beginning January 1, 2016.
For FQHCs billing under the PPS, more than one medically-necessary face-to-face visit
with a FQHC practitioner on the same day is payable as one visit, except for the
following circumstances:
The patient, subsequent to the first visit, suffers an illness or injury that requires
additional diagnosis or treatment on the same day, (for example, a patient sees
their practitioner in the morning for a medical condition and later in the day has a
fall and returns to the FQHC),
The patient has a medical visit and a mental health visit on the same day.
Separate payment is not made to FQHCs under the PPS for an IPPE or DSMT/MNT visit
that is furnished on the same day as another FQHC medical visit.
30.2 - Adjustments under the PPS
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
The FQHC PPS rate will be adjusted to account for geographic differences in costs by the
FQHC geographic adjustment factor (FQHC GAF). In calculating the PPS rate, the
FQHC GAF will be based on the locality of the site where the services are furnished. For
FQHC organizations with multiple sites, the FQHC GAF may vary depending on the
location of the FQHC delivery site.
The FQHC PPS rate for a covered visit will be calculated as follows:
Base payment rate x FQHC GAF = PPS rate
Updates to the FQHC GAFs will be made in conjunction with updates to the Physician
Fee Schedule Geographic Practice Cost Indices for the same period and will be posted on
CMS’s FQHC PPS webpage at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/FQHCPPS/index.html.
The PPS per-diem rate will be adjusted by a factor of 1.3416 when a FQHC furnishes
care to a patient who is new to the FQHC (has not been a patient at any site that is part of
the FQHC organization within the previous 3 years) or to a beneficiary receiving an IPPE
or an annual wellness visit (AWV). This is a composite adjustment factor and only one
adjustment per day can be applied.
If the patient is new to the FQHC, or the FQHC furnishes an Initial Preventive Physical
Examination (IPPE) or Annual Wellness Visit (AWV), the FQHC PPS rate for a covered
visit will be calculated as follows:
Base payment rate x FQHC GAF x 1.3416 = PPS rate
For more information on the FQHC PPS, please see the FQHC PPS Final Rule located at:
https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-
Center.html
40 - Deductible and Coinsurance
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
40.1 - Part B Deductible
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHC services are subject to an annual deductible of twenty percent of charges for
covered services. Effective for dates of service on or after January 1, 2011, the
deductible is not applicable for certain preventive services. Please see section 80 for
more information on how to bill for preventive services.
RHCs collect the patient’s deductible or the portion of the patient’s deductible that has
not already been met. Once RHCs have billed the MAC for services, they do not collect
or accept any additional money from the patient for their deductible until the MAC
notifies the RHC of how much of the deductible has been met.
The Part B deductible does not apply to FQHC services.
40.2 - Part B Coinsurance
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
After any applicable deductibles have been satisfied, RHCs and FQHCs paid under the
AIR system will be paid 80 percent of their AIR. The patient is responsible for a
coinsurance amount of 20 percent of the charges after deduction of the deductible, where
applicable.
Effective for dates of service on or after January 1, 2011, coinsurance is not applicable
for certain preventive services. See section 80 of this manual for information on how to
bill for preventive services on a RHC and FQHC claims.
FQHCs paid under the PPS will be paid 80 percent of the lesser of the FQHC’s actual
charge for the specific payment code or the adjusted PPS rate. The patient is responsible
for a coinsurance amount of 20 percent of the lesser of the FQHC’s actual charge for the
specific payment code or the adjusted PPS rate. See section 60.2 for more information on
the FQHC specific payment codes.
50 - General Requirements for RHC and FQHC Claims
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13 for coverage requirements
for RHCs and FQHCs. This section addresses requirements for claim submission only.
Section §1862 (a)(22) of the Act requires that all claims for Medicare payment must be
submitted in an electronic form specified by the Secretary of Health and Human Services,
unless an exception described at §1862 (h) applies. The electronic format required for
billing RHC and FQHC services is the ASC X12 837 institutional claim transaction.
Instructions relative to the data element names on the Form CMS-1450 hardcopy form
are described below. Each data element name is shown in bold type. Information
regarding the form locator numbers that correspond to these data element names is found
in Chapter 25.
Not all data elements are required or utilized by all payers. Detailed information is given
only for items required for Medicare RHC and FQHC claims. Only the items listed
below are required for RHCs and FQHCs.
Provider Name, Address, and Telephone Number, Form Locator (FL) 01
The RHC/FQHC enters this information for their agency.
Type of Bill, FL 4
This four-digit alphanumeric code gives three specific pieces of information. The first
digit is a leading zero. CMS ignores the first digit. The second digit identifies the type
of facility. The third classifies the type of care. The fourth indicates the sequence of this
bill in this particular benefit period. It is referred to as a “frequency” code.
Code Structure
1st Digit – Leading Zero
CMS ignores the first digit
2nd Digit - Type of Facility
7 - Special facility (Clinic)
3rdDigit - Classification (Special Facility Only)
1 – Rural Health Clinic
7 – Federally Qualified Health Centers
4th Digit – Frequency
Definition
0 - Nonpayment/Zero Claims
Used when no payment from Medicare is
anticipated.
l - Admit Through Discharge Claim
This code is used for a billing for a
confined treatment.
7 - Replacement of Prior Claim
This code is used by the provider when it
wants to correct a previously submitted
bill. This is the code used on the corrected
or “new” bill.
For additional information on replacement
bills see Chapter 3.
8 - Void/Cancel of a Prior Claim
This code is used to cancel a previously
processed claim.
For additional information on void/cancel
bills see Chapter 3.
Statement Covers Period (From-Through), FL 06
The RHC/FQHC shows the beginning and ending dates of the period covered by this bill
in numeric fields (MM-DD-YY).
Patient Name/Identifier, FL 08
The RHC/FQHC enters the beneficiary’s name exactly as it appears on the Medicare
card.
Patient Address, FL 09
The RHC/FQHC enters the mailing address of the patient. Enter the complete mailing
address.
Patient Birth date, FL10
The RHC/FQHC enters the date of birth of the patient.
Patient Sex, FL 11
The RHC/FQHC enters the sex of the patient as recorded at the start of care.
Priority (Type) of Admission or Visit, FL14
The RHC/FQHC enters the most appropriate NUBC approved code indicating the
priority of the visit.
Point of Origin for Admission or Visit, FL 15
The RHC/FQHC enters the most appropriate NUBC approved code indicating the point
of origin for this admission or visit.
Patient Discharge Status, FL 16
The RHC/FQHC enters the most appropriate NUBC approved code indicating the
patient’s status as of the “Through” date of the billing period.
Condition Codes, FL 18-28
The RHC/FQHC enters any appropriate NUBC approved code(s) identifying conditions
related to this bill that may affect processing.
Value Codes and Amounts, FL 39-41
The RHC/FQHC enters any appropriate NUBC approved code(s) and the associated
value amounts identifying numeric information related to this bill that may affect
processing.
Revenue Codes, FL42
The RHC/FQHC assigns a revenue code for each type of service provided and enters the
appropriate four-digit numeric revenue code to explain each charge.
For FQHC claims with dates of service on or after January 1, 2010, FQHCs may report
additional revenue codes when describing services rendered during an encounter.
However, Medicare payment will continue to be reflected only on claim lines with the
revenue codes in the following table:
Code
0521
0522
Code
0524
covered Part A stay at the SNF
0525
SNF (not in a covered Part A stay) or NF or ICF
MR or other residential facility
0527
member’s home when in a home health shortage
area
0528
RHC/FQHC site (e.g., scene of accident)
0519
supplemental payment)
0900
When billing for additional services rendered during the FQHCs encounter, any valid
revenue codes may be used with a HCPCS code. However, the following revenue codes
are not allowed on FQHC claims:
002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096-
310x.
HCPCS/Accommodation Rates/HIPPS Rate Codes, FL 44
For all services provided in a FQHC on or after January 1, 2010 and for approved
preventive services provided in a RHC, HCPCS codes are required to be reported on the
service lines.
The following HCPCS codes must be reported on FQHC PPS claims:
HCPCS Code
Definition
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.
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.
G0468
FQHC visit, IPPE or AWV
A FQHC visit that includes an IPPE or 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
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.
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.
Modifiers, FL 44
The FQHC reports modifier 59 when billing for a subsequent injury or illness. This is
not to be used when a patient sees more than one practitioner on the same day, or has
multiple encounters with the same practitioner on the same day, unless the patient,
subsequent to the first visit, leaves the FQHC and then suffers an illness or injury that
requires additional diagnosis or treatment on the same day.
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).
For claims subject to the FQHC PPS, modifier 59 is only valid with FQHC Payment
Code G0467. Please see section 60.2 of this manual for more information on the FQHC
Payment Codes.
Service Date, FL 45
Medicare requires a line item dates of service for all outpatient claims. Medicare
classifies RHC/FQHC claims as outpatient claims. Non-payment service revenue codes –
report dates as described in the table above under Revenue Codes.
Line items on outpatient claims under HIPAA require reporting of a line-item service
date for each iteration of revenue code. A single date must be reported on a line item for
the date the service was provided, not a range of dates.
For services that do not qualify as a billable visit, the usual charges for the services are
added to those of the qualified visit. RHCs/FQHCs use the date of the visit as the single
date on the line item. If there is no is billable visit associated with the services, then no
claim is filed.
Service Units, FL 46
The RHC/FQHC enters the number of units for each type of service. Units represent
visits, which are paid based on the AIR or the FQHC PPS, no matter how many services
are delivered. Only one visit is billed per day unless the patient leaves and later returns
with a different illness or injury suffered later on the same day.
Total Charges, FL 47
The RHC/FQHC enters the total charge for the service described on each revenue code
line.
Payer Name, FL 50
The RHC/FQHC identifies the appropriate payer(s) for the claim.
National Provider Identifier (NPI) – Billing Provider, FL 56
The RHC/FQHC enters its own NPI. When more than one encounter/visits is reported on
the same claim i.e., medical and mental health visits, please choose the NPI of the
provider that furnished the majority of the services.
Principal Diagnosis Code, FL 67
The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM
Coding Guidelines.
Other Diagnosis Codes, FL 67A-Q
The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM
Coding Guidelines.
Attending Provider Name and Identifiers, FL 76
The RHC/FQHC enters the NPI and name of the attending physician designated by the
patient as having the most significant role in the determination and delivery of the
patient’s medical care.
Other Provider Name and Identifiers, FL78-79
The RHC/FQHC enters the NPI and name
NOTE: For electronic claims using version 5010 or later, this information is reported in
Loop ID 2310F – Referring Provider Name.
60 - Billing Requirements for RHCs and FQHCs
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHCs and FQHCs are institutional claims and are submitted to the MAC on TOB 71x
and 77x. Generally, only those services that are included in the RHC and FQHC benefits
are billed on these claims.
• The RHC and FQHC benefits are defined in Pub. 100-02, Medicare Benefit
Policy Manual, Chapter 13
(http://www.cms.hhs.gov/manuals/Downloads/bp102c13.pdf.)
All professional services in the RHC and FQHC benefit are paid through the AIR system
or the FQHC PPS payment for each patient encounter or visit. Technical services (or
technical components of services with both professional and technical components) are
not billed on RHC/FQHC claims.
For FQHCs with cost reporting periods beginning on or after October 1, 2014, all services
are paid according to the FQHC PPS methodology. The visit rate includes: covered
services provided by a FQHC practitioner and services and supplies furnished incident to
the visit. For additional information on FQHC services, see the Medicare Policy Manual,
Chapter 13.
60.1 - Billing Guidelines for RHCs and FQHC Claims under the AIR
System
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
When billing Medicare, FQHCs must report all services provided during the
encounter/visit by listing the appropriate HCPCS code. The additional revenue lines with
detailed HCPCS code(s) are for information and data gathering purposes. RHCs are only
required to report the appropriate revenue code for medical and mental health services.
Encounters with more than one health professional and multiple encounters with the same
health professionals that take place on the same day and at a single location generally
constitute a single visit. For FQHCs, payment is applied to the service line with revenue
code 052X and a valid evaluation and management (E&M) HCPCS code for medical
visits and revenue code 0900 for mental health visits. Since RHCs are not required to
reported detailed HCPCS codes, the payment is applied to the service line with revenue
code 052X for medical and revenue code 0900 for mental health visits. However, an
additional AIR payment may be made for IPPE, DSMT or MNT (FQHCs only), and a
subsequent illness and injuries billed with modifier 59 (FQHCs only).
When reporting multiple services on FQHC claims, the 052X revenue line with the E&M
HCPCS code must include the total charges for all of the services provided during the
encounter, minus any charges for approved preventive services.
For approved preventive services with a grade of A or B from the United States
Preventive Services Task Force (USPSTF), the charges for these services must be
deducted from the E&M HCPCS code for the purposes of calculating beneficiary
coinsurance correctly. For example, if the total charge for the visit is $350.00, and
$50.00 of that is for a qualified preventive service, the beneficiary coinsurance is based
on $300.00 of the total charge.
For Example:
Rev Code
HCPCS code
Modifier
Date of
Service
Charges
0521
E&M code*
01/01
300.00
0771
Preventive Service
code
01/01
50.00
* RHCs are not required to report a HCPCS code.
Medicare will make an additional AIR payment for IPPE, when billed on the same day
with a qualified encounter/visit. When reporting an additional encounter/visit for IPPE,
the FQHC or RHC reports the appropriate HCPCS code for the service. The revenue
lines should be reflected as follows:
For Example:
Rev
Code
HCPCS
code
Modifier
Date of
Service
Charges
0521
Office Visit
01/01
75.00
0419
Breathing
Treatment
01/01
75.00
0521
IPPE
01/01
150.00
For FQHCs, Medicare will make an additional AIR payment for a subsequent illness or
injury that occurs on the same day. This is reported on the claim with an additional
service line with revenue code 052X, a valid HCPCS code and modifier 59. Please see
section 50 for more information on reporting modifier 59.
For Example:
Rev Code
HCPCS code
Modifier
Date of
service
Charges
0521
Office Visit
01/01
150.00
0479
Removal of
Wax From Ear
01/01
50.00
0521
Office Visit
59
01/01
135.00
0271
Wound
Cleaning
01/01
25.00
0279
Bone Setting
With Casting
01/01
95.00
Medicare will make an additional AIR payment to FQHCs when DSMT or MNT is
reported on the same day with a qualified encounter/visit. When reporting an additional
encounter/visit for DSMT or MNT Report the appropriate HCPCS code for the service.
The revenue lines should be reflected as follows:
For Example:
Rev
Code
HCPCS
code
Modifier
Date of
Service
Charges
0521
Office Visit
01/01
75.00
0419
Breathing
Treatment
01/01
75.00
0521
DSMT or
MNT
01/01
150.00
FQHCs must report HCPCS codes for influenza and pneumococcal vaccines and their
administration on a FQHC claim, the reporting of these codes are informational only.
MACs shall continue to pay for the influenza and pneumococcal vaccines and their
administration through the cost report.
60.2 - Billing for FQHC Claims Paid under the PPS
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
FQHCs transitioning to the PPS must submit separate claims for services subject to the
PPS and services paid under the AIR.
CMS established five FQHC payment specific codes to be used by FQHCs submitting
claims under the PPS. When reporting an encounter/visit for payment, the FQHC must
bill on the claim (77X TOB) a FQHC specific payment code.
FQHC Specific Payment Codes
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.
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.
G0468 – FQHC visit, IPPE or AWV
A FQHC visit that includes an IPPE or 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– 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.
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.
FQHCs must use the specific payment code that corresponds to the type of visit that
qualifies the encounter for Medicare payment, and these codes will correspond to the
appropriate PPS rates. Each FQHC shall report a charge for the FQHC visit code that
would reflect the sum of regular rates charged to both beneficiaries and other paying
patients for a typical bundle of services that would be furnished per diem to a Medicare
beneficiary.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under
revenue code 052X or 0519.
NOTE: Revenue code 0519 is used for Medicare Advantage (MA) Supplemental claims
only.
FQHC specific payment codes G0469 and G0470 must be reported under revenue code
0900 or 0519.
FQHCs must report HCPCS coding on the claim to describe all services that occurred
during the encounter. All service lines must be reported with their associated charges.
The additional services reported on the claim that are part of the FQHC encounter, will
not be paid. The payment for these services is included in the payment under the FQHC
payment code.
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. The link below contains the list of
the qualifying visits for each payment specific code:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
For example:
Revenue Code
HCPCS code
Modifier
Service Date
0521
G0467 – FQHC Payment
code
10/01
0521
99213 – Qualifying visit
10/01
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.
For example:
Revenue Code
HCPCS code
Modifier
Service Date
0521
G0468 – FQHC Payment
code
10/01
0521
G0439 – Qualifying visit
10/01
0900
G0470 – FQHC Payment
code
10/01
0900
90832 -Qualifying visit
10/01
When submitting a claim for a subsequent illness or injury, the FQHCs reports G0467 for
a medical visit), with modifier 59. A qualifying visit is still required when reporting
modifier 59 with G0467.
Revenue Code
HCPCS code
Modifier
Service Date
0521
G0468 – FQHC Payment
code
10/01
0521
G0439 – Qualifying visit
10/01
0521
G0467 – FQHC Payment
code
59
10/01
0900
99211 -Qualifying visit
10/01
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, for FQHCs transitioning to
the PPS, a separate claim must be submitted for services subject to the PPS and services
paid based on the AIR. MACs will 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.
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.
60.3 - Payments for FQHC PPS Claims
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Payment for FQHC PPS claims is made by comparing the adjusted FQHC PPS rate to the
total submitted covered charges reported for the specific payment codes G0466, G0467,
G0468, G0469, and G0470.
To calculate payment, follow the steps below:
Step 1: Determine the lesser of the provider’s submitted charges for the specific payment
code(s) and the fully-adjusted PPS rate.
Step 2: Determine if preventive services for which the coinsurance is waived are present.
Step 3: Subtract the charges for the preventive services from the lesser of the provider’s
charge for the specific payment code(s) or the PPS Rate.
(Lesser of the provider’s charge for the specific payment code or the PPS rate) -
(Preventive services charges) = Step 3 total
Note: If no preventive services are present, use the lesser of the providers charge for the
specific payment code(s) or the PPS rate as the Step 3 total.
Step 4: Multiply the total from Step 3 by 80%.
Step 3 total * 80% = Step 4 total
Note: If no preventive services are present, contractors will pay this amount and skip
step 5.
Step 5: Add the charges for the approved preventive services to the total from step 4.
Contractors will pay this amount.
Step 4 total + preventive services charges = Medicare Payment
Note: If the charges for the approved preventive services are greater than the total
payment amount identified in Step 1 (i.e., the lesser of the charges for the specific
payment code or the PPS rate), pay 100% of the total payment amount determined
in Step 1 and do not apply coinsurance. (Please see example 3)
To calculate coinsurance, follow the steps below:
Step 1: Determine the lesser of the submitted charges for the G-code (s) and the PPS
rate.
Step 2: Determine if approved preventive services (i.e., preventive services for which
coinsurance is waived) are present.
Step 3: Subtract the charges for the preventive services from the lesser of the provider’s
charge for the specific payment code(s) or the PPS Rate.
(Lesser of the provider’s charge for the specific payment code or the PPS rate) -
(Preventive services charges) = Step 3 total
Note: If no approved preventive services are present, use the lesser the provider’s charge
for the specific payment code(s) or the PPS rate as the Step 3 total.
Step 4: Multiply the total from Step 3 by 20%.
Step 3 total * 20% = Coinsurance
• Example: Payment based on the charges
PPS rate = 160.00
Provider’s actual charge for the specific payment code, G0467 = $150
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0467
10/01
150.00
150.00
0521
99213
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0001
310.00
310.00
The comparison is between the PPS rate and the provider’s $150 actual charge for the
specific payment code, G0467. In this case, the sum of the line items exceeds the
provider’s actual charge for the payment code.
Payment based on the provider’s charge of 150.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Coinsurance
0521
G0467
10/01
150.00
150.00
120.00
30.00
0521
99213
10/01
135.00
135.00
CO 97*
0
0300
36415
10/01
25.00
25.00
CO 97
0
0001
310.00
310.00
Payment = 150.00 (charges) * 80%
Coinsurance = 150.00 (charges) * 20%
For service lines that do not receive payment, group code CO- contractual obligation and
the appropriate claim adjustment reason code (CARC) will be used.
* CARC 97 – the benefit for this service is included in the payment/allowance for another
service/procedure that has already been adjudicated.
• Example: Payment based on the charges with approved preventive service
PPS rate = 160.00
Provider’s actual charge for the specific payment code, G0468 = $150
Preventive Service = 135.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
150.00
150.00
0521
G0439 PS**
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0001
310.00
310.00
Payment based on the provider’s actual charge of 150.00 for the specific payment code,
G0468.
REV
CODE
HCPC
CODE
MOD
S
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Co-
insurance
0521
G0468
10/01
150.00
150.00
147.00
3.00
0521
G0439 PS
10/01
135.00
135.00
CO 97*
0
0300
36415
10/01
25.00
25.00
CO 97
0
0001
310.00
310.00
Payment = (150.00 (charges) – 135.00 (preventive service G0439)) * 80% + 135.00
preventive service
Coinsurance = (150.00 (charges) – 135.00 (preventive service G0439)) * 20%
• ** PS – Preventive Service -These are approved preventive services where the
coinsurance is waived based on the USPSTF recommendation.
Example: Payment based on the charges when preventive service is greater
than G-code
PPS rate = 160.00
Provider’s actual charge for the specific payment code, G0468 = $150 Preventive Service
= 155.00
REV
CODE
HCPC
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
150.00
150.00
0521
G0439 PS
10/01
155.00
155.00
0300
36415
10/01
25.00
25.00
0001
330.00
330.00
Payment based on charges of 150.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Co-
insurance
0521
G0468
10/01
150.00
150.00
150.00
0
0521
G0439
PS
10/01
155.00
155.00
CO 97*
0
0300
36415
10/01
25.00
25.00
CO 97
0
0001
330.00
330.00
Payment = (150.00 (charges) * 100% = 150.00
Since the charges for the preventive service, G0439 are greater than the provider’s actual
charge for the specific payment code G0468, Medicare pays 100% of the provider’s
actual charge for the specific payment code, G0468.
Reporting Multiple G-codes
When a FQHC reports multiple specific payment codes (G-codes) on the same day, the
total payment amount will be determined by comparing the sum of the charges for all the
G-codes reported to the PPS rate. When a qualified mental health visit occurs on the
same day as a qualified medical visit, the G-codes will be totaled separately (see example
8).
Listed below is the order in which payment will be applied when multiple G-codes are
reported on the same day:
Medical visits:
• G0468-IPPE or AWV
• G0466-Medical, new patient
• G0467-Established patient
Mental health visits:
• G0469-Mental health, new patient
• G0470- Mental health, established patient
When G0466 (Medical, new patient) and G0468 (IPPE or AWV) are reported together,
the add-on payment will be applied to G0468.
• Example: Payment based on PPS rate with multiple G-codes and preventive
services
Because this scenario does not qualify for an exception to a per diem payment, the system
will calculate and apply a PPS rate to only one of the specific payment codes. However,
the FQHC may list its actual charges for both specific payment codes, and the
comparison would be between the PPS rate and the total of the provider’s charges for the
specific payment codes. Payment would be based on the lesser amount.
PPS RATE, reflecting a 1.3416 adjustment for new patients or a visit including an IPPE
or AWV = 215.00
Total of provider charges for the specific payment codes (170.00 + 65.00) = 235.00
Provider’s charge for the Preventive Service = 135.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
170.00
170.00
0521
G0438 PS
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0521
G0466
10/01
65.00
65.00
0521
92004
10/01
45.00
45.00
0001
440.00
440.00
Payment based on adjusted PPS rate of 215.00
REV
CODE
HCPC
CODE
MOD
S
SERV
DATE
TOTAL
CHARG
E
COV
CHARG
E
Payment
Coinsurance
0521
G0468
10/01
170.00
170.00
199.00
16.00
0521
G0438 PS
10/01
135.00
135.00
CO 97
0
0300
36415
10/01
25.00
25.00
CO 97
0
0521
G0466
10/01
65.00
65.00
CO 97
0
0521
92004
10/01
45.00
45.00
CO 97
0
0001
440.00
440.00
Payment = (215.00 (PPS rate) – 135.00 (preventive service G0438) * 80% + 135.00
preventive service
Coinsurance = (215.00 (PPS rate) – 135.00 (preventive service G0438)) * 20%
Reporting Multiple Preventive Services
When multiple preventive services are reported on the same day, the coinsurance will be
determined by carving out the total preventive services charges.
• Example: Payment based on PPS rate with multiple G-codes and multiple
preventive services
PPS RATE =225.00
Total G code charges (140.00 + 75.00 + 55.00) = 270.00
Total Preventive Services (135.00 +60.00) =195.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
140.00
140.00
0521
G0439 PS
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0521
G0467
10/01
75.00
75.00
0521
97802 PS
10/01
60.00
60.00
0521
G0466
10/01
55.00
55.00
0521
92004
10/01
45.00
45.00
0001
535.00
535.00
Payment based on PPS rate of 225.00
REV
CODE
HCPC
CODE
MOD
S
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Co-
insurance
0521
G0468
10/01
140.00
140.00
219.00
6.00
0521
G0439 PS
10/01
135.00
135.00
CO 97
0
0300
36415
10/01
25.00
25.00
CO 97
0
0521
G0467
10/01
75.00
75.00
CO 97
0
0521
97802 PS
10/01
60.00
60.00
CO 97
0
0521
G0466
10/01
55.00
55.00
CO 97
0
0521
92004
10/01
45.00
45.00
CO 97
0
0001
535.00
535.00
Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00
Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20%
Influenza and Pneumococcal Pneumonia Vaccination (PPV)
Flu and PPV vaccines and their administration will continue to be paid through the cost
report. However, these services should be reported on the claim for information purposes
only. Flu and PPV vaccines and their administration codes will not be carved out of the
coinsurance calculation.
• Example: Payment based on charges with Flu and Flu administration code
services
PPS rate = 160.00
Preventive Service = 135.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
150.00
150.00
0521
G0438 PS
10/01
135.00
135.00
0636
90655
10/01
15.00
15.00
771
G0008
10/01
5.00
5.00
0001
305.00
305.00
Payment based on charges of 150.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Co-
insurance
0521
G0468
10/01
150.00
150.00
150.00
0
0521
G0438 PS
10/01
135.00
135.00
CO 97
0
0636
90655
****
10/01
15.00
15.00
CO
246***
0
0771
G0008
****
10/01
5.00
5.00
CO 246
0
0001
305.00
305.00
Because flu and PPV are reported on the claim for information purposes only, G0438
remains as the only service payable on this claim. Because the claim consists solely of
preventive services for which coinsurance is waived, the contractor will pay 100% of the
provider’s actual charge for the specific payment code, G0468.
*** CARC 246- This non-payable code is for required reporting only.
**** Flu/PPV are reported on the claim for information purposes only, the payment and
coinsurance are not impacted by the charges associated with the Flu/PPV vaccine and
their administration code.
Hepatitis B
Hepatitis B should be reported on the claim and is included in the claim payment. These
services will be carved out of the coinsurance calculation.
• Example: Payment based on charges with Hepatitis B
PPS rate= 160.00
Preventive Services = 20.00 (15.00 +5.00)
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0467
10/01
150.00
150.00
0521
99213
10/01
135.00
135.00
0300
36415
10/01
5.00
5.00
0636
90746 PS
10/01
15.00
15.00
771
G0010 PS
10/01
5.00
5.00
0001
310.00
310.00
Payment based on charges of 150.00
REV
CODE
HCPC
CODE
MOD
S
SERV
DATE
TOTAL
CHARG
E
COV
CHARGE
Payment
Co-
insurance
0521
G0467
10/01
150.00
150.00
124.00
26.00
0521
99213
10/01
135.00
135.00
CO 97
0
0300
36415
10/01
5.00
5.00
CO 97
0
0636
90746 PS
10/01
15.00
15.00
CO 97
0
0771
G0010 PS
10/01
5.00
5.00
CO 97
0
0001
310.00
310.00
Payment = (150.00 (charges) – 20.00 (preventive service 90746 + G0010)) * 80% +
20.00 preventive
Coinsurance = (150.00 (charges) – 20.00 (preventive service 90746 + G0010)) * 20%
Mental Health Services
Qualified mental health visits billed under revenue code 0900 receive an additional
payment when billed on the same day as a medical visit.
• Example: Mental Health Services
PPS RATE for G0468: $225.00
PPS rate for G0470: $160
Total of provider’s actual charges for the specific payment codes representing medical
visits (140.00 + 75.00 + 55.00) = 270.00- This does not include charges for G0470
Provider’s charge for the specific payment code representing mental health services =
159.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
140.00
140.00
0521
G0439 PS
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0521
G0467
10/01
75.00
75.00
0521
97802 PS
10/01
60.00
60.00
0521
G0466
10/01
55.00
55.00
0521
92004
10/01
45.00
45.00
0900
G0470
10/01
159.00
159.00
0900
90832
10/01
139.00
139.00
0636
J3490
10/01
15.00
15.00
0001
848.00
848.00
Payment based on PPS rate of 225.00 for the specific payment codes describing the
medical visits and based on the provider’s actual charges for the specific payment code
describing the mental health visit.
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
Payment
Co-
insurance
0521
G0468
10/01
140.00
140.00
219.00
6.00
0521
G0439 PS
10/01
135.00
135.00
CO 97
0
0300
36415
10/01
25.00
25.00
CO 97
0
0521
G0467
10/01
75.00
75.00
CO 97
0
0521
97802 PS
10/01
60.00
60.00
CO 97
0
0521
G0466
10/01
55.00
55.00
CO 97
0
0521
92004
10/01
45.00
45.00
CO 97
0
0900
G0470
10/01
159.00
159.00
127.20
31.80
0900
90832
10/01
139.00
139.00
CO 97
0
0636
J3490
10/01
15.00
15.00
CO 97
0
0001
848.00
848.00
For Medical visit with revenue code 052X
Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00
Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20%
For Mental Health visit with revenue code 0900
Payment = 159.00 *80% = 127.20
Coinsurance =159.00 * 20% = 31.80
Modifier 59
Medicare allows for an additional payment when an illness or injury occurs subsequent to
the initial visit, and the FQHC bills these visits with the specific payment codes and
modifier 59. Services billed with a modifier 59 will be paid an additional per diem rate
• Example: Modifier 59
PPS rate for G0468 = 225.00
Total G code charges (140.00 + 75.00 + 55.00) = 270.00 – This does not include charges
for G0470 and G-code charges for modifier 59
Total mental Health Services = 159.00
PPS rate for G0467 (billed with Modifier 59) = 160.00
REV
CODE
HCPC
CODE
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0521
G0468
10/01
140.00
140.00
0521
G0438 PS
10/01
135.00
135.00
0300
36415
10/01
25.00
25.00
0521
G0467
10/01
75.00
75.00
0521
97802 PS
10/01
60.00
60.00
0521
G0466
10/01
55.00
55.00
0521
92004
10/01
45.00
45.00
0900
G0470
10/01
159.00
159.00
0900
90832
10/01
139.00
139.00
0636
J3490
10/01
15.00
15.00
0521
G0467
59
10/01
165.00
165.00
0521
99211
10/01
105.00
105.00
0001
1118.00
1118.00
Payment based on PPS rate of 225.00 for the G-codes, based on the charges for the
mental health visit and based on the PPS rate for G0467 billed with modifier 59.
REV
CODE
HCPC
CODE
MOD
S
SERV
DATE
TOTAL
CHARG
E
COV
CHARG
E
Payment
Coinsurance
0521
G0468
10/01
140.00
140.00
219.00
6.00
0521
G0438 PS
10/01
135.00
135.00
CO 97
0
0300
36415
10/01
25.00
25.00
CO 97
0
0521
G0467
10/01
75.00
75.00
CO 97
0
0521
97802 PS
10/01
60.00
60.00
CO 97
0
0521
G0466
10/01
55.00
55.00
CO 97
0
0521
92004
10/01
45.00
45.00
CO 97
0
0900
G0470
10/01
159.00
159.00
127.20
31.80
0900
90832
10/01
139.00
139.00
CO 97
0
0636
J3490
10/01
15.00
15.00
CO 97
0
0521
G0467
59
10/01
165.00
165.00
128.00
32.00
0521
99211
10/01
105.00
105.00
CO 97
0
0001
1118.00
1118.00
For Medical visit with revenue code 052X
Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00
Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20%
For Mental Health visit with revenue code 0900
Payment = 159.00 *80% = 127.20
Coinsurance =159.00 * 20% = 31.80
For G0467 billed with modifier 59
Payment = 160.00 * 80% = 128.00
Coinsurance = 160.00 * 20% = 32.00
60.4 - Billing for Supplemental Payments to FQHCs under Contract
with Medicare Advantage (MA) Plans
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Section 237 of the Medicare Modernization Act (MMA) requires CMS to provide
supplemental payments to FQHCs that contract with MA organizations to cover the
difference, if any, between the payment received by the FQHC for treating MA enrollees
and the payment to which the FQHC would be entitled to receive under the cost-based
all-inclusive payment rate as set forth in 42 CFR, Part 405, Subpart X.
This supplemental payment for covered FQHC services furnished to MA enrollees
augments the direct payments made by the MA organization to FQHCs for all covered
FQHC services. The Medicare per diem payment, which continues to be made for all
covered FQHC services furnished to Medicare beneficiaries participating in the original
Medicare program, is based on the FQHC's unique cost-per-visit as calculated by the
MAC. The MAC determines if the Medicare payments that the FQHC would be entitled
to exceed the amount of payments received by the FQHC from the MA organization and,
if so, pay the difference to the FQHC.
FQHCs seeking the supplemental payment are required to submit (for the first two rate
years) to the MAC an estimate of the average MA payments (per visit basis) for covered
FQHC services. They are required to submit a documented estimate of their average per
visit payment for their MA enrollees, for each MA plan they contract with, and any other
information as may be required to enable the MAC to accurately establish an interim
supplemental payment.
Expected payments from the MA organization would only be used until actual MA
revenue and visits collected on the FQHC’s cost report can be used to establish the
amount of the supplemental payment.
Effective January 1, 2006, eligible FQHCs will report actual MA revenue and visits on
their cost reports. At the end of each cost reporting period the MAC shall use actual MA
revenue and visit data along with the FQHC’s final all-inclusive payment rate, to
determine the FQHC’s final actual supplemental per visit payment. Once this amount
(per visit basis) is determined it will serve as the interim rate for the next full rate year.
Actual aggregated supplemental payments will then be reconciled with aggregated
interim supplemental payments, and any underpayment or overpayment thereon will then
be accounted for in determining final Medicare FQHC program liability at cost
settlement.
An FQHC is only eligible to receive this supplemental payment when FQHC services are
provided during a face-to-face encounter between an MA enrollee and one or more of the
following FQHC covered core practitioners: physicians, nurse practitioners, physician
assistants, certified nurse midwives, clinical psychologists, or clinical social workers.
The supplemental payment is made directly to each qualified FQHC through the MAC.
Each FQHC seeking the supplemental payment is responsible for submitting a claim for
each qualifying visit to the MAC on type of bill (TOB) 77x with revenue code 0519 for
the amount of the interim supplemental payment rate (FQHC interim all-inclusive rate –
estimated average payment from the MA plan plus any beneficiary cost sharing = billed
amount > 0). Do not submit revenue codes 052X and/or 0900 on the same claim as
revenue code 0519.
For services of plan years beginning on and after January 1, 2006 and before, an interim
supplemental rate can be determined by the MAC based on cost report data, MACs shall
calculate an interim supplemental payment for each MA plan the FQHC has contracted
with using the documented estimate provided by the FQHC of their average MA payment
(per visit basis) under each MA plan they contract with. Once an interim supplemental
rate is determined for a previous plan year based on cost report data, use that interim rate
until the MAC receives information that changes in service patterns that will result in a
different interim rate. MACs shall calculate an interim supplemental payment rate for
each MA plan the FQHC has contracted with. Reconcile all interim payments at cost
settlement.
Do not apply the Medicare deductible when calculating the FQHC interim supplemental
payment. Do not apply the original Medicare co-insurance (20%) to the FQHC all
inclusive rate when calculating the FQHC interim supplemental payment. Any
beneficiary cost sharing under the MA plan is included in the calculation of the FQHC
interim supplemental payment rate.
MACs shall submit all claims to CWF for approval. CWF will verify each beneficiary’s
enrollment in an MA plan for the line item date of service (LIDOS) on the claim. CWF
shall reject all claims for the FQHC interim supplemental payment for beneficiaries who
are not MA enrollees on the same date as the LIDOS on the claim. MACs shall RTP
such claims to the FQHCs. MACs shall accept TOB 77x with revenue code 0519 and
pay the interim supplemental payment rate for each qualified visit billed.
Billing for Supplemental Payments under the AIR
When billing for supplemental payment to the MAC, the encounter is reported on type of
bill (TOB) 77x with revenue code 0519 for the amount of the interim supplemental
payment rate (FQHC interim all-inclusive rate – estimated average payment from the MA
plan plus any beneficiary cost sharing = billed amount > 0). Do not submit revenue
codes 0520 and/or 0900 on the same claim as revenue code 0519. HCPCS coding is not
required.
For Example:
Rev Code
HCPCS code
Modifier
Date of
Service
Charges
0519
blank
01/01
150.00
Billing for Supplemental Payments under the PPS
When billing for supplemental payment to the MAC under the PPS, a FQHC payment
specific code and a qualifying visit must be reported under revenue code 0519.
For example:
Revenue Code
HCPCS code
Modifier
Service Date
0519
G0467 – FQHC Payment
code
10/01
0519
99213 – Qualifying visit
10/01
60.5 - PPS Payments to FQHCs under Contract with MA Plans
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
For claims with the 0519 revenue code, the wraparound payment is based on the PPS rate
without comparison to the provider’s charge. The rate is also NOT adjusted for
coinsurance or preventive services as the MA plan would have already assessed any
applicable coinsurance and related waivers of coinsurance.
Medicare will compare the PPS rate with the MA contract rate for a FQHC visit.
When the MA contract rate is lower than the applicable PPS rate that would otherwise
have been paid by traditional Medicare had the beneficiary not been covered by the MA
plan, the contractor will pay the difference as a supplemental wraparound payment.
The FQHC does not qualify for a supplemental wraparound payment when the MA
contract rate is higher than the applicable PPS rate that would otherwise have been paid
by traditional Medicare had the beneficiary not be covered by the MA plan.
• Example: MA Claim that Qualifies for a Supplemental Wraparound
Payment
PPS Rate = $225
Rev
HCPC
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0519
G0468
10/01
170.00
170.00
0519
G0439 PS
10/01
150.00
150.00
0001
320.00
320.00
If the MA contract rate is lower than the applicable PPS rate – e.g., $200:
Wraparound payment = PPS rate – MA contract rate = $225 - $200 = $25
Note that the charge of $170 would reflect the FQHC’s typical charge for G0468, but
would not be used to calculate the supplemental payment.
• Example : MA Claim that Does Not Qualify for a Supplemental
Wraparound Payment
PPS Rate = $225
Rev
HCPC
MODS
SERV
DATE
TOTAL
CHARGE
COV
CHARGE
0519
G0468
10/01
170.00
170.00
0519
G0439 PS
10/01
150.00
150.00
0001
320.00
320.00
If the MA contract rate was higher than the applicable PPS rate – e.g., the MA contract
rate was $250- no wraparound payment is due to the FQHC.
60.6 - RHCs and FQHCs for billing Hospice Attending Physician
Services
(Rev. 11200, Issued :01-12-22, Effective: 01-01-22, Implementation: 01-03-22)
Effective for services furnished on or after January 1, 2022, RHCs or FQHCs can bill and
receive payment under the RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment
System (PPS), when a designated attending physician employed by or working under
contract with the RHC or FQHC furnishes hospice attending physician services during a
patient’s hospice election.
RHCs must report a GV modifier on the claim line for payment (that is, along with the
CG modifier) each day a hospice attending physician service is furnished.
FQHCs must report a GV modifier on the claim line with the payment code (G0466 –
G0470) each day a hospice attending physician service is furnished.
The hospice attending physician services are subject to coinsurance and deductibles on
RHC claims and only coinsurance on FQHC claims.
70 - General Billing Requirements for Preventive Services
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Professional components of preventive services are covered under the RHC and FQHC
benefit. The payment for most preventive services is included with a qualified visit as
part of the overall encounter/visit. To ensure coinsurance and deductible (deductible
applies to RHC claims only) are applied correctly, detailed HCPCS coding is required for
approved preventive services recommended by the USPSTF with a grade of A or B for
TOBs 71x or 77x. Additionally, RHCs/FQHCs are required to report HCPCS codes for
certain preventive services subject to frequency limits.
70.1 - RHCs Billing Approved Preventive Services
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
An additional line with the appropriate site of service revenue code in the 052X series
should be submitted with the approved preventive service HCPCS code and the
associated charges. For example, if the total charge for the visit is $150.00, and $50.00
of that is a qualified preventive service, the service lines should be coded as follows:
Revenue Code
HCPCS code
Modifier
Service Date
Charges
0521
Encounter = Blank or valid
HCPCS code
10/01
100.00
0521
Preventive Service Code
10/01
50.00
In the example above, the encounter service line will receive the AIR payment. The
charges reported on this line should not include the charges for the approved preventive
service. Coinsurance and deductible will be accessed based on the charges reported on
this service line. The qualified preventive service reported on the additional service line
will not receive payment, as payment is made under the AIR for the services reported
under the encounter service line. Coinsurance and deductible are accessed based on the
charges reported on the preventive services line.
70.2 - FQHCs Billing Approved Preventive Services under the AIR
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Detailed HCPCS codes are required for all service lines. When reporting the
encounter/visit, revenue code 052X for medical and revenue code 0900 for mental health
visits must be used. For additional services, the most appropriate revenue code for the
service rendered should be used.
Revenue Code
HCPCS code
Modifier
Service Date
Charges
0521
Encounter = E&M HCPCS
code
10/01
100.00
0771
Preventive Service Code
10/01
50.00
In the example above, the services reported under the encounter/visit service line will
receive the AIR payment. The charges reported on this line should not include the
charges for the approved preventive service. Since deductible does not apply to FQHC
claims, only coinsurance will be applied to the charges reported on the encounter service
line. The qualified preventive service reported on the second revenue line will not
receive payment. Coinsurance and deductible are not accessed to the services reported
under the preventive services line.
70.3 - FQHC Billing Approved Preventive Services under the PPS
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
An additional line with the appropriate site of service revenue code in the 052X series
should be submitted with the approved preventive service HCPCS code and the
associated charges. For example, if the total charge for the visit is $150.00, report the
total charges for the encounter. NOTE: Do not carve out the charges for the approved
preventive services. The service lines should be coded as follows:
Revenue Code
HCPCS code
Modifier
Service Date
Charges
0521
Encounter = FQHC
Payment Code (G-code)
code
10/01
150.00
0771
Preventive Service code
10/01
75.00
In the example above, the services reported under the encounter/visit service line will
receive the PPS payment. The charges reported on this line should include the charges
for the approved preventive service. The coinsurance will be applied to the charges
reported on the encounter service line. Coinsurance will not be applied to the charges
reported for the approved preventive service. The qualified preventive service reported
on the second revenue line will not receive payment. NOTE: A qualified HCPCS code
visit must be reported if the preventive service is not a qualified visit.
70.4 - Vaccines
(Rev. 12070; Issued: 06-07-23; Effective: 07-10-23; Implementation: 07-10-23)
Influenza virus, pneumococcal and COVID-19 vaccines do not count as RHC/FQHC
visits. The cost for these vaccines is included in the cost report and a visit is not billed
for these services. RHCs do not report vaccines on the claim, TOB 71x. However, for
FQHCs, if there was another reason for the visit, the vaccine and the administration code
should be reported on the claim, TOB 77x, for informational and data collection
purposes only. Coinsurance and deductible do not apply to these vaccines.
Monoclonal antibody products used for the treatment or for post-exposure prophylaxis of
COVID-19 (when they are not purchased by the government) and their administration
are paid through the cost report until the end of the calendar year in which the
Emergency Use Authorization declaration for drugs and biological products with respect
to COVID-19 ends.
Hepatitis B vaccine is included in the RHC all-inclusive and the FQHC /PPS rate. The
charges of the vaccine and its administration can be included in the line item for the
otherwise qualifying visit. A visit cannot be billed if vaccine and its administration is the
only service the RHC/FQHC provides.
Additional information on vaccines can be found in Chapter 18, section 10 of this
manual. Additional coverage requirements for pneumococcal vaccine, hepatitis B
vaccine, and influenza virus vaccine can be found in Publication 100-02, the Medicare
Benefit Policy Manual, Chapter 13.
70.5 - Diabetes Self Management Training (DSMT) and Medical
Nutrition Services (MNT)
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
FQHCs billing under the AIR system
Payment is made at the all-inclusive encounter rate to the FQHC for DSMT or MNT.
This payment can be in addition to payment for another qualifying visit on the same date
of service as the beneficiary received qualifying DSMT services.
For FQHCs to qualify for a separate visit payment for DSMT or MNT services, the
services must be a one-on-one face-to-face encounter. Group sessions do not constitute a
billable visit for any FQHC services. To receive separate payment for DSMT or MNT
services, the services must be billed on TOB 77x with HCPCS code G0108 (DSMT) or
HCPCS code 97802, 97803, or G0270 (MNT) and the appropriate site of service revenue
code in the 052X revenue code series. This payment can be in addition to payment for
any other qualifying visit on the same date of service that the beneficiary received
qualifying DSMT /MNT services as long as the claim for DSMT/MNT services contains
the appropriate coding specified above. Additional information on DSMT can be found in
Chapter 18, section 120 of Pub. 100-04.
Additional information on MNT can be found in Chapter 4, section 300 of Pub. 100-04.
Group services (G0109, 97804 and G0271) do not meet the criteria for a separate
qualifying encounter. A ll line items billed on TOBs 77x with group services will be
denied.
DSMT and 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 billing under the PPS
DSMT and MNT are qualifying visits when billed under G0466 or G0467. For
additional information on the payment specific codes and qualifying visits, see section
60.2 of this manual. Under the FQHC PPS, DSMT and MNT do not qualify for a
separate payment when billed on the same day with another qualified visit.
RHCs
RHCs are not paid separately for DSMT and MNT services. All line items billed on
TOB 71x with HCPCS codes for DSMT and MNT services will be denied.
70.6 - Initial Preventive Physical Examination (IPPE)
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
FQHCs and RHCs billing under the AIR system
Medicare provides for coverage for one IPPE for new beneficiaries only, subject to
certain eligibility and other limitations.
Payment for the professional services will be made under the AIR. However,
RHCs/FQHCs can receive a separate payment for an encounter in addition to the
payment for the IPPE when they are performed on the same day.
When IPPE is provided in an RHC or FQHC, the professional portion of the service is
billed on TOBs 71X and 77X, respectively, and the appropriate site of service revenue
code in the 052X revenue code series, and must include HCPCS code G0402. Additional
information on IPPE can be found in Chapter 18, section 80 of Pub. 100-04.
EKGs
The professional component is included in the AIR or FQHC PPS and is not separately
billable.
The technical component of an EKG performed at a RHC/FQHC billed to Medicare on
professional claims (Form CMS-1500 or 837P) under the practitioner’s ID following
instructions for submitting practitioner claims for independent/freestanding clinics.
Practitioners at provider-based clinics bill the applicable TOB to the A/B MAC using the
base provider’s ID.
FQHCs billing under the PPS:
IPPE is qualifying visits when billed under G0468, for additional information on the
payment specific codes and qualifying visits, please refer to section 60.2 of this manual.
Under the FQHC PPS, IPPE does not qualify for a separate payment when billed on the
same day with another encounter/visit.
70.7 - Virtual Communication Services
(Rev. 10357, Issued: 09-18-2020, Effective: 10-19-2020, Implementation: 10-19-2020)
In the CY 2019 PFS final rule, CMS finalized a policy for payment to RHCs and FQHCs
for communication technology-based services (“virtual check-in”) or remote evaluation
services, effective January 1, 2019. CMS created a new Virtual Communications G Code,
G0071 for use by RHCs and FQHCs only, with the payment rate set at the average of the
PFS non-facility payment rate for communication technology-based services and remote
evaluation services.
RHCs and FQHCs receive an additional payment for the costs of communication
technology-based services or remote evaluation services that are not already captured in
the RHC AIR or the FQHC PPS payment when the requirements for these services are
met. Coinsurance and deductibles apply to RHC claims, and coinsurance applies to
FQHC claims for these services.
RHCs and FQHCs can bill HCPCS code G0071 alone or with other payable services on
an RHC or FQHC claim. The services should be billed with a revenue code 052x and
should not be billed with modifier CG for payment on RHC claims. HCPCS codes
G0071 are paid based on the lesser of the charges or the rate from the Medicare
Physician Fee Schedule (MPFS).
70.8- General Care Management Services – Chronic Care or Psychiatric
Collaborative Care Model
(CoCM) Services
(Rev. 10357, Issued: 09-18-2020, Effective: 10-19-2020, Implementation: 10-19-2020)
Effective for services furnished on or after January 1, 2018, RHCs and FQHCs are paid
for General Care Management or Psychiatric CoCM services when G0511 or G0512 is
billed alone or with other payable services on an RHC or FQHC claim. HCPCS code
G0511 or G0512 can only be billed once per month per beneficiary, and cannot be billed
if other care management services are billed for the same time period.
HCPCS codes G0511 and G0512 are subject to coinsurance and deductibles on RHC
claims. Only coinsurance applies on FQHC claims. Coinsurance is 20 percent of the
lesser of the RHC or FQHC’s charge for HCPCS codes G0511 and G0512, or the
corresponding rate.
The allowable revenue code is 052X. These HCPCS codes of G0511 or G0512 should not be
billed with modifier CG for payment on RHC claims.
80 - Telehealth Services
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or
FQHC claim under revenue code 0780 and HCPCS code Q3014. Telehealth services are
the only services billed on FQHC claims that are subject to the Part B deductible.
Additionally, a FQHC payment code and qualifying visit HCPCS code are not required
when the only service reported on the claim is for Telehealth services. RHCs and FQHCs
are not authorized to serve as distant practitioners for Telehealth services.
For more information on Telehealth services please see Pub 100-04, chapter 12, section
190: http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
90 - Services non-Covered on RHC and FQHC Claims
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
Technical Services
RHCs/FQHCs do not bill using TOBs 71x or 77x for technical components of services
because they are not within the scope of Medicare-covered RHC/FQHC services. The
associated technical components of services furnished by the RHC/FQHC are billed on
other types of claims that are subject to applicable frequency limits edits.
For services that can be split into professional and technical components, RHCs and
FQHCs bill for the professional component as part of the AIR or the FQHC PPS payment
and bill the MAC separately for the technical component. See Chapter 17, section 30.1.1,
for more information on how RHCs and FQHCs can bill the MAC for laboratory
services. See Chapter 13 for more information on how to bill the MAC for technical
components of diagnostic services.
o Technical services/components associated with professional
services/components performed by independent RHCs or FQHCs are
submitted to the MAC in the designated claim format (837P or Form CMS-
1500.) See chapters 12
(http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf) and 26
(http://www.cms.hhs.gov/manuals/downloads/clm104c26.pdf) of this manual
for billing instructions.
o Technical services/components associated with professional
services/components performed by provider-based RHCs or FQHCs are
submitted by the base-provider on the appropriate TOB to the MAC in the
designated claim format (837I or the UB-04 claim form); see the applicable
chapter of this manual based on the base-provider type, such as
(http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf) for outpatient
hospital services, chapter 6
(http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf) for inpatient
SNF services chapter 7 for Outpatient SNF services, etc.
Laboratory Services
RHCs must furnish the following lab services to be approved as an RHC. However,
these and other lab services that may be furnished are not included in the encounter rate
and must be billed separately.
• Chemical examinations of urine by stick or tablet method or both;
• Hemoglobin or hematocrit;
• Blood sugar;
• Examination of stool specimens for occult blood;
• Pregnancy tests; and
• Primary culturing for transmittal to a certified laboratory (No CPT code
available).
RHCs/FQHCs bill all laboratory services to their MAC under the host provider’s bill type
and payment is made under the fee schedule. HCPCS codes are required for lab services.
Venipuncture is included in the AIR and the PPS per diem payment and is not separately
billable.
Refer to Chapter 16 for general billing instructions.
Durable Medical Equipment (DME), ambulance services, hospital-based services, group
services, and non-face-to-face services are also non-covered and are billed separately.
When billing these services on FQHC PPS claims, a FQHC payment code and qualifying
visit HCPCS code is not required.
100 - Frequency of Billing and Same Day Billing
(Rev. 3434, Issued: 12-31-15, Effective: 03-31-16, Implementation: 03-31-16)
RHC and FQHC claims cannot overlap calendar years. Therefore, the statement dates, or
from and through dates of the claim, must always be in the same calendar year.
RHCs and FQHCs billing under the FQHC PPS may submit claims that span multiple
days of service.
FQHCs billing under the PPS must submit all services that are rendered on the same day
on one claim.
General information on basic Medicare claims processing can be found in this manual in:
Chapter 1, “General Billing Requirements,”
(http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf) for general claims
processing information;
Chapter 2, “Admission and Registration Requirements,”
(http://www.cms.hhs.gov/manuals/downloads/clm104c02.pdf) for general filing
requirements applicable to all providers.
For Medicare institutional claims:
See the Medicare Claims Processing Manual on the CMS website for general
Medicare institutional claims processing requirements, such as for timely filing
and payment, admission processing, and Medicare Summary Notices.
Contact your MAC for basic training and orientation material if needed.
Transmittals Issued for this Chapter
Rev # Issue Date Subject Impl Date CR#
R12070CP
06/07/2023 Internet Only Manual Update to
Publication 100-04, Chapters 9 and 18
to Clarify Vaccine Payment Instructions
for Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs)
07/10/2023 13218
R11200CP 01/12/2022 Implementation of the GV Modifier for
Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs) for Billing Hospice Attending
Physician Services
01/03/2022
12357
R11095CP 10/29/2021 Implementation of the GV Modifier for
Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs) for Billing Hospice Attending
Physician Services - Rescinded and
replaced by Transmittal 11200
01/03/2022 12357
R11029CP 09/29/2021 Implementation of the GV Modifier for
Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs) for Billing Hospice Attending
Physician Services - Rescinded and
replaced by Transmittal 11095
01/03/2022 12357
R10907CP 08/10/2021 Implementation of the GV Modifier for
Rural Health Clinics (RHCs) and
Federally Qualified Health Centers
(FQHCs) for Billing Hospice Attending
Physician Services - Rescinded and
replaced by Transmittal 11029
01/03/2022 12357
R10357CP 09/18/2020 Update to the Internet Only Manual
(IOM) Publication (Pub.) 100-04,
Chapter 9, Section 70.7 and 70.8.
10/19/2020 11961
R3434CP 12/31/2015 Reorganization of Chapter 9 03/31/2016 9397
R3000CP 07/25/2014 Update to Pub. 100-04, Chapter 09 to
Provide Language-Only Changes for
Updating ASC X12
08/25/2014 8670
R2186CP 03/28/2011 Waiver of Coinsurance and Deductible
for Preventive Services in Rural Health
Clinics (RHCs), Section 4104 of
Affordable Care Act (ACA)
04/04/2011 7208
R2122CP 12/21/2010 Waiver of Coinsurance and Deductible
for Preventive Services in Rural Health
Clinics (RHCs), Section 4104 of
Affordable Care Act (ACA) –
Rescinded and replaced by Transmittal
2186
04/04/2011 7208
R2093CP 11/12/2010 Waiver of Coinsurance and Deductible
for Preventive Services in Rural Health
Clinics (RHCs), Section 4104 of
Affordable Care Act (ACA) –
Rescinded and replaced by Transmittal
2122
04/04/2011 7208
R2034CP 08/24/2010 Affordable Care Act (ACA) Mandated
Collection of Federally Qualified
Health Center (FQHC) Data and
Updates to Preventive Services
Provided by FQHCs
01/03/2011 7038
R2013CP 07/30/2010 Affordable Care Act (ACA) Mandated
Collection of Federally Qualified
Health Center (FQHC) Data and
Updates to Preventive Services
Provided by FQHCs - Rescinded and
replaced by Transmittal 2034
01/03/2011 7038
R1843CP 10/30/2009 Outpatient Mental Health Treatment
Limitation
01/04/2010 6686
R1719CP 04/24/2009 Rural Health Clinic (RHC) and
Federally Qualified Health Clinic
(FQHC) Updates
10/05/2009 6445
R1707CP 03/27/2009 Assignment of Initial Enrollment
FQHC’S, ESRD Facilities, and RHC’s
04/27/2009 6207
R1472CP 03/06/2008 Update of Institutional Claims
References
04/07/2008 5893
R1426CP 02/01/2008 Announcement of Medicare Rural
Health Clinics (RHCs) and Federally
02/12/2008 5896
Qualified Health Centers (FQHCs)
Payment Rate Increases
R1421CP 01/25/2008 Update of Institutional Claims
References - Rescinded and Replaced
by Transmittal 1472
04/07/2008 5893
R1255CP 05/25/2007 Guidelines for Payment of Diabetes
Self-Management Training DSMT)
07/02/2007 5433
R1158CP 01/19/2007 Guidelines for Payment of Diabetes
Self-Management Training DSMT) –
Replaced by Transmittal 1255
07/02/2007 5433
R820CP 02/01/2006 Sites of Service Revenue Codes for
Rural Health Clinics and Federally
Qualified Health Centers
07/03/2006 4210
R794CP 12/29/2005 Announcement of Medicare
Supplemental Payments to Federally
Qualified Health Centers Under
Contract with Medicare Advantage Plan
04/03/2006 3886
R773CP 12/02/2005 Announcement of the Medicare
Federally Qualified Health Center
Supplemental Payment
04/03/2006 3886
R771CP 12/02/2005 Revisions to Pub. 100-04, Medicare
Claims in Preparation for the National
Provider Identifier (NPI)
01/03/2006 4181
R371CP 11/19/2004 Updated Billing Instructions for Rural
Health Clinics (RHCs) and Federally
Qualified Health Centers (FQHCs)
04/04/2005 3487
R167CP 04/30/2004 Discontinued Use of Revenue Code
0910
10/04/2004 3194
R001CP 10/01/2003 Initial Publication of Manual NA NA
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