NGOs and Road Safety Advocacy
NGOs play a crucial role in advocating for road safety, bringing attention to the issue, creating political will, and promoting changes in policies and programs to prevent road traffic crashes. They engage in various activities such as research, advocacy, and community-based initiatives to address road traffic injuries as a public health concern.
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FQHC Evaluation and Management Billing 2021 Charles A. James, Jr. President and CEO North American Healthcare Management Services
Overview Section I: FQHC Billing Overview FQHC Services FQHC Preventive Services Non-FQHC Services FQHC Preventive Services Multiple Encounters Claim Examples Care Management Services Telehealth
Federally-Qualified Health Center What We are: Federally Qualified Health Centers (FQHCs) were established in 1990 by section 4161 of the Omnibus Budget Reconciliation Act of 1990 and were effective beginning on October 1, 1991. As with RHCs, they are also facilities that are primarily engaged in providing services that are typically furnished in an outpatient clinic. Why we are here: FQHCs are safety net providers that primarily provide services typically furnished in an outpatient clinic. FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program look-alikes. (Medicare Benefit Policy Manual. Chapter 13. Section 10.2.)
Federally-Qualified Health Center How We Are Paid: FQHCs are paid based on the FQHC Prospective Payment System (PPS) for medically- necessary primary health services and qualified preventive health services furnished by a FQHC practitioner. (Medicare Benefit Policy Manual. Chapter 13. Section 10.2.)
FQHC Guidance The policy language and claims examples in this presentation are from, respectively: Medicare Benefit Policy Manual Chapter 13 [MBPM] Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services Medicare Claims Processing Manual Chapter 9 [MCPM] Rural Health Clinics/ Federally Qualified Health Centers
The FQHC Encounter is: A FQHC visit is defined as a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more FQHC or FQHC services are rendered. A Transitional Care Management (TCM) service can also be a FQHC visit. (Medicare Benefit Policy Manual. Chapter 13. Section 40.)
Medicare Fees (Patient Charges) FQHCs must charge Medicare beneficiaries the same rate that non-Medicare beneficiaries are charged. (Medicare Benefit Policy Manual. Chapter 13. Section 80.)
Qualified Providers An FQHC encounter can be billed for the following providers: Physicians; Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives; Clinical Psychologists (PhD); Clinical Social Workers (CSW or LCSW). Outpatient diabetes self-management training (DSMT) and medical nutrition therapy (MNT) for beneficiaries with diabetes or renal disease.
Medical Necessity The following examples are not medically necessary: A visit solely for administration of an injection (e.g. B-12, allergy) Dressing changes/ suture Lab results or tests Writing or re-filling prescriptions Nurse Visits
99211 Office Visit Nursing Services E/M code 99211 is commonly used for nursing visits, (injection administration, etc.), even though physicians sometimes bill them. These are NOT considered encounters. These cannot be billed as encounters. If an RHC/FQHC provider is reporting 99211, the provider is typically under-coding.
FQHC Services Physicians' services; Services and supplies incident to a physician s service; Services of nurse practitioners (NP), physician assistants (PA), and certified nurse midwives (CNM); Services and supplies incident to the services of nurse practitioners and physician assistants (including services furnished by nurse midwives); (Medicare Benefit Policy Manual Chapter 13)
FQHC Services (Continued) Visiting nurse (VN) services to the homebound; Clinical psychologist (CP) and clinical social worker services (CSW); Services of registered dieticians or nutritional professionals for diabetes training services and medical nutrition therapy; Otherwise covered drugs that are furnished by, and incident to, services of physicians and non-physician practitioners of the FQHC . (Medicare Benefit Policy Manual Chapter 13)
Additional FQHC Services FQHC services also include certain preventive primary health services. The law defines Medicare-covered preventive services provided by a FQHC as the preventive primary health services that a FQHC is required to provide under section 330 of the Public Health Service (PHS) Act. Medicare may not cover some of the preventive services that FQHCs provide, such as dental services, which are specifically excluded under Medicare law.
Section 330 PHS Required FQHC Services prenatal and perinatal services; appropriate cancer screening; well-child services; immunizations against vaccine preventable diseases; screenings for elevated blood lead levels, communicable diseases, and cholesterol; pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care; voluntary family planning services; preventive dental services.
FQHC Preventive Encounters IPPE Welcome to Medicare Annual Wellness Visit (AWV) Subsequent Annual Wellness Visits Medicare-covered preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) with a grade of A or B, as appropriate for the individual. (Medicare Benefit Policy Manual Chapter 13)
Medicare Preventive Screenings Screening mammography; Screening pap smear and screening pelvic exam; Prostate cancer screening tests; Colorectal cancer screening tests; DSMT services; Diabetes screening tests; MNT services; Bone mass measurement; Screening for glaucoma; Cardiovascular screening blood tests; and Ultrasound screening for abdominal aortic aneurysm.
Influenza and Pneumococcal Influenza and pneumococcal vaccines and their administration are paid through the cost report, and payment for the hepatitis B vaccine and its administration is included in an otherwise billable visit.
Incident-to Services Defined Commonly rendered without charge or included in the RHC or FQHC bill; Commonly furnished in a physician office or clinic; Furnished under the physician s direct supervision; and Furnished by a member of the RHC or FQHC staff. Drugs and biologicals that are not usually self-administered, and Medicare-covered preventive injectable drugs (e.g., influenza, pneumococcal); Bandages, gauze, oxygen, and other supplies; or Assistance by auxiliary personnel such as a nurse, medical assistant, or anyone acting under the supervision of the physician.
Provision of Incident-to Services Services and supplies furnished incident to physician s services are limited to situations in which there is direct physician supervision of the person performing the service. Direct supervision does not mean that the physician must be present in the same room the physician must be in the RHC or FQHC and immediately available. Source: Medicare Benefit Policy Manual. Chapter 13. Section 110.1
Incident-To: NP-PA Claims Nurse Practitioner or Physician Assistant claims billed as their supervising physician are considered incident-to claims. This billing method assumes that the supervising provider in in the clinic at the time the patient is seen. Since Nurse Practitioners and Physician Assistants are approved providers, they are paid 100% the same as physician in an FQHC. There is no purpose to billing under the physician in an RHC or FQHC. Commercial Claims for NP/PA services should be billed according to the payer contract.
Examples of incident-to services Injections Suture Removal Dressing Changes Prescription Services Blood Pressure Monitoring Nurse Visits/Services Registered Dietician NOT rendering DSMT/MNT Visits
FQHC Payments The PPS Rate Payment reflects the following components: Geographic Adjustment Factor based on locality New Patient Adjustment 1.3416 IPPE/AWV Adjustment 1.3416 GAFs can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for- ServicePayment/FQHCPPS/index.html.
Payment Codes for FQHCs (70.2.1 MBPM) 1. 2. 3. 4. 5. G0466 FQHC visit, new pt. G0467 FQHC visit, established pt. G0468 FQHC visit, IPPE or AWV G0469 FQHC visit, mental health, new pt. G0470 FQHC visit, mental health, established. pt.
FQHC Qualifying Visit List See the FQHC Qualifying Visit List https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G0466 New Patient Qualifying Visits HCPCS 92002 92004 97802 99201 99202 99203 99204 99205 99304 99305 99306 99324 99325 99326 99327 99328 99341 99342 99343 99344 99345 Qualifying Visits for G0466 Eye exam new patient Eye exam new patient Medical nutrition indiv in Office/outpatient visit new Office/outpatient visit new Office/outpatient visit new Office/outpatient visit new Office/outpatient visit new Nursing facility care init Nursing facility care init Nursing facility care init Domicil/r-home visit new pat Domicil/r-home visit new pat Domicil/r-home visit new pat Domicil/r-home visit new pat Domicil/r-home visit new pat Home visit new patient Home visit new patient Home visit new patient Home visit new patient Home visit new patient 99406 99407 99497 G0101 G0102 G0108 G0117 G0118 G0296 G0442 G0443 G0444 G0445 G0446 G0447 G0490 Q0091 2 Behav chng smoking 3-10 min 2 Behav chng smoking > 10 min Advncd care plan 30 min Ca screen; pelvic/breast exam Prostate ca screening; dre Diab manage trn per indiv Glaucoma scrn hgh risk direc Glaucoma scrn hgh risk direc Visit to determ LDCT elig Annual alcohol screen 15 min Brief alcohol misuse counsel Depression screen annual High inten beh couns std 30 min Intens behave ther cardio dx Behavior counsel obesity 15 min Home visit RN, LPN by RHC/FQ Obtaining screen pap smear
G0467 Established Patient Qualifying Visits HCPCS Qualifying Visits for G0467 92012 Eye exam establish patient 92014 Eye exam & tx estab pt 1/>vst 97802 Medical nutrition indiv in 97803 Med nutrition indiv subseq 99212 Office/outpatient visit est 99213 Office/outpatient visit est 99214 Office/outpatient visit est 99215 Office/outpatient visit est 99304 Nursing facility care init 99305 Nursing facility care init 99306 Nursing facility care init 99307 Nursing fac care subseq 99308 Nursing fac care subseq 99309 Nursing fac care subseq 99310 Nursing fac care subseq 99315 Nursing fac discharge day 99316 Nursing fac discharge day 99318 Annual nursing fac assessmnt 99334 Domicil/r-home visit est pat 99335 Domicil/r-home visit est pat 99336 Domicil/r-home visit est pat 99337 Domicil/r-home visit est pat 99347 99348 Home visit est patient 99349 Home visit est patient 99350 Home visit est patient 99406 2 Behav chng smoking 3-10 min 99407 2 Behav chng smoking > 10 min 99496 Trans care mgmt 7 day disch 99497 Advncd care plan 30 min G0101 Ca screen; pelvic/breast exam G0102 Prostate ca screening; dre G0108 Diab manage trn per indiv G0117 Glaucoma scrn hgh risk direc G0118 Glaucoma scrn hgh risk direc HCPCS Qualifying Visits for G0467 G0270 Mnt subs tx for change dx G0296 Visit to determ LDCT elig G0442 Annual alcohol screen 15 min G0443 Brief alcohol misuse counsel G0444 Depression screen annual G0445 High inten beh couns std 30 min G0446 Intens behave ther cardio dx G0447 Behavior counsel obesity 15 min G0490 Home visit RN, LPN by RHC/FQ Q0091 Obtaining screen pap smear Home visit est patient
G0468 Preventive Visit Qualifying Codes HCPCS Qualifying Visits for G0468 G0402 Initial preventive exam G0438 PPPS, initial visit G0439 PPPS, subseq visit
G0469 - Behavioral Health, New Patient HCPCS Qualifying Visits for G0469 90791 Psych diagnostic evaluation 90792 Psych diag eval w/med srvcs 90832 Psytx pt &/family 30 minutes 90834 Psytx pt &/family 45 minutes 90837 Psytx pt &/family 60 minutes 90839 Psytx crisis initial 60 min 90845 Psychoanalysis
G0470 - Behavioral Health, Established Patient HCPCS Qualifying Visits for G0470 90791 Psych diagnostic evaluation 90792 Psych diag eval w/med srvcs 90832 Psytx pt &/family 30 minutes 90834 Psytx pt &/family 45 minutes 90837 Psytx pt &/family 60 minutes 90839 Psytx crisis initial 60 min 90845 Psychoanalysis
Medicare Preventive Reference Follow these links to: Medicare Preventive Services Quick Chart CMS Preventive Services Center Medlearn Matters 9234 (Revised) Chronic Care Management (CCM) Services for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). November 15, 2015
80.1 - Charges and Waivers Charges for services furnished to Medicare beneficiaries must be the same as the charges for non-Medicare beneficiaries. FQHCs may waive collection of all or part of the copayment, depending on the beneficiary s ability to pay. Medicare Benefit Policy Manual Chapter 13
Incident-to/Claim Detail FQHCs must submit separate service lines with revenue codes and HCPCS codes to reflect any cost associated with all FQHC covered services provided by the FQHC but not reflected on the service line submitted for the billable visit. For example, for Part B covered injectable drugs administered in an FQHC during a billable visit, the FQHC should report a separate line item with the appropriate revenue code and HCPCS codes to reflect the charge for the drug and its administration which is covered as an incident to service. SOURCE: Medicare Claims Processing Manual Chapter 9
Service Level Information Professional or primary services not subject to the Medicare outpatient mental health treatment limitation are bundled into line item(s) using revenue code 052x; Diabetes Self Management Training (DSMT) billed under revenue code 052x and HCPCS code G0108 and Medical Nutrition Therapy (MNT) billed under revenue code 052x and HCPCS code 97802, 97803, or G0270; and Medicare outpatient mental health services are billed under revenue code 0900;
50 General Requirements for RHC/FQHC Claims Revenue Codes, FL42 Rev Cd Description 0521 Clinic Visit at RHC/FQHC by qualified provider 0522 Home visit by RHC/FQHC provider 0524 Part A SNF Visit by RHC/FQHC practitioner 0525 Nursing/Intermediate Care Visit or other residential facility RHC/FQHC (non-Part A) 0527 Visiting Nurse service - home health shortage 0528 Visit by RHC/FQHC practitioner to other non- RHC/FQHC site (e.g., scene of accident) 0519 FQHC supplemental payment 0300 Venipuncture 0636 Injection/Immunization 0780 Telehealth 0900 Behavioral Health
Global Billing Surgical procedures furnished in an FQHC by an FQHC practitioner are considered FQHC services. The Center is paid based on [PPS] rate and is not subject to the Medicare global billing requirements. Surgical procedures furnished at locations other than the Center may be subject to Medicare global billing requirements. (Medicare Benefit Policy Manual. Chapter 13. Section 40.3)
Minor Surgical Procedures Minor surgical procedures performed in the FQHC, during FQHC hours, must be billed as encounters. Follow-up visits for dressing changes, or suture removal can only be billed as encounters if there is a medically-necessary, documented reason and it is performed by an FQHC provider.
Office Visit and Surgical Procedure If an office visit is performed during the same visit as a minor surgical procedure, the clinic will only have one encounter to bill. - Modifier 25 can be used to report this in an FQHC. - These will be reported as one encounter.
Injections and Surgical Procedures When performed during FQHC hours, injections are incident to an encounter. Surgical procedures are definitely an encounter. Any services provided during FQHC hours and, defined in this Section as FQHC Services, may not be billed to Medicare Part B on a 1500. [Commingling]
90 - Commingling Commingling refers to the sharing of FQHC space, staff (employed or contracted), supplies, equipment, and/or other resources with an onsite Medicare Part B or Medicaid fee-for-service practice operated by the same FQHC or FQHC physician(s) and/or non-physician(s) practitioners.
90 - Commingling Duplicate Medicare or Medicaid reimbursement (including situations where the RHC or FQHC is unable to distinguish its actual costs from those that are reimbursed on a fee-for-service basis), Selectively choosing a higher or lower re-imbursement rate for the services.
Hospice If a Medicare beneficiary who has elected the hospice benefit receives care from an RHC or FQHC related to his/her terminal illness, the RHC or FQHC cannot be reimbursed for the visit. (Medicare Benefit Policy Manual. Chapter 13. Section 200) When the FQHC provider DOES see a hospice patient for non-hospice related condition: Enter 07 in condition code (FL18). Enter Non-Hospice Related Service in remarks.
Non-Covered Services If a rejection for a Medicare non-covered service is needed so that we can submit a claim to the patient s secondary insurer. A claim with a type of bill 710 (non-covered service) should be submitted to Medicare. This will prompt a rejection that can be submitted to the secondary payer.
Visiting Specialists Scenario #1: Scenario #2: A specialist rents space from the FQHC one morning per week, brings his own staff, and does his own billing. A general surgeon comes to the FQHC once per week. She sees Center patients and bills them as FQHC encounters. Configuration: The Center carves out the cost of the space and removes all associated costs from the cost report. Configuration: FQHC billing requirements will apply.
Behavioral Health Providers Medicare BH providers are: Clinical Psychologist (PhD) LCSW LCPC or CPC is not payable by Medicare (Check with your own state to see if LCPC or CPC are eligible in most states they are not) Mental Health Services performed by a qualified provider are billed using revenue code 900. Diagnostic and therapeutic services are paid as an encounters.
G-Code Charges 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. G-Code Charges are set by each Center based on the normal complement of services . Each Center will set their own G-Code charge amount for each payment code. The G-Gode charges for used in this presentation are based on the total charge for services rendered in each example.
Payment Calculation 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: the lesser of the provider s charge for the specific payment code(s) or the PPS Rate. (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%. = Medicare Payment
To Calculate Co-Insurance 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: 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. G-Code PPS Rate = Step 3 total Step 4: Multiply the total from Step 3 by 20%. Step 3 total * 20% = Coinsurance
G0466 FQHC visit, New Patient A medically-necessary medical, or a qualified preventive health, face-to-face encounter (one-on-one) between a new patient (as defined in section 70.3), 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. G0466: New Patient Medical Visit FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 FQHC Visit, New Pt G0466 1/31/2021 1 $ 195.00 0521 OV New, Level 4 99204 1/31/2021 1 $ 180.00 0300 Routine Venipuncture 36415 1/31/2021 1 $ 15.00 0001 $ 390.00
G0466 New Patient Payment Example 3. The G-Code charge is less than the PPS Rate. 1. Calculate the PPS Base Rate $ 158.85 $ 168.22 Geo. Adj 1.059 1.3416 Adjusted PPS $ 168.22 $ 225.68 4. Medicare will pay $156 (80% of $195) 5. Patient Co-Insurance is $39.00 (20% of $195). 2. Compare PPS Rate to specific payment code (G-Code) amount. 6. The total payment is $195.00. Charge $195.00 < $225.68 PPS Rate Coins $39.00
G0467 FQHC visit, Established Patient A medically-necessary medical, or a qualifying preventive health, 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. G0467: Established Patient Visit FL42 FL43 FL44 FL45 FL46 FL47 Rev CD Desc HCPCS/CPT DOS Units Total Charge 0521 FQHC Visit, Established Pt G0467 1/31/2018 1 $ 150.00 0521 OV Est Patient III 99213 1/31/2018 1 $ 135.00 0001 $ 285.00
