Preventive Health Services in RHCs

220.1 - Preventive Health Services in RHCs (Rev. 13600; Issued: 02-20-26; Effective: 01-01-26; Implementation:03-23-26) Influenza (G0008), Pneumococcal (G0009), and COVID-19 (90480) Vaccines, and Certain COVID-19 Monoclonal Antibody Products Prior to July 1, 2025, influenza, pneumococcal, COVID-19 vaccines, and their administration were not paid at the time of service and were paid at 100 percent of reasonable cost through the cost report. Effective for dates of service on or after July 1, 2025, RHCs shall report all Part B preventive vaccines and their administration – pneumococcal, influenza, and COVID-19 on the claim at the time of service. A visit/encounter is not required for these services; however, if reported on the same day, the vaccines and administrations shall receive a separate payment. Coinsurance and deductible do not apply to these vaccines or their administration. Although paid at the time of service, payments for these services must be annually reconciled with the RHC’s actual vaccine and vaccine administration costs, to ensure these services are ultimately reimbursed at 100% of reasonable costs through the cost report. Each year, CMS updates the Seasonal Influenza Vaccines Pricing webpage: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/vaccine-pricing to reflect the seasonal influenza virus vaccines and their applicable payment allowances that are effective August 1 through July 31 of the following year. RHCs must refer to this webpage to ensure they are billing the appropriate HCPCS codes for the applicable influenza season. Note: An additional payment for influenza, pneumococcal, COVID-19 vaccine administration in the home can be made, provided that a home visit meets all the requirements of both part 405, subpart X, for RHC services provided in the home, and § 410.152(h)(3)(iii) for the in-home additional payment for Part B preventive vaccine administration. See Pub. 100-02, Chapter 15, Section 50.4.4.2.E. Covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration are paid at 100 percent of reasonable cost through the cost report. 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 (G0010) Prior to January 1, 2025, hepatitis B vaccine and its administration was included in the RHC visit and was not separately billable. The cost of the vaccine and its administration could be included in the line item for the otherwise qualifying visit. A visit could not be billed if vaccine administration was the only service the RHC provides. The beneficiary coinsurance and deductible were waived. Effective January 1, 2025, payment for the hepatitis B vaccine and its administration is through the cost report and no longer included in the RHC AIR. Effective for dates of service on or after July 1, 2025, RHCs shall report all Part B preventive vaccines and their administration – including hepatitis B on the claim at the time of service. A visit/encounter is not required for these services; however, if a visit occurs on the same day, the vaccines and administrations shall receive a separate payment. Coinsurance and deductible do not apply to these vaccines or their administration. Note: An additional payment for hepatitis B vaccine administration in the home can be made, provided that a home visit meets all the requirements of both part 405, subpart X, for RHC services provided in the home, and § 410.152(h)(3)(iii) for the in-home additional payment for Part B preventive vaccine administration. See Pub. 100-02, Chapter 15, Section 50.4.4.2.E for more information. Although paid at the time of service, payments for these services must be annually reconciled with the RHC’s actual vaccine and vaccine administration costs, to ensure these services are ultimately reimbursed at 100% of reasonable costs through the cost report. Initial Preventive Physical Exam (G0402) The IPPE is a face-to-face one-time exam that must occur within the first 12 months following the beneficiary’s enrollment. The IPPE can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If an IPPE visit is furnished on the same day as another billable visit, two visits may be billed. The beneficiary coinsurance and deductible are waived. Annual Wellness Visit (G0438 and G0439) The AWV is a face-to-face personalized prevention visit for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an IPPE or AWV within the past 12 months. Advance Care Planning (ACP) and administration of a standardized, evidence-based assessment of physical activity and nutrition can be furnished as a part of the AWV. The AWV can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If the AWV is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible are waived. More information regarding ACP and an evidence-based assessment of physical activity and nutrition as an optional AWV element is available on the CMS website: https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness- visits/annual-wellness-visit Diabetes Self-Management Training (G0108) and Medical Nutrition Therapy (97802 and 97803) Diabetes self-management training or medical nutrition therapy provided by a registered dietician or nutritional professional at an RHC may be considered incident to a visit with an RHC practitioner provided all applicable conditions are met. DSMT and MNT are not billable visits in an RHC, although the cost may be allowable on the cost report. RHCs cannot bill a visit for services furnished by registered dieticians or nutritional professionals. However, RHCs are permitted to become certified providers of DSMT services and report the cost of such services on their cost report for inclusion in the computation of their AIR. The beneficiary coinsurance and deductible apply. Screening Pelvic and Clinical Breast Examination (G0101) Screening pelvic and clinical breast examination can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible are waived. Screening Papanicolaou Smear (Q0091) Screening Papanicolaou smear can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible are waived. Prostate Cancer Screening (G0102) Prostate cancer screening can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible apply. Glaucoma Screening (G0117 and G0118) Glaucoma screening for high risk patients can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible apply. Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296) LDCT can be billed as a stand-alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance and deductible are waived. Drugs Covered as Additional Preventive Services (DCAPS) DCAPS drugs, and any supply and administration fee, are paid at 100 percent of the Medicare payment amount. The Medicare payment amount for DCAPS drugs, and any supply and administration fee, is described in the Medicare Claims Processing Manual (100-04), Chapter 18, Section 250. The beneficiary coinsurance and deductible are waived. These services are separately billable and are paid on a claim-by-claim basis. Therefore, they do not affect any other claims billed on the same day. Coding for DCAPS drugs and related supply and administration fees is listed on the CMS webpage: • The coding and other guidance for Part B coverage and payment of PrEP for HIV is located at https://www.cms.gov/medicare/coverage/prep. The HCPCS code for the injection of PrEP for HIV is G0012. NOTE: Hepatitis C Screening (G0472) is a technical service only and therefore it is not paid as part of the RHC visit.