Per-Diem Payment and Exceptions under the PPS

30.1 - Per-Diem Payment and Exceptions under the PPS (Rev. 13264, Issued:06-09-25; Effective: 06-02-25; Implementation: 06-02-25) 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 were transitioned to the PPS by December 31, 2015. FQHC payments are made under the PPS, the Medicare payment is based on the lesser of the FQHC 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, after 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. • The patient has an IOP service and medical visit on the same day. • The patient has a dental visit and a medical 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.