General Requirements for RHC and FQHC Claims

50 - General Requirements for RHC and FQHC Claims (Rev. 13264, Issued:06-09-25; Effective: 06-02-25; Implementation: 06-02-25) 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 The RHC/FQHC enters this information for their agency. Type of Bill 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) 3rd Digit - 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) 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 The RHC/FQHC enters the beneficiary’s name exactly as it appears on the Medicare card. Patient Address The RHC/FQHC enters the mailing address of the patient. Enter the complete mailing address. Patient Birth date The RHC/FQHC enters the date of birth of the patient. Patient Sex The RHC/FQHC enters the sex of the patient as recorded at the start of care. Priority (Type) of Admission or Visit The RHC/FQHC enters the most appropriate NUBC approved code indicating the priority of the visit. Point of Origin for Admission or Visit The RHC/FQHC enters the most appropriate NUBC approved code indicating the point of origin for this admission or visit. Patient Discharge Status 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 The RHC/FQHC enters any appropriate NUBC approved code(s) identifying conditions related to this bill that may affect processing. Value Codes and Amounts 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 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: When billing for additional services rendered during the FQHCs encounter or RHC visit, a valid revenue code is required with an appropriate HCPCS code. However, the following revenue codes are not allowed on FQHC or RHC claims: Rev Code Description 0521 Clinic visit by member to RHC/FQHC 0522 Home visit by RHC/FQHC practitioner 0524 Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF 0525 Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility 0527 RHC/FQHC Visiting Nurse Service(s) to a member’s home when in a home health shortage area 0528 Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident) 0519 Clinic, Other Clinic (only for the FQHC supplemental payment) 0900 Mental Health Treatment/Services 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096- 310x. HCPCS/Accommodation Rates/HIPPS Rate Codes 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 The FQHC or RHC 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 or RHC and then suffers an illness or injury that requires additional diagnosis or treatment on the same day. Modifier 59 is the FQHC and RHC’s attestation that the patient, after 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 or RHC 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. Modifier CG - RHCs should report modifier CG on one line with a medical and/or mental health HCPCS code that represents the primary reason for the medically necessary face- to-face visit. Service Date Medicare requires a line-item date 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 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 the same day. Total Charges The RHC/FQHC enters the total charge for the service described on each revenue code line. Payer Name The RHC/FQHC identifies the appropriate payer(s) for the claim. National Provider Identifier (NPI) – Billing Provider The RHC/FQHC enters its own NPI. When more than one encounter/visit is reported on the same claim i.e., medical and mental health visits, please choose the NPI of the provider that furnished most of the services. Principal Diagnosis Code The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM Coding Guidelines. Other Diagnosis Codes The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM Coding Guidelines. Attending Provider Name and Identifiers 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 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. See the link to Publication 100-04, Medicare Claims Processing Manual, Chapter 25 for additional information on form 1450: https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/downloads/clm104c25.pdf