Billing for FQHC Claims Paid under the PPS

60.2 - Billing for FQHC Claims Paid under the PPS (Rev. 13547; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26) 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: Appropriate Rev Code Appropriate HCPCS Code MOD DOS 0521 G0467 - FQHC Specific Payment code (FSPC) 10/01 0521 99213 - Qualifying visit (QV) 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: Appropriate Rev Code Appropriate HCPCS Code MOD DOS 0521 G0468 – FSPC 10/01 0521 G0439 – QV 10/01 0900 G0470 - FSPC 10/01 0900 90832 – QV 10/01 When submitting a claim for a subsequent illness or injury, the FQHC reports G0467 for a medical visit), with modifier 59. A qualifying visit is still required when reporting modifier 59 with G0467. Appropriate Rev Code Appropriate HCPCS Code MOD DOS 0521 G0468 - FSPC 10/01 0521 G0439 - QV 10/01 0521 G0467 - FSPC 59 10/01 0900 99211 - QV 10/01 FQHCs must report all services that occurred on the same day on one claim. FQHCs may submit claims that span multiple days of service. 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. Beginning in 2020, FQHCs must report HCPCS codes for COVID-19 vaccines and their administration on a FQHC claim, and these HCPCS codes will be considered informational only. MACs shall pay for the COVID-19 vaccines and their administration through the cost report. Effective January 1, 2025, payment for the hepatitis B vaccine and its administration is through the cost report and no longer included in the FQHC PPS rate. Therefore, FQHCs must report HCPCS codes for the hepatitis B vaccine and their administration on a FQHC claim, and these HCPCS codes will be considered informational only. Effective for dates of service on or after July 1, 2025, FQHCs shall report all Part B preventive vaccines and their administration – pneumococcal, influenza, hepatitis B, and COVID-19 -- on the claim for payment 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 does 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 FQHC’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. FQHCs must refer to this webpage to ensure they are billing the appropriate HCPCS codes for the applicable influenza season. Note: FQHCs can bill HCPCS code M0201 for an in-home additional payment for influenza, pneumococcal, hepatitis B, COVID-19 vaccine administration, provided that a home visit meets all the requirements of both part 405, subpart X, for FQHC 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.