Payments for FQHC PPS Claims

60.3 - Payments for FQHC PPS Claims (Rev. 13547; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26) 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. 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: 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. (Lesser of the provider’s charge for the specific payment code or the PPS rate) - (Preventive services charges) = Step 3 total Note: If no preventive services are present, 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%. Step 3 total * 80% = Step 4 total Note: If no preventive services are present, contractors will pay this amount and skip step 5. Step 5: Add the charges for the approved preventive services to the total from step 4. Contractors will pay this amount. Step 4 total + preventive services charges = Medicare Payment Note: If the charges for the approved preventive services are greater than the total payment amount identified in Step 1 (i.e., the lesser of the charges for the specific payment code or the PPS rate), pay 100% of the total payment amount determined in Step 1 and do not apply coinsurance. (Please see example 3) To calculate coinsurance, follow the steps below: 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. (Lesser of the provider’s charge for the specific payment code or the PPS rate) - (Preventive services charges) = Step 3 total 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. Step 4: Multiply the total from Step 3 by 20%. Step 3 total * 20% = Coinsurance Example: Payment based on the charges PPS rate = 160.00 Note: The examples below may vary by description or HCPCS. Provider’s actual charge for the specific payment code, G0467 = $150 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0467 - FQHC Specific 10/01 150.00 150.00 Payment Code (FSPC) 0521 99213 - Qualifying Visit (QV) 10/01 135.00 135.00 0300 36415 - Venipuncture (VP) 10/01 25.00 25.00 0001 310.00 310.00 The comparison is between the PPS rate and the provider’s $150 actual charge for the specific payment code, G0467. In this case, the sum of the line items exceeds the provider’s actual charge for the payment code. Payment based on the provider’s charge of 150.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covere d Charge Payment Coinsurance 0521 G0467 - FSPC 10/01 150.00 150.00 120.00 30.00 0521 99213 - QV 10/01 135.00 135.00 CO 97* 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0001 310.00 310.00 Payment = 150.00 (charges) * 80% Coinsurance = 150.00 (charges) * 20% For service lines that do not receive payment, group code CO- contractual obligation and the appropriate claim adjustment reason code (CARC) will be used. * CARC 97 – the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Example: Payment based on the charges with approved preventive service PPS rate = 160.00 Provider’s actual charge for the specific payment code, G0468 = $150 Preventive Service (PS) = 135.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covere d Charge 0521 G0468 - FSPC 10/01 150.00 150.00 0521 G0439 - PS 10/01 135.00 135.00 0300 36415 - VP 10/01 25.00 25.00 0001 310.00 310.00 Payment based on the provider’s actual charge of 150.00 for the specific payment code, G0468. Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covere d Charge Payment Coinsurance 0521 G0468 - FSPC 10/01 150.00 150.00 147.00 3.00 0521 G0439 - PS 10/01 135.00 135.00 CO 97* 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0001 310.00 310.00 Payment = (150.00 (charges) – 135.00 (preventive service G0439)) * 80% + 135.00 preventive service. Coinsurance = (150.00 (charges) – 135.00 (preventive service G0439)) * 20% • PS – Preventive Service -These are approved preventive services where the coinsurance is waived based on the USPSTF recommendation. Example: Payment based on the charges when preventive service is greater than G- code PPS rate = 160.00 Provider’s actual charge for the specific payment code, G0468 = $150 Preventive Service = 155.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0468 - FSPC 10/01 150.00 150.00 0521 G0439 - PS 10/01 155.00 155.00 0300 36415 - VP 10/01 25.00 25.00 0001 330.00 330.00 Payment based on charges of 150.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge Payment Coinsurance 0521 G0468 - FPSC 10/ 01 150.00 150.00 150.00 0 0521 G0439 - PS 10/ 01 155.00 155.00 CO 97* 0 0300 36415 - VP 10/ 01 25.00 25.00 CO 97 0 0001 330.00 330.00 Payment = (150.00 (charges) * 100% = 150.00 Since the charges for the preventive service, G0439 are greater than the provider’s actual charge for the specific payment code G0468, Medicare pays 100% of the provider’s actual charge for the specific payment code, G0468. Reporting Multiple G-codes When a FQHC reports multiple specific payment codes (G-codes) on the same day, the total payment amount will be determined by comparing the sum of the charges for all the G-codes reported to the PPS rate. When a qualified mental health visit occurs on the same day as a qualified medical visit, the G-codes will be totaled separately (see example 8). Listed below is the order in which payment will be applied when multiple G-codes are reported on the same day: Medical visits: • G0468-IPPE or AWV • G0466-Medical, new patient • G0467-Established patient Mental health visits: • G0469-Mental health, new patient • G0470- Mental health, established patient When G0466 (Medical, new patient) and G0468 (IPPE or AWV) are reported together, the add-on payment will be applied to G0468. Example: Payment based on PPS rate with multiple G-codes and preventive services Because this scenario does not qualify for an exception to a per diem payment, the system will calculate and apply a PPS rate to only one of the specific payment codes. However, the FQHC may list its actual charges for both specific payment codes, and the comparison would be between the PPS rate and the total of the provider’s charges for the specific payment codes. Payment would be based on the lesser amount. PPS RATE, reflecting a 1.3416 adjustment for new patients or a visit including an IPPE or AWV = 215.00 Total of provider charges for the specific payment codes (170.00 + 65.00) = 235.00 Provider’s charge for the Preventive Service = 135.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0468 - FSPC 10/01 170.00 170.00 0521 G0438 - PS 10/01 135.00 135.00 0300 36415 - VP 10/01 25.00 25.00 0521 G0466 - FSPC 10/01 65.00 65.00 0521 92004 - Ophthalmo- logical Exam 10/01 45.00 45.00 0001 440.00 440.00 Payment based on adjusted PPS rate of 215.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge Payment Coinsurance 0521 G0468 - FSPC 10/01 170.00 170.00 199.00 16.00 0521 G0438 - PS 10/01 135.00 135.00 CO 97 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0521 G0466 - FSPC 10/01 65.00 65.00 CO 97 0 0521 92004 - Ophthalmo- logical Exam 10/01 45.00 45.00 CO 97 0 0001 440.00 440.00 Payment = (215.00 (PPS rate) – 135.00 (preventive service G0438) * 80% + 135.00 preventive service Coinsurance = (215.00 (PPS rate) – 135.00 (preventive service G0438)) * 20% Reporting Multiple Preventive Services When multiple preventive services are reported on the same day, the coinsurance will be determined by carving out the total preventive services charges. Example: Payment based on PPS rate with multiple G-codes and multiple preventive services PPS RATE =225.00 Total G code charges (140.00 + 75.00 + 55.00) = 270.00 Total Preventive Services (135.00 +60.00) =195.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0468 - FSPC 10/01 140.00 140.00 0521 G0439 - PS 10/01 135.00 135.00 0300 36415 - VP 10/01 25.00 25.00 0521 G0467 - FSPC 10/01 75.00 75.00 0521 97802 - PS 10/01 60.00 60.00 0521 G0466 - FSPC 10/01 55.00 55.00 0521 92004 - Ophthalmological Exam 10/01 45.00 45.00 0001 535.00 535.00 Payment based on PPS rate of 225.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge Payment Coinsurance 0521 G0468 - FSPC 10/01 140.00 140.00 219.00 6.00 0521 G0439 - PS 10/01 135.00 135.00 CO 97 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0521 G0467 - FSPC 10/01 75.00 75.00 CO 97 0 0521 97802 - PS 10/01 60.00 60.00 CO 97 0 0521 G0466 - FSPC 10/01 55.00 55.00 CO 97 0 0521 92004 - Ophthalmo- logical Exam 10/01 45.00 45.00 CO 97 0 0001 535.00 535.00 Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20% Influenza and Pneumococcal Pneumonia Vaccination (PPV) (Prior to July 1, 2025) Flu and PPV vaccines and their administration will continue to be paid through the cost report. However, these services should be reported on the claim for information purposes only. Flu and PPV vaccines and their administration codes will not be carved out of the coinsurance calculation. See section 60.2 for updates regarding billing requirements for Medicare Part B preventive vaccines and their administration. Example: Payment based on charges with Flu and Flu administration code services PPS rate = 160.00 Preventive Service = 135.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0468 - FSPC 10/01 150.00 150.00 0521 G0438 - PS 10/01 135.00 135.00 0636 90655 - Vaccine 10/01 15.00 15.00 771 G0008 - Admin Vaccine 10/01 5.00 5.00 0001 305.00 305.00 Payment based on charges of 150.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge Payment Coinsurance 0521 G0468 - FSPC 10/0 1 150.00 150.00 150.00 0 0521 G0438 - PS 10/0 1 135.00 135.00 CO 97 0 0636 90655 - Vaccine **** 10/0 1 15.00 15.00 CO 246*** 0 0771 G0008 Admin Vaccine **** 10/0 1 5.00 5.00 CO 246 0 0001 305.00 305.00 Because flu and PPV are reported on the claim for information purposes only, G0438 remains as the only service payable on this claim. Because the claim consists solely of preventive services for which coinsurance is waived, the contractor will pay 100% of the provider’s actual charge for the specific payment code, G0468. *** CARC 246- This non-payable code is for required reporting only. **** Flu/PPV are reported on the claim for information purposes only, the payment and coinsurance are not impacted by the charges associated with the Flu/PPV vaccine and their administration code. Hepatitis B (prior to January 1, 2025) Hepatitis B should be reported on the claim and is included in the claim payment. These services will be carved out of the coinsurance calculation. Effective January 1, 2025, Hepatitis B is treated like flu, PPV and COVID. See section 60.2 for updates regarding billing requirements for Medicare Part B preventive vaccines and their administration. Example: Payment based on charges with Hepatitis B PPS rate= 160.00 Preventive Services = 20.00 (15.00 +5.00) Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0467 - FSPC 10/01 150.00 150.00 0521 99213 - E&M 10/01 135.00 135.00 0300 36415 - VP 10/01 5.00 5.00 0636 90746 - PS Vaccine 10/01 15.00 15.00 771 G0010 - PS Admin Vaccine 10/01 5.00 5.00 0001 310.00 310.00 Payment based on charges of 150.00 Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covere d Charge Payment Coinsurance 0521 G0467 - FSPC 10/01 150.00 150.00 124.00 26.00 0521 99213 - E&M 10/01 135.00 135.00 CO 97 0 0300 36415 - VP 10/01 5.00 5.00 CO 97 0 0636 90746 - PS Vaccine 10/01 15.00 15.00 CO 97 0 0771 G0010 - PS Admin Vaccine 10/01 5.00 5.00 CO 97 0 0001 310.00 310.00 Payment = (150.00 (charges) – 20.00 (preventive service 90746 + G0010)) * 80% + 20.00 preventive Coinsurance = (150.00 (charges) – 20.00 (preventive service 90746 + G0010)) * 20% Mental Health Services Qualified mental health visits billed under revenue code 0900 receive an additional payment when billed on the same day as a medical visit. Example: Mental Health Services PPS RATE for G0468: $225.00 PPS rate for G0470: $160 Total of provider’s actual charges for the specific payment codes representing medical visits (140.00 + 75.00 + 55.00) = 270.00- This does not include charges for G0470 Provider’s charge for the specific payment code representing mental health services = 159.00 Appropriat e Rev Code Appropriate HCPCS Code MO D DOS Total Charge Covere d Charge 0521 G0468 - FSPC 10/01 140.00 140.00 0521 G0439 - PS 10/01 135.00 135.00 0300 36415 - VP 10/01 25.00 25.00 0521 G0467 - FSPC 10/01 75.00 75.00 0521 97802 - PS 10/01 60.00 60.00 0521 G0466 - FSPC 10/01 55.00 55.00 0521 92004 - Ophthalmo- logical Exam 10/01 45.00 45.00 0900 G0470 - FSPC 10/01 159.00 159.00 0900 90832 - Psychotherapy 10/01 139.00 139.00 0636 J3490 - Injection 10/01 15.00 15.00 0001 848.00 848.00 Payment based on PPS rate of 225.00 for the specific payment codes describing the medical visits and based on the provider’s actual charges for the specific payment code describing the mental health visit. Appropriat e Rev Code Appropriate HCPCS Code MO D DOS Total Charge Covere d Charge Payment Coinsurance 0521 G0468 - FSPC 10/01 140.00 140.00 219.00 6.00 0521 G0439 - PS 10/01 135.00 135.00 CO 97 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0521 G0467 - FSPC 10/01 75.00 75.00 CO 97 0 0521 97802 - PS 10/01 60.00 60.00 CO 97 0 0521 G0466 - FSPC 10/01 55.00 55.00 CO 97 0 0521 92004 - Ophthalmo- logical Exam 10/01 45.00 45.00 CO 97 0 0900 G0470 - FSPC 10/01 159.00 159.00 127.20 31.80 0900 90832 - Psychotherapy 10/01 139.00 139.00 CO 97 0 0636 J3490 - Injection 10/01 15.00 15.00 CO 97 0 0001 848.00 848.00 For Medical visit with revenue code 052X Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20% For Mental Health visit with revenue code 0900 Payment = 159.00 *80% = 127.20 Coinsurance =159.00 * 20% = 31.80 Modifier 59 Medicare allows for an additional payment when an illness or injury occurs after the initial visit, and the FQHC bills these visits with the specific payment codes and modifier 59. Services billed with a modifier 59 will be paid an additional per diem rate Example: Modifier 59 PPS rate for G0468 = 225.00 Total G code charges (140.00 + 75.00 + 55.00) = 270.00 – This does not include charges for G0470 and G-code charges for modifier 59 Total mental Health Services = 159.00 PPS rate for G0467 (billed with Modifier 59) = 160.00 Appropriate Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covered Charge 0521 G0468 - FSPC 10/01 140.00 140.00 0521 G0438 - PS 10/01 135.00 135.00 0300 36415 - VP 10/01 25.00 25.00 0521 G0467 - FSPC 10/01 75.00 75.00 0521 97802 - PS 10/01 60.00 60.00 0521 G0466 - FSPC 10/01 55.00 55.00 0521 92004 - Ophthalmological Exam 10/01 45.00 45.00 0900 G0470 - FSPC 10/01 159.00 159.00 0900 90832 - Psychotherapy 10/01 139.00 139.00 0636 J3490 - Injection 10/01 15.00 15.00 0521 G0467 - FSPC 59 10/01 165.00 165.00 0521 99211 - E&M 10/01 105.00 105.00 0001 1118.00 1118.00 Payment based on PPS rate of 225.00 for the G-codes, based on the charges for the mental health visit and based on the PPS rate for G0467 billed with modifier 59. Appropriat e Rev Code Appropriate HCPCS Code MOD DOS Total Charge Covere d Charge Payment Coinsurance 0521 G0468 - FSPC 10/01 140.00 140.00 219.00 6.00 0521 G0438 - PS 10/01 135.00 135.00 CO 97 0 0300 36415 - VP 10/01 25.00 25.00 CO 97 0 0521 G0467 - FSPC 10/01 75.00 75.00 CO 97 0 0521 97802 - PS 10/01 60.00 60.00 CO 97 0 0521 G0466 - FSPC 10/01 55.00 55.00 CO 97 0 0521 92004 - Ophthalmological Exam 10/01 45.00 45.00 CO 97 0 0900 G0470 - FSPC 10/01 159.00 159.00 127.20 31.80 0900 90832 - Psychotherapy 10/01 139.00 139.00 CO 97 0 0636 J3490 - Injection 10/01 15.00 15.00 CO 97 0 0521 G0467 - FSPC 59 10/01 165.00 165.00 128.00 32.00 0521 99211 - E&M 10/01 105.00 105.00 CO 97 0 0001 1118.00 1118.00 For Medical visit with revenue code 052X Payment = (225.00 – (135.00 +60.00)) * 80% + 135.00 + 60.00 Coinsurance = (225.00 (PPS rate) – (135.00 + 60.00)) * 20% For Mental Health visit with revenue code 0900 Payment = 159.00 *80% = 127.20 Coinsurance =159.00 * 20% = 31.80 For G0467 billed with modifier 59 Payment = 160.00 * 80% = 128.00 Coinsurance = 160.00 * 20% = 32.00