CPAs & ADVISORS
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THE IMPACT OF THE MEDICARE PROSPECTIVE
PAYMENT SYSTEM (PPS) ON THE BILLING PROCESS
TEXAS ASSOCIATION OF COMMUNITY HEALTH CENTERS
October 7, 2014
NEW PATIENT DEFINED
 A new patient is one who has not received any
professional medical or mental health services from
any sites within the FQHC organization within the
past three years
 If a new patient is also receiving a mental health visit
on the same day, the patient is considered
“new” for only one of these visits
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NEW PATIENT FAQS
 Q1. If an established patient sees a specialist in the
FQHC for the first time, will we get the new patient
adjustment?
 A1. No. The new patient adjustment is only for patients
that have not received services from any practitioner in
the FQHC organization within the last 3 years.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q2. If a patient was seen in a satellite of the FQHC but
not in the main location, would they be a new
patient?
 A2. No. If a patient was seen in any location of the
FQHC by any provider within the last 3 years they
would not be considered a new patient.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q3. If a patient received only behavioral health
services & then had a medical visit, would they be a
new patient?
 A3. No, because the patient is not new to the FQHC.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q4. If a patient was seen in another FQHC that is not
affiliated with my FQHC, would they be a new
patient?
 A4. Yes, because they would be new to your FQHC.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q5. If a patient was seen in the hospital that we are
affiliated with & then came to the FQHC for follow-up,
would they be a new patient?
 A5. Yes. FQHCs are not authorized to furnish hospital
services (inpatient or outpatient), so if the patient has
not been seen in the FQHC within the past 3 years,
he/she would be a new patient.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q6. When does the 34% increase for IPPE, AWV &
new patients begin?
 A6. It will begin for claims submitted under the PPS,
which is determined based on when your cost
reporting period begins.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q7. Does the new patient, IPPE & AWV adjustment
vary by region?
 A7. No. The 34% increase is the same for all FQHCs.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
NEW PATIENT FAQS, CONT.
 Q8. If a medical visit, mental health visit &
subsequent illness/injury are reported on the same
day, can we bill for 3 visits?
 A8. Yes, although we would not expect that to be a
common occurrence.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
REPORTING CHANGES
 All services rendered on the
same day must be submitted
on 1 claim or the claim will be
rejected
 Multiple claims submitted
with the same date of service
will be rejected
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REPORTING SAME DAY VISITS FAQS
 Q1. If I have to bill medical and mental health encounters on
the same claim, what NPI do I put in form locator 76
(attending provider) on the UB-04?
 A1. Please refer to the National Billing Uniform Committee
(NUBC) definition for attending NPI: ‘The attending provider
is the individual who has overall responsibility for the
patient’s medical care and treatment reported in this claim’.
The person who has overall responsibility will vary depending
on which services are furnished on that day.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
REPORTING SAME DAY VISITS FAQS, CONT.
 Q2. If a patient is seen at one site of a FQHC organization
for a medical visit and is seen at different site of the
same FQHC organization on the same date but at a
different time of day or with a different provider, should
both visits be reported on the same claim?
 A2. Yes. All visits that occur within the FQHC organization
on the same day to the same patient should be on the
same claim, even if they occurred at different sites.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G-CODES
 Establishes a new set of HCPCS G-codes (five payment
codes) for FQHCs to report services
• Established Medicare patient (medical & mental health)
 G0467 & G0470
• A new patient visit (medical & mental health)
 G0466 & G0469
• An IPPE or AWV
 G0468
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WHAT IS G0466?
 G0466 – FQHC visit, new patient
• A medically-necessary, face-to-face (one-on-one) encounter
between a new patient and a qualified FQHC practitioner
during which time one or more FQHC services are rendered
and includes a typical bundle of services that would be
furnished per diem to a Medicare beneficiary receiving
medical services. A new patient is one who has not received
any professional medical or mental health services from any
sites within the FQHC organization within the past three
years prior to the date of service.
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WHAT IS G0467?
 G0467 – FQHC visit, established patient
• A medically-necessary, face-to-face (one-on-one)
encounter between an established patient and a qualified
FQHC practitioner during which time one or more FQHC
services are rendered and includes a typical bundle of
services that would be furnished per diem to a Medicare
beneficiary receiving medical services. An established
patient is one who has received any professional medical
or mental health services from any sites within the FQHC
organization within three years prior to the date of service.
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WHAT IS G0468?
 G0468 – FQHC visit, IPPE or AWV
• A FQHC visit that includes an IPPE or AWV and includes the
typical bundle of services that would be furnished per diem
to a Medicare beneficiary receiving an IPPE or AWV, including
all services that would otherwise be billed as a FQHC visit
under G0466 or G0467.
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WHAT IS G0469?
 G0469 – FQHC visit, mental health, new patient
• A medically-necessary, face-to-face (one-on-one) mental
health encounter between a new patient and a qualified
FQHC practitioner during which time one or more FQHC
services are rendered and includes a typical bundle of
services that would be furnished per diem to a Medicare
beneficiary receiving a mental health visit.
• The encounter must include a qualified mental health visit,
such as a psychiatric diagnostic evaluation, psychotherapy,
or pharmacologic management.
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WHAT IS G0470?
 G0470 – FQHC visit, mental health, established patient
• A medically-necessary, face-to-face (one-on-one) mental
health encounter between an established patient and a
qualified FQHC practitioner during which time one or more
FQHC services are rendered and includes a typical bundle of
services that would be furnished per diem to a Medicare
beneficiary receiving a mental health visit. An established
patient is one who has received any professional medical or
mental health services from any sites within the FQHC
organization within three years prior to the date of service.
• The encounter must include a qualified mental health visit,
such as a psychiatric diagnostic evaluation, psychotherapy, or
pharmacologic management.
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G-CODES, CONT.
 FQHC payment codes G0466, G0467 & G0468 must be
reported with revenue code 052X or 0519
 FQHC payment codes G0469 & G0470 must be reported
with revenue code 0900 or 0519
 Each FQHC payment code (G0466 – G0470) must have a
corresponding service line with a HCPCS code that
describes the qualifying visit
• Complete listing of the qualifying visit codes located at CMS
FQHC PPS website: http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/FQHCPPS/index.html
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HCPCS LISTING
 HCPCS associated with G codes are defined
 Example: (not all-inclusive)
• HCPCS Qualifying Visits for G0467 Conditions
o 92012
o 92014
o 97802
o 97803
o 99211
o 99212
o 99213
o 99214
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Eye exam establish patient
Eye exam & tx est pt
Medical nutrition indiv in
Med nutrition indiv subseq
Office/outpatient visit est
Office/outpatient visit est
Office/outpatient visit est
Office/outpatient visit est
o 99215 Office/outpatient visit est
o 99304 Nursing facility care init
o 99305 Nursing facility care init
o 99306 Nursing facility care init
o 99307 Nursing fac care subseq
o 99308 Nursing fac care subseq
o 99309 Nursing fac care subseq
FQHC ENCOUNTER
 Claim must include:
• Medical
 Transitional Care Management (TCM)
 Evaluation and Management (E&M)
 DSMT, MNT, IPPE or AWV
• Mental Health
 Psychiatric diagnostic testing
 Psychotherapy
 Pharmacologic management
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QUALIFYING VISITS
 Each payment code must be submitted with a qualifying
visit on a separate line
 When furnishing an IPPE or AWV, include all medical
services
• Only bill G0466 or G0467 on the same day, when there is a
subsequent illness or injury
• Submit with modifier 59
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G CODE SUBMISSION FAQ
 Q1. Does the FQHC G code have to be the first line on
the claim?
 A1. No. The Medicare claims processing system will sort
the lines as long as there is both a FQHC G code and a
qualifying visit code.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
SUPPLEMENTAL PAYMENTS
 Billing for supplemental payments under contract with
Medicare Advantage (MA) plans:
• FQHCs are entitled to payments to cover difference between
payment received for MA enrollee & PPS payment rate
• Must establish a rate with fiscal intermediary (FI) or MAC
 Contact Provider Audit & Reimbursement department
• Submit claims with revenue code 0519
 Effective for FQHCs with cost reporting years beginning on or after
October 1, 2014, all supplemental FQHC claims are required to
report detailed lines using a G-code (s) & a qualifying visit
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SUPPLEMENTAL PAYMENTS, CONT.
 Wraparound payment is based on PPS rate without
comparison to provider’s charge
 Rate is not adjusted for coinsurance or preventive
services
 When MA contract rate is lower than PPS rate, a
supplemental payment will be made
 When MA contract rate is higher than applicable PPS
rate the FQHC does not qualify for a supplemental
payment
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VENIPUNCTURE
 Routine venipuncture (CPT code 36415) is included in
the FQHC PPS encounter rate
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FLU AND PNEUMOCOCCAL VACCINES
 If influenza and pneumococcal vaccines
were the only services provided, there is
no claim & these services are reported
only on the cost report
 If they were provided as part of an encounter, they
should be reported on both the claim & the cost
report
 Continue to be reimbursed at 100% of reasonable
costs through the cost report
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Considerations for G Code
Charge Establishment
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REVIEW FEE ESTABLISHMENT METHODOLOGY
 Establishment of charges for HCPCS G codes will require
thought & analysis
• Final rule indicates that a charge for a specific payment code
would reflect the sum of regular rates charged to both
beneficiaries (Medicare) & other paying patients for a typical
bundle of services that would be furnished per diem to a
Medicare beneficiary
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FEE ESTABLISHMENT METHODOLOGY
 Establishment of charges for HCPCS G codes will require
thought and analysis
• Final rule includes references to charge setting requirements in
section 330(k)(3)(G) of the Public Health Services Act and HRSA
guidance
 Related to the costs of operation
 Consideration of locally prevailing rates
 See also Section V (Fee Schedule)
of PIN 2014-02 dated
September 22, 2014
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G CODE CHARGES FAQS
 Q1. How do I set my FQHC G codes?
 A1. The first step is to determine the typical bundle of
services that your FQHC furnishes to Medicare patients
during an encounter. Once you have determined the
services to be included, total you normal charges for
those services.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G CODE CHARGES FAQS, CONT.
 Q2. Can I change my FQHC G codes for each patient?
 A2. You can change your FQHC G codes whenever you
change your charges for the services included in your
bundle, but the charges have to be uniform for all
patients.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G CODE CHARGES FAQS, CONT.
 Q3. Does the FQHC G code have to equal the charges
on the claim?
 A3. No. It is possible that the charges would equal the
FQHC G code, but the FQHC G code reflects the typical
bundle of services furnished to your Medicare patients,
which may be different than the services furnished to
the patient on that particular day.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G CODE CHARGES FAQS, CONT.
 Q4. Do we have to submit the list of services included
in our FQHC G codes?
 A4. No. All services furnished to the patient must be
listed on the claim, but the bundle of services that
comprises your FQHC G code should be maintained in
your records and made available if requested.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G CODE CHARGES FAQS, CONT.
 Q5. Is there a penalty if my FQHC G code is higher than
my PPS rate?
 A5. No. Your payment will be the lesser of your PPS rate
or FQHC G code.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
G CODE CHARGES FAQS, CONT.
 Q6. Do I need to use the FQHC G codes for nonMedicare patients?
 A6. Other payers will determine what information is
required for their payment systems.
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Source: http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf
DISCUSSION POINTS FOR G CODE CHARGE
CONSIDERATION
 How does the Health Center define its “typical
bundle” of services per G code?
 What is the average charge for Medicare beneficiaries
for each individual G code?
 Does the Health Center’s existing fee structure
comply with HRSA expectations?
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DISCUSSION POINTS FOR G CODE CHARGE
CONSIDERATION, CONT.
 What methodology will the Health Center implement
for G code charge establishment?
• Encounter based
• RVU
• Procedural
 Can this methodology be documented and
supported?
 Does the Health Center’s existing fee structure
support G code charge?
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Medicare PPS Transition Checklist
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