Federally Qualified Health Center Billing and Coverage

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1 Federally Qualified Health Center Billing and Coverage May 1, 2014

2 Today s Presenter Mimi Vier, CPC Provider Outreach and Education Consultant 2

3 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at 3

4 Agenda FQHC Encounters Covered services FQHC Basic Billing Requirements Examples References and Resources Questions 4

5 Objectives Provide basic billing and coverage instructions for FQHC providers 5

6 FQHC Encounters Visit or billable encounter defined as: face-to-face encounter in outpatient setting between patient and FQHC core practitioner Encounter between CP or CSW and family member only is not billable Encounters with more than one health professional and multiple encounters with same health professional, which takes place on same day and location are billed as one unit 6

7 FQHC Encounters Face-to-face encounters between patient and: Physician PA NP CNM CP or CSW FQHC covered service is rendered 7

8 8 Preventive Services

9 Preventive Services Examples of preventive services: Cardiovascular screening blood test Diabetes screening test Screening mammography Screening pap smears Screening pelvic exam (can include clinical breast exam) Prostate cancer screening Colorectal cancer screening tests 9

10 Initial Physical Preventive Exam Beneficiary has no later than 12 months from effective Part B coverage for exam Copayment and Deductible not applied Services include: Patient history (height, weight, and blood pressure at a minimum) Visual acuity screen Measurement of body mass 10

11 IPPE Other factors deemed appropriate based on the individual s medical and social history and current clinical standards End of life planning Screening electrocardiogram (as needed) Patient counseling after results are received Wellness visit/ippe is billable in the same day when all Medicare requirements are met Performed by a physician (doctor of medicine, or osteopathy), or a qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist) 11

12 IPPE HCPCS Codes Physical examination component Revenue code 0521 HCPCS code G0402 Coinsurance is waived A sick visit is billable on the same day as the IPPE when it is medically necessary 12

13 IPPE and EKG EKG FQHCs are instructed to bill the technical component of the EKG to the carrier when applicable CMS-1500 claim form or 837P Use practitioner s NPI As noted in the CMS IOM Publication , Chapter 9, Section 150, the professional component is included in the all-inclusive rate for FQHCs 13

14 Annual Wellness Visit Personalized prevention plan or wellness visit provided prior to or as part of a visit with physician Includes but is not limited to health risk assessment, and may contain: Establishment or updated individual medical and family history List of current providers and suppliers that are regularly involved in providing medical care (list prescribed drugs) Measurement of height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements Detection of cognitive impairment 14

15 Annual Wellness Visit Provided on an annual basis Separate payment is not made to FQHCs when wellness/sick visit is provided on the same Copayment and Deductible not applied MLN Matters Number: MM

16 Annual Wellness Visit HCPCS Codes G0438: Annual wellness visit, includes PPPS, first visit (annual wellness first) G0439: Annual wellness visit, includes PPPS, subsequent visit (subsequent) Revenue code from 052X series Will not be paid on same day as an IPPE CMS IOM Publication , Medicare Claims Processing Manual, Chapter 9, Section

17 DSMT and MNT Registered dietitians or nutritional professionals that provide DSMT and MNT - billable as an encounter CMS will recognize registered nurses as professionals that can provide DSMT if they are properly certified 17

18 DSMT and MNT Cannot be billed for payment when provided in a group setting Group services do not meet the criteria for a face-to-face encounter Cost of group sessions is included in the all-inclusive rate for an FQHC Bill either DSMT or MNT in a day Claims will be returned if both services are billed to Medicare 18

19 DSMT Bill DSMT service when it is a face-to-face encounter Payment is made in addition to a qualifying medical visit on the same day 19

20 MNT Bill MNT service when it is a face-to-face encounter Payment is made in addition to a qualifying medical visit on the same day 20

21 DSMT and MNT Billing DSMT bill: Revenue code 052X HCPCS G0108 MNT bill: Revenue code 052X HCPCS codes 97802, 97803, or G0270 Use a revenue code 052X series for reimbursement on the claim 21

22 Vaccines FQHC requirement for vaccines Pneumococcal, influenza, and hepatitis B and the administration of these drugs are billed on the UB- 04/Electronic equivalent with appropriate HCPCS code/revenue code Use condition code A6 on claims with vaccines identified in reason code narrative Do not include cost with services on line with revenue codes in 52X series Include the appropriate diagnosis code(s) 22

23 Vaccines Hepatitis B is paid as part of the visit It should not be included in the 521 revenue line (no coinsurance applies) FQHCs continue to report the Influenza and pneumococcal vaccines and their administration on the cost report CMS IOM Publication , Medicare Claims Processing Manual, Chapter 18, Section

24 FQHC Billing Example with Flu vaccine Note: FISS looks for condition code A6 when certain HCPCS codes are used for vaccines. HCPCS code Q2035 is one of the HCPCS codes TOT COV SERV CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE E&M=$ J Q2035 vaccine not in 521rev G0008 Admin not in 521 rev

25 25 Transitional Care Management (TCM)

26 Transitional Care Management Services Furnished within 30 days of discharge from hospital, SNF, CMHC Communication (direct, telephone, or electronic) must occur within 2 days of discharge Face to face visit must occur within 14 days of discharge for moderate complexity decision making (CPT code 99495) or within 7 days of discharge for high complexity decision making (CPT code 99496) 26

27 Transitional Care Management Services Subject to applicable deductible and copayments TCM visit is billed on the day the TCM takes place Only 1 TCM visit may be paid during the 30 day postdischarge period If the TCM visit occurs on the same day as another billable visit, only 1 visit may be billed 27

28 28 FQHC Services Outside the FQHC Facility

29 FQHC and Hospital Services Inpatient and outpatient services at a hospital are not payable to FQHCs When agreement exists that specifically doesn t compensate a practitioner for hospital services, payment may be sought under Part B carrier 29

30 FQHC Services for SNF Outpatients or Inpatients Patient in Part A stay may bill for FQHC services to MAC Patient lives at SNF Not receiving care from SNF, but living in designated livingassist area, FQHC practitioner can bill the MAC for FQHC services 30

31 FQHC and Hospice FQHC may not bill for any services related to a hospice patient s terminal illness Hospice patients may elect to have FQHC physicians or NPs serve as their attending practitioner during times when they are not working for the FQHC In this scenario, practitioners will bill Part B claims to carrier directly FQHC may bill and be reimbursed for services not related to patient s terminal illness Append CC 07 to claim 31

32 32 Non-FQHC Services

33 Services Provided by Clinics that are Not FQHC Services Leg, arm, back, and neck braces Artificial legs, arms, and eyes, including replacements if required, due to change in physical condition 33

34 Services Provided by Clinics that are Not FQHC Services Technical component of specific preventive services are not FQHC services for example: Prostate cancer screening Colorectal cancer screening tests Screening mammography Bone mass measurements Screening pap smears and screening pelvic exams CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 13 Section

35 Laboratory Services Independent FQHCs bill laboratory services to Part B carrier for reimbursement when applicable Provider-based FQHCs bill laboratory services to MAC through the host provider s bill type and provider number CLIA waiver to bill the carrier for all laboratory services 35

36 Laboratory Services Cost of space, equipment, supplies, facility overhead and personnel adjusted out of the FQHC cost report Venipuncture is included in the all-inclusive rate CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 13, Section 60.1; CMS IOM Publication , Medicare Claims Processing Manual, Chapter 9, Section

37 37 FQHC Basic Billing

38 Deductible and Coinsurance No Part B deductible is applied to FQHC services Coinsurance is 20% of FQHC charges FQHC can waive collection of all or part of coinsurance 38

39 Bill Type Bill type for FQHC is 77X 771 = Original claim admit through discharge (same day) 777 = Replacement of original claim 778 = Cancel/Void prior claim 39

40 FQHC Revenue Codes 0900 = Psychological services Services provided by psychologist and CSW for treatment of mental illness of patient 0519 = FQHC supplemental payment 0521 = Clinic visit by member to FQHC 0522 = Home visit by FQHC practitioner 0524 = Visit by FQHC practitioner to member in covered Part A stay at SNF 40

41 FQHC Revenue Codes 0525 = Visit by FQHC practitioner to member in SNF (no Part A stay) or NF or ICF or other residential facility 0527 = FQHC visiting nurse service(s) to member s home when in home health shortage area 0528 = Visit by FQHC practitioner to other non-fqhc site (e.g., scene of accident) 41

42 Billing Requirements FQHCs are to include all covered FQHC services provided in a visit on the claim This means that for each service provided and a CPT or HCPCS code is available, include it with appropriate revenue code Submit separate service lines with revenue codes and HCPCS codes to reflect any cost associated with all FQHC covered services but not reflected on the service line for the billable visit 42

43 Billing Requirements Claims processing Claims without HCPCS/CPT codes will be returned to the provider FISS accepts all valid revenue code lines for detailed coding requirements Except 002X 024X, 029x, 045X, 054x, 056X, 060X, 065X, 067X 072X, 080X 088X, 093X, or 096X-310X 43

44 Multiple Encounters Rule Encounters with more than one health professional and multiple encounters with the same health professionals which take place on the same day and at a single location constitute a single visit, except when one of the following conditions exist After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment Bill both encounters on same claim 44

45 Multiple Encounters The patient has a medical visit and a clinical psychologist or CSW visit on the same day Bill on separate claims The patient has a medical visit and a telehealth visit on the same day DSMT encounter and medical visit on the same day MNT encounter and medical visit on the same day 45

46 Billing Requirements Claims processing Providers should submit two visits on the same day on one claim Visits must be independent and distinct from each other Use modifier 59 on claims submitted with two clinic visits Modifier 59 is defined as a condition being treated as totally unrelated and services are provided at separate times of the day 46

47 FQHC Billing Example TOT COV CL REV HCPC MODIFS SERV RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE E&M=$ E&M=$

48 FQHC Billing Example TOT COV CL REV HCPC MODIFS SERV RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE E&M=$ J

49 FQHC Billing Example TOT COV CL REV HCPC MODIFS SERV RATE UNIT UNIT TOT CHARGE NCOV CHARGE DATE $ for J

50 50 Resources

51 Resources CMS IOM Publication , Medicare Benefit Policy Manual, Chapter 13 CMS IOM Publication , Medicare Claims Processing Manual, Chapter 9 CMS IOM Publication , Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services CMS IOM Publication , State Operations Manual, Chapter 6, Special Procedures for Laboratories (CLIA Waiver) 51

52 Resources National Uniform Billing Committee Web site: NUBC Official UB-04 Data Specifications Manual Annual fee Providers also receive updates throughout the year U.S. Preventive Services Task Force (USPSTF) Web site: Provides Grade A and B preventive services 52

53 Resources Current Procedural Terminology CPT Standard Edition Published by the American Medical Association FISS/DDE providers have revenue codes and HCPCS codes files available 53

54 Resources FQHC Homepage, resources, tools and materials Outpatient mental health limitation guide FQHC EOB secondary payer job aid FQHCs and group therapy services job aid FQHCs and multiple line item dates of service job aid FQHC Behavioral Health Claims Job Aid Seasonal Influenza virus vaccine reimbursement job aid 54

55 Resources FQHC fact sheet: Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/fqhcfactsheet.pdf Transitional Care Management Services: Learning-Network-MLN/MLNProducts/Downloads/Transitional- Care-Management-Services-Fact-Sheet-ICN pdf Provider Type Federally Qualified Health Center 55

56 56 Questions & Answers

57 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic = <Insert course name/delete arrows> Medicare University Credits (MUCs) = # Catalog Number = <Insert catalog number> Course Code = <Enter course code> For step-by-step instructions on self-reporting please visit > Medicare University > Accessing the Self-Reporting Tool 57

58 58 Thank You!

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