Tag: FQHC/RHC

From: CMS MLN Articles – MM9442 – 12/31/15

Background:

New Information Includes:

• Section 30.1 states that a RHC can count the time of a nurse practitioner (NP), physician assistant (PA), or certified nurse midwife (CNM) when furnishing direct patient care in a patient’s home or another location towards the requirement that an NP, PA, or CNM be available to furnish care at least 50 percent of the time the RHC is open to provide patient care.
• Section 110.5 states that payment for chronic care management (CCM) services is authorized for RHCs and FQHCs beginning on January 1, 2016, and provides an overview of the requirements.
• Sections 220.1 and 220.3 state that lung cancer screening using low-dose computed tomography is a covered preventive service and can be billed as a stand-alone visit if it is the only service furnished on that day with a RHC or FQHC practitioner, and applicable coinsurance and deductibles are waived.

Clarifying Information Includes:

• Use of Modifier 59 (Section 40.3)
• Payment for procedures (Section 40.4)
• Description of ambulance services that are non-covered (Section 60.1)
• Description of group services that are non-covered (Section 60.1)
• Information on payment codes for FQHCs (Section 70.4)
• Cost reporting requirements (Section 80.1 and 80.2)
• Billable visits by dentists, podiatrist, optometrists, and chiropractors (Section 110.1)
• Description of mental health visits, billing for mental health visits, and payment for medication management (Section 170)
• Hepatitis C screening in RHCs and FQHCs (Sections 220.1 and 220.2).

RHC/FQHC Medicare Benefit Policy Manual Update – Chapter 13

From: CMS Transmittal 1576 – 11/18/15

General Information Excerpt

A.  Background: 

This Change request (CR) provides instructions to the Medicare Administrative Contractors (MACs) for payment to RHCs billing under the all-inclusive rate (AIR) and FQHCs billing under the prospective payment system (PPS) for CCM services for dates of service on or after January 1, 2016.

In Calendar Year (CY) 2015, the Centers for Medicare & Medicaid Services (CMS) began making separate payment under the Medicare Physician Fee Schedule (PFS) for CCM services under current procedural terminology (CPT) code 99490. CCM services are non-face-to-face care management and coordination services for Medicare beneficiaries having multiple (two or more) chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS finalized aspects of the payment methodology, scope of services, and requirements for billing and supervision for practitioners permitted to bill Medicare under the PFS in the CY 2014 PFS final rule (78 74414 through 74427) and made further refinements in the CY 2015 final rule (79 67715 through 67730).

As authorized by §1861(aa) of the Social Security Act, RHCs and FQHCs are paid for physician services and services and supplies incident to physician services. CCM services are RHC and FQHC services but payment for the additional costs associated with such services are not included in the RHC AIR or the FQHC PPS rate. In the CY 2016 PFS proposed rule (80 FR 41793), CMS proposed requirements and a payment methodology for CCM services furnished by RHCs and FQHCs. In the CY 2016 PFS final (80 FR 71080), CMS finalized the requirements and payment methodology for CCM services furnished by RHCs and FQHCs.

B.  Policy:

Effective January 1, 2016, RHCs and FQHCs shall be paid for CCM services furnished to patients with multiple chronic conditions that are expected to survive at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Payment shall be based on the PFS national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim. CCM payment to RHCs and FQHCs would be based on the PFS amount, but would be paid as part of the RHC and FQHC benefit, using the CPT code to identify that the requirements for payment are met and a separate payment should be made. The RHC and FQHC face-to-face requirements are waived when CCM services are furnished to a RHC or FQHC patient. Coinsurance would be applied as applicable to FQHC claims, and coinsurance and deductibles would apply as applicable to RHC claims. RHCs and FQHCs would continue to be required to meet the RHC and FQHC Conditions of Participation and any additional RHC or FQHC payment requirements.

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From: MLN Connects Provider eNews – 5/28/15

As a result of the recent passing of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, Medicare Administrative Contractors (MACs) will be mass adjusting all Federally Qualified Health Center (FQHC) claims billed under the Prospective Payment System (PPS) with dates of service on or after April 1, 2015, through May 3, 2015.

Mass Adjustment of FQHC PPS Claims