FQHC PPS payment and billing requirements
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Defines the specific HCPCS/CPT payment codes, qualifying visit definitions, and payment adjustments FQHCs must use when billing under the Federally Qualified Health Center Prospective Payment System (FQHC PPS); applies to providers billing Highmark Delaware for FQHC PPS services.
No material clinical or coverage changes in this revision.
FQHC PPS Coverage and Payment Criteria
FQHC PPS billing and payment criteria
Requirements to qualify for FQHC PPS payment and payment adjustments
Payment adjustments
- Apply the PPS payment rate adjustment factor of 1.3416 when the FQHC furnishes an Initial Preventive Physical Exam (IPPE) or an Annual Wellness Visit (AWV) (use G0468 for IPPE/AWV).
Qualifying visit lists and same-day visit billing rules
Qualifying visits for each payment code; when multiple visits occur on the same day follow the stated same-day billing rules.
Examples of qualifying services (non-exhaustive)
- Office/outpatient visit codes (e.g., 99201-99205 for new; 99212-99215 for established).
- Home visit and domiciliary visit codes (e.g., 99324-99328, 99341-99345 for new; 99334-99350 for established).
- Behavioral health and psychiatric codes (e.g., 90791-90845 series listed as qualifying mental health visits).
- Other qualifying services shown in the policy’s HCPCS qualifying lists for each G0466–G0470 code.
Same-day medical and mental health visit rules
- If both a medical and a mental health visit occur on the same day, apply the following: for a patient who is new to the FQHC for only one of the visits, bill G0466 for the medical new-patient visit and G0470 for the mental health visit as directed; an established patient may have two payable visits on the same day (bill G0467 for medical and G0470 for mental health).
HCPCS/CPT Codes, Effective Dates, and Reporting
Billing Requirements and Provider Guidance
Claim coding requirement for FQHC PPS
FQHC claims submitted for FQHC PPS payment must use the specific HCPCS payment codes established for the FQHC PPS and include detailed HCPCS coding with associated line‑item charges listing the qualifying visit and all other FQHC services furnished during the encounter.
- Use the FQHC PPS HCPCS payment codes specified in the policy when submitting claims.
- Include detailed HCPCS coding and the associated line‑item charges that list the visit that qualifies the encounter and all other FQHC services furnished during the encounter.
Chronic care and behavioral health integration reporting guidance
When chronic care management (CCM), general behavioral health integration (BHI), or psychiatric Collaborative Care Model (CoCM) services are reported as a stand‑alone billable visit, use the listed CPT/HCPCS codes and note that a separate FQHC payment code is not required for those stand‑alone reports; CPT 99490 is paid through 12/31/2017 but service lines with 99490 are denied on/after 1/1/2018 when billed as a service line.
- CPT 99490: paid based on PFS non‑facility rate when billed alone through 12/31/2017; service lines reported with CPT 99490 will be denied for dates of service on or after January 1, 2018.
- HCPCS G0511: effective 1/1/2018 for CCM or general BHI reporting; payment set annually at an average of national non‑facility PFS rates for 99490, 99487, and 99484; a separate FQHC payment code is not required when reported as a stand‑alone visit.
- HCPCS G0512: effective 1/1/2018 for psychiatric CoCM reporting; payment set annually at an average of national non‑facility PFS rates for 99492 and 99493; a separate FQHC payment code is not required when reported as a stand‑alone visit.
Key Definitions for FQHC PPS
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