Medicare FQHC PPS

Medicare FQHC PPS
May 2014
Susan Dahl, MHA, RHIA, CHC, CHPS
Changes Medicare FQHC PPS
• Published in Federal Register 5/2/14
• Establish national encounter rate
• Move all FQHC’s to new PPS system
– Cost reporting periods beginning 10/1/14
– All moved by 1/1/16
Billing under new system
• Require HCPCS codes and facility charges
• CMS to establish new G codes for preventive
visits, annual wellness exams, IPPE, and new
• Eliminate separate payment for DSMT/MNT and
IPPE visits (will be billed as visit)
• Allow payment for
– Medical and mental health visit on same day
– Return visit for illness/injury occurring after visit
– Preventive physical exam and other medical visit or
other mental health visit on same day
PPS Rate
• Will be adjusted annually,
– calendar year for all Medicare FQHC’s
• $158.85 before adjustments (10/1/14)
– GAF (geographic adjustment)
– Adjustment for IPPE, New Patient, and Annual
Wellness visit (1.3416)
– Example for IPPE: Rate = $158.85 x GAF X 1.3416
• Technical components not included,
– billed separately: X-ray, lab, DME
• Lesser of Actual Charges or PPS Rate
– Paid at 100% for preventive services
– 80% for other services
• Reimbursed Separately, through cost report:
– Reasonable costs of influenza & pneumococcal
vaccines and their administration, allowable graduate
medical education costs and bad debts
• Wrap around from MAC for difference between
Medicare Advantage plan and what FQHC would
otherwise be entitled to

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