1. experience momentum // CPAs & ADVISORS TEXAS ASSOCIATION OF COMMUNITY HEALTH CENTERS October 7, 2014 THE IMPACT OF THE MEDICARE PROSPECTIVE PAYMENT SYSTEM (PPS) ON THE BILLING PROCESS

2. 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 2 //

3. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 3 //

4. 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. 4 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

5. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 5 //

6. 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. 6 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

7. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 7 //

8. 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. 8 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

9. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 9 //

10. 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. 10 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

11. 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 11 //

12. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 12 //

13. 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. 13 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

14. 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 14 14 //

15. 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. 15 //

16. 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. 16 //

17. 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. 17 //

18. 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. 18 //

19. 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. 19 //

20. 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/Medicare- Fee-for-Service-Payment/FQHCPPS/index.htmlhttp://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/FQHCPPS/index.html 20 //

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22. HCPCS LISTING  HCPCS associated with G codes are defined  Example: (not all-inclusive) HCPCS Qualifying Visits for G0467 Conditions 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 o 92012 Eye exam establish patient o 92014 Eye exam & tx est pt o 97802 Medical nutrition indiv in o 97803 Med nutrition indiv subseq o 99211 Office/outpatient visit est o 99212 Office/outpatient visit est o 99213 Office/outpatient visit est o 99214 Office/outpatient visit est 22 //

23. 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 23 //

24. 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 24 //

25. 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. Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf 25 //

26. 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 26 //

27. 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 27 //

28. VENIPUNCTURE  Routine venipuncture (CPT code 36415) is included in the FQHC PPS encounter rate 28 //

29. 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 29 //

30. Considerations for G Code Charge Establishment 30 //

31. 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 31 //

32. 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 32 //

33. 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. 33 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

34. 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. 34 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

35. 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. 35 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

36. 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. 36 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

37.  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. 37 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf G CODE CHARGES FAQS, CONT.

38.  Q6. Do I need to use the FQHC G codes for non- Medicare patients?  A6. Other payers will determine what information is required for their payment systems. 38 // Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

40. 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? 40 //

41. 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? 41 //

42. Medicare PPS Transition Checklist 42 //

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