Federally Qualified Health Centers (FQHC) Center
Spotlights
- Section 1861(aa)(1)(C) of the Social Security Act authorizes FQHCs located in areas with a shortage of home health agencies to furnish part-time or intermittent nursing care and related medical supplies (other than drugs and biologicals) by a Registered Professional Nurse (RN) or Licensed Practical Nurse (LPN) to a homebound individual under a written plan of treatment. The current evaluation and management codes for home health visits are not billable by RNs or LPNs furnishing FQHC home health visits. Beginning with dates of service on or after October 1, 2016, FQHCs should bill HCPCS code G0490 for these visits. HCPCS code G0490 will be paid as a visit when reported on a FQHC claim with revenue code 052X and HCPCS code G0466 or G0467.
- 2016 Update - Medicare Benefit Policy Manual, Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 258KB]
- Chronic Care Management (CCM) Services for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) MLN Matters Article and FAQs.
- Effective January 1, 2016, Advanced Care Planning (ACP) (CPT code 99497) is a stand-alone billable visit in a FQHC.
- FQHC PPS Specific Payment Codes - See FQHC PPS Specific Payment Codes - Opens in a new window
- FQHC PPS Geographic Adjustment Factors (GAFs) for Services Furnished 1/01/2017 – 12/31/2017
See CY 2017 FQHC GAFs [ZIP, 14KB] - FQHC Preventive Services [PDF, 450KB] - (Updated on 08/10/2016)
- Effective January 1, 2016, a clinic that is operated by a tribe or tribal organization under the Indian Self-Determination Education and Assistance Act, and was billing as if it were provider-based to an IHS hospital on or before April 7, 2000, and is no longer operating as a provider-based department of an IHS hospital, may be certified as a grandfathered tribal FQHC. See MM9267 [PDF, 50KB] and the Grandfathered Tribal FQHCs page.
- Questions on the FQHC PPS? Email FQHC-PPS@cms.hhs.gov
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Important Links
Payment Policy/Billing
- CY 2017 Payment Rate Update to the FQHC PPS. See MM9831 [PDF, 56KB]
- Medicare Benefit Policy Internet Only Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services [PDF, 258KB]
- FQHC Preventive Services [PDF, 450KB] – Information on preventive services in FQHCs including HCPCS coding, same day billing, and waivers of co-insurance.
- FQHC PPS Specific Payment Codes [PDF, 336KB] (Updated 12/21/2016)
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Billing Guide ( SE1039 [PDF, 92KB] )
- Medicare Claims Processing Manual: Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers [PDF, 241KB]
- Chapter 29-(T12) -- Independent Rural Health Clinic and Freestanding Federally Qualified Health Center cost Report Form CMS 222-92 (Instructions) [ZIP, 358KB]
- MLN Matters® Article SE1606 – Guidance on the Physician Quality Reporting System (PQRS) 2014 Reporting Year and 2016 Payment Adjustment for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs)
Policy/Regulations
- 2016 Physician Fee Schedule Final Rule with Comment
Information on CCM, ACP, and Grandfathered Tribal FQHCs. See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
- 2015 Physician Fee Schedule Final Rule with Comment
Final policies on specific aspects of the FQHC PPS. The CY 2015 PFS Final Rule is available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
- FQHC PPS Final Rule with Comment Period
Final methodology and payment rates for the new FQHC PPS. CMS-1443-F (PDF Version) - Opens in a new window
- FQHC PPS Proposed Rule
The FQHC PPS proposed rule with comment period was published in the Federal Register on September 23, 2013. This rule proposed a methodology and payment rates for the new FQHC PPS. CMS-1443-P (PDF Version) - Opens in a new window and CMS-1443-P (Text Version) - Opens in a new window
- Supporting Files Available for the Final Rule with Comment Period
FQHC Summary Data (CMS-1443-F) [ZIP, 577KB] : This file contains data summarized by the CMS Certification Number (CCN) assigned to the FQHC. The data can be used to model the final methodology and calculate projected payments and impacts under the final FQHC PPS.
- Supporting Files Available for the Proposed Rule
FQHC Summary Data (CMS-1443-P) [ZIP, 549KB] : This file contains data summarized by the CMS Certification Number (CCN) assigned to the FQHC. The data can be used to model the proposed methodology and calculate projected payments and impacts under the proposed PPS.
- PPS Structure Design Document
PPS Structure Design Document [PDF, 1MB] : A report prepared by Arbor Research Collaborative for Health that describes analyses performed and options modeled to support the development and implementation of the PPS.
- Change Request 8743
R1383OTN : Implementation of a Prospective Payment System for FQHCs
FQHC PPS Geographic Adjustment Factors (GAFs)
FQHC PPS Training and Information
- June 25, 2014, National Provider Call - Operational requirements for the new Medicare PPS for FQHCs. See http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-06-25-FQHC-NPC.html.
- May 21, 2014, National Provider Call- Final policies for the new Medicare PPS for FQHCs. See http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-05-21-FQHC.html.
- November 4, 2013 - Special Open Door Forum - Medicare Prospective Payment System for Federally Qualified Health Centers. See http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html.
- Medicare FQHC PPS Frequently Asked Questions (FAQs) - See FQHC PPS FAQs [PDF, 460KB] .
Enrollment/Certification
- Medicare Provider-Supplier Enrollment
- Enrollment Applications
- Conditions for Coverage (CfCs) & Conditions of Participations (CoPs)
- CfC and CoP: Rural Health Clinic/Federally Qualified Health Center
- Survey & Certification - General Information
- National Provider Identifier Standard (NPI)
Legislation
- Section 10501 of the Patient Protection and Affordable Care Act of 2010, as consolidated and amended through May 10, 2010.
CMS Manuals & Transmittals
Additional CMS Information
How to Stay Informed
- Weekly MLN Connects Provider eNews for the latest Fee-For-Service program information, event announcements, claims and pricer information, and MLN educational product updates
- MLN Homepage
- MLN Publications & Multimedia
- Quarterly Provider Updates
- Open Door Forums
- Press Releases - Opens in a new window
