FINAL RULE – Medicare FQHC PPS

FINAL RULE – Medicare FQHC PPS May 2014 Susan Dahl, MHA, RHIA, CHC, CHPS

Changes Medicare FQHC PPS • Published in Federal Register 5/2/14 • http://www.gpo.gov/fdsys/pkg/FR-2014-05-02/pdf/2014-09908.pdf • 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 patients • 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

Payment • 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

FINAL RULE – Medicare FQHC PPS