Categorized | Featured, Other Providers


Important Medicare Changes for FQHCs

The Patient Protection and Affordable Care Act (PPACA) clearly states the current Medicare payment system for Federally Qualified Health Centers (FQHCs) will change to a new Prospective Payment System (PPS) in 2014. Beginning January 1, 2011, claim submission requirements for FQHC services changed based on PPACA mandates.

When billing Medicare services dated on or after January 1, 2011, FQHCs must report all pertinent services provided and list the appropriate Healthcare Common Procedure Coding System (HCPCS) code for each line item, along with revenue codes for each FQHC visit. If service lines do not contain valid HCPCS codes, the claim will be returned to the provider, except for those revenue codes that do not permit HCPCS code reporting. When claims service lines contain a valid HCPCS code but not a revenue code, the claim will be returned to the provider. Until the FQHC PPS is implemented in 2014, the Medicare claims processing system will continue to make payments under the current FQHC interim per-visit payment rate system.

Please note that the updates provided in Change Request 7038 (CR7038) and detailed in Medicare Learning Network’s MLN Matters article MM7038 do not affect claims for supplemental payments to FQHCs under contract with Medicare Advantage Plans. In addition, preventive services covered by Medicare for beneficiaries were expanded effective January 1, 2011.

For FQHCs to respond to these changes, extra effort may be required for organizations to update or modify practice management systems or claims submission processes. In addition, expanded billing and coding training for clinicians and billing staff may be necessary to address changes that could affect your organization’s ability to receive appropriate reimbursement.

Additional details of CR7038 can be found in the attached MLN Matters article and with information provided by your respective fiscal intermediary or Medicare Administrative Contractor.

If you need additional assistance, please contact your BKD advisor or click on one of the photos below to email one of our community health center professionals.

Mike Schnake
Jeff Allen
Managing Consultant
Rebekah Wallace

This post was written by:

Rebekah, a member of BKD National Health Care Group, has more than 15 years of coding, revenue cycle management and operations experience. A managing consultant in the Springfield, Missouri, office, she provides medical reimbursement consulting and operational reviews for physician clinics, federally qualified health centers, rural health clinics and behavioral health centers.

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Recent Comment

  • Karen Vance says:
    This would be under §484.18 of the Conditions of Participation describing regulations for the Plan of Care. Below is the Standard that addresses your issue: "§484.18(b) - Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care." From the State Operations Manual (guidance for state surveyors) "The
    February 24, 2011 on Webinars

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