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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

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final rule medicare fqhc pps

FINAL RULE – Medicare FQHC PPS

May 2014

Susan Dahl, MHA, RHIA, CHC, CHPS

changes medicare fqhc pps
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
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
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
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
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