CMS Pub. 100-02, ch. 13, § 40.3

Except as noted below, encounters with more than one RHC or FQHC practitioner on

the same day, or multiple encounters with the same RHC or FQHC practitioner on the

same day, constitute a single RHC or FQHC visit and is payable as one visit. This

policy applies regardless of the length or complexity of the visit, the number or type of

practitioners seen, whether the second visit is a scheduled or unscheduled

appointment, or whether the first visit is related or unrelated to the subsequent visit.

This would include situations where an RHC or FQHC patient has a medically-necessary face-to-face visit with an RHC or FQHC practitioner, and is then seen by

another RHC or FQHC practitioner, including a specialist, for further evaluation of the

same condition on the same day, or is then seen by another RHC or FQHC

practitioner, including a specialist, for evaluation of a different condition on the same

day.

Exceptions are for the following circumstances only:

• The patient, subsequent to the first visit, suffers an illness or injury that

requires additional diagnosis or treatment on the same day (for example, a

patient sees their practitioner in the morning for a medical condition and

later in the day has a fall and returns to the RHC or FQHC). In this situation

only, the FQHC would use modifier 59 on the claim and the RHC would

use modifier 59 or 25 to attest that the conditions being treated qualify as 2

billable visits;

• The patient has a medical visit and a mental health visit on the same day (2

billable visits);

• For RHCs only, the patient has an initial preventive physical exam (IPPE)

and a separate medical and/or mental health visit on the same day (2 or 3

billable visits); or

• An IOP service and medical visit on the same day.

Note: A mental health visit and IOP service may occur on the same day;

however, if a mental health visit is furnished on the same day as IOP services,

payment will only be made at the IOP rate, and the mental health visit will be

considered packaged.

NOTE: These exceptions do not apply to grandfathered tribal FQHCs.