CMS Pub. 100-04, ch. 9, § 50

See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 13 for coverage requirements

for RHCs and FQHCs. This section addresses requirements for claim submission only.

Section §1862 (a)(22) of the Act requires that all claims for Medicare payment must be

submitted in an electronic form specified by the Secretary of Health and Human Services,

unless an exception described at §1862 (h) applies. The electronic format required for

billing RHC and FQHC services is the ASC X12 837 institutional claim transaction.

Instructions relative to the data element names on the Form CMS-1450 hardcopy form

are described below. Each data element name is shown in bold type. Information

regarding the form locator numbers that correspond to these data element names is found

in Chapter 25.

Not all data elements are required or utilized by all payers. Detailed information is given

only for items required for Medicare RHC and FQHC claims. Only the items listed

below are required for RHCs and FQHCs.

Provider Name, Address, and Telephone Number, Form Locator

The RHC/FQHC enters this information for their agency.

Type of Bill

This four-digit alphanumeric code gives three specific pieces of information. The first

digit is a leading zero. CMS ignores the first digit. The second digit identifies the type

of facility. The third classifies the type of care. The fourth indicates the sequence of this

bill in this particular benefit period. It is referred to as a “frequency” code.

Code Structure

1st Digit – Leading Zero

CMS ignores the first digit

2nd Digit - Type of Facility

7 - Special facility (Clinic)

3rd Digit - Classification (Special Facility Only)

1 – Rural Health Clinic

7 – Federally Qualified Health Centers

4th Digit – Frequency Definition

0 - Nonpayment/Zero Claims Used when no payment from Medicare is

anticipated.

l - Admit Through Discharge Claim This code is used for a billing for a confined

treatment.

7 - Replacement of Prior Claim This code is used by the provider when it

wants to correct a previously submitted bill.

This is the code used on the corrected or

“new” bill.

For additional information on replacement

bills see Chapter 3.

8 - Void/Cancel of a Prior Claim This code is used to cancel a previously

processed claim.

For additional information on void/cancel

bills see Chapter 3.

Statement Covers Period (From-Through)

The RHC/FQHC shows the beginning and ending dates of the period covered by this bill

in numeric fields (MM-DD-YY).

Patient Name/Identifier

The RHC/FQHC enters the beneficiary’s name exactly as it appears on the Medicare

card.

Patient Address

The RHC/FQHC enters the mailing address of the patient. Enter the complete mailing

address.

Patient Birth date

The RHC/FQHC enters the date of birth of the patient.

Patient Sex

The RHC/FQHC enters the sex of the patient as recorded at the start of care.

Priority (Type) of Admission or Visit

The RHC/FQHC enters the most appropriate NUBC approved code indicating the

priority of the visit.

Point of Origin for Admission or Visit

The RHC/FQHC enters the most appropriate NUBC approved code indicating the point

of origin for this admission or visit.

Patient Discharge Status

The RHC/FQHC enters the most appropriate NUBC approved code indicating the

patient’s status as of the “Through” date of the billing period.

Condition Codes

The RHC/FQHC enters any appropriate NUBC approved code(s) identifying conditions

related to this bill that may affect processing.

Value Codes and Amounts

The RHC/FQHC enters any appropriate NUBC approved code(s) and the associated

value amounts identifying numeric information related to this bill that may affect

processing.

Revenue Codes

The RHC/FQHC assigns a revenue code for each type of service provided and enters the

appropriate four-digit numeric revenue code to explain each charge.

For FQHC claims with dates of service on or after January 1, 2010, FQHCs may report

additional revenue codes when describing services rendered during an encounter.

However, Medicare payment will continue to be reflected only on claim lines with the

revenue codes in the following table:

When billing for additional services rendered during the FQHCs encounter or RHC visit,

a valid revenue code is required with an appropriate HCPCS code. However, the

following revenue codes are not allowed on FQHC or RHC claims:

Rev

Code

Description

0521 Clinic visit by member to RHC/FQHC

0522 Home visit by RHC/FQHC practitioner

0524 Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF

0525 Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A

stay) or NF or ICF MR or other residential facility

0527 RHC/FQHC Visiting Nurse Service(s) to a member’s home when in a home

health shortage area

0528 Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of

accident)

0519 Clinic, Other Clinic (only for the FQHC supplemental payment)

0900 Mental Health Treatment/Services

002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x-088x, 093x, or 096-

310x.

HCPCS/Accommodation Rates/HIPPS Rate Codes

For all services provided in a FQHC on or after January 1, 2010, and for approved

preventive services provided in a RHC, HCPCS codes are required to be reported on the

service lines.

The following HCPCS codes must be reported on FQHC PPS claims:

HCPCS

Code

Definition

G0466 FQHC visit, new patient

A medically necessary, face-to-face encounter (one-on-one) between a new patient

and a FQHC practitioner during which time one or more FQHC services are

rendered and includes a typical bundle of Medicare-covered services that would be

furnished per diem to a patient receiving a FQHC visit.

G0467 FQHC visit, established patient

A medically necessary, face-to-face encounter (one-on-one) between an

established patient and a FQHC practitioner during which time one or more FQHC

services are rendered and includes a typical bundle of Medicare-covered services

that would be furnished per diem to a patient receiving a FQHC visit.

G0468 FQHC visit, IPPE or AWV

A FQHC visit that includes an IPPE or AWV and includes a typical bundle of

Medicare-covered services that would be furnished per diem to a patient receiving

an IPPE or AWV.

G0469 FQHC visit, mental health, new patient

A medically necessary, face-to-face mental health encounter (one-on-one)

between a new patient and a FQHC practitioner during which time one or more

FQHC services are rendered and includes a typical bundle of Medicare-covered

services that would be furnished per diem to a patient receiving a mental health

visit.

G0470 FQHC visit, mental health, established patient

A medically necessary, face-to-face mental health encounter (one-on-one)

between an established patient and a FQHC practitioner during which time one or

more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental

health visit.

Modifiers

The FQHC or RHC reports modifier 59 when billing for a subsequent injury or illness.

This is not to be used when a patient sees more than one practitioner on the same day or

has multiple encounters with the same practitioner on the same day, unless the patient,

subsequent to the first visit, leaves the FQHC or RHC and then suffers an illness or injury

that requires additional diagnosis or treatment on the same day.

Modifier 59 is the FQHC and RHC’s attestation that the patient, after the first visit,

suffers an illness or injury that requires additional diagnosis or treatment on the same

day. Modifier 59 should only be used when reporting unrelated services that occurred at

separate times during the day (e.g., the patient had left the FQHC or RHC and returned

later in the day for an unscheduled visit for a condition that was not present during the

first visit).

For claims subject to the FQHC PPS, modifier 59 is only valid with FQHC Payment

Code G0467. Please see section 60.2 of this manual for more information on the FQHC

Payment Codes.

Modifier CG - RHCs should report modifier CG on one line with a medical and/or mental

health HCPCS code that represents the primary reason for the medically necessary face-to-face visit.

Service Date

Medicare requires a line-item date of service for all outpatient claims. Medicare

classifies RHC/FQHC claims as outpatient claims. Non-payment service revenue codes –

report dates as described in the table above under Revenue Codes.

Line items on outpatient claims under HIPAA require reporting of a line-item service

date for each iteration of revenue code. A single date must be reported on a line item for

the date the service was provided, not a range of dates.

For services that do not qualify as a billable visit, the usual charges for the services are

added to those of the qualified visit. RHCs/FQHCs use the date of the visit as the single

date on the line item. If there is no is billable visit associated with the services, then no

claim is filed.

Service Units

The RHC/FQHC enters the number of units for each type of service. Units represent

visits, which are paid based on the AIR or the FQHC PPS, no matter how many services

are delivered. Only one visit is billed per day unless the patient leaves and later returns

with a different illness or injury suffered later the same day.

Total Charges

The RHC/FQHC enters the total charge for the service described on each revenue code

line.

Payer Name

The RHC/FQHC identifies the appropriate payer(s) for the claim.

National Provider Identifier (NPI) – Billing Provider

The RHC/FQHC enters its own NPI. When more than one encounter/visit is reported on

the same claim i.e., medical and mental health visits, please choose the NPI of the

provider that furnished most of the services.

Principal Diagnosis Code

The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM

Coding Guidelines.

Other Diagnosis Codes

The RHC/FQHC enters diagnosis coding as required by ICD-9-CM or ICD-10-CM

Coding Guidelines.

Attending Provider Name and Identifiers

The RHC/FQHC enters the NPI, and name of the attending physician designated by the

patient as having the most significant role in the determination and delivery of the

patient’s medical care.

Other Provider Name and Identifiers

The RHC/FQHC enters the NPI and name

NOTE: For electronic claims using version 5010 or later, this information is reported in

Loop ID 2310F – Referring Provider Name.

See the link to Publication 100-04, Medicare Claims Processing Manual, Chapter 25 for

additional information on form 1450:

https://www.cms.gov/Regulations-and

Guidance/Guidance/Manuals/downloads/clm104c25.pdf