CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 2034 Date: August 24, 2010 Change Request 7038 NOTE: This Transmittal is no longer sensitive and is being re-communicated November 16, 2010. The Transmittal Number, date of Transmittal and all other information remain the same. This instruction may now be posted to the Internet. NOTE: Transmittal 2013, dated July 30, 2010 is being rescinded and replaced by Transmittal 2034 dated August 24, 2010 to indicate the new waiver of coinsurance and deductible for Preventive Services as enacted by 4104 of the Affordable Care Act. Business Requirement 7038.11 and the Claims Processing Manual, Pub. 100-04, Chapter 9, sections 120 and 150 have been updated to reflect the above policy changes. All other material remains the same. “This policy is discussed in the CY 2011 physician fee schedule proposed rule published on July 13, 2010 and may change based on analysis of public comments. This advance notice is provided so contractors can begin making the necessary systems changes for the policy to go in effect January 1, 2011.” SUBJECT: Affordable Care Act (ACA) Mandated Collection of Federally Qualified Health Center (FQHC) Data and Updates to Preventive Services Provided by FQHCs I. SUMMARY OF CHANGES: The ACA provides the statutory framework for development and implementation of a prospective payment system (PPS) for Medicare FQHCs in 2014. The ACA grants the Secretary of HHS the authority to require FQHCs to submit such information as may be required in order to develop and implement a PPS for Medicare FQHCs. The ACA mandates the collection of the data begins no later than January 1, 2011. ACA also expands the definition of FQHC preventive services. NOTE: The original section 110.1 is being deleted from Chapter 9. Sections 110.2 and 110.3 have been re-numbered to 110.1 and 110.2. EFFECTIVE DATE: January 1, 2011 IMPLEMENTATION DATE: January 3, 2011 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row.
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CMS Manual System Department of Health & Human Services
(DHHS)
Pub 100-04 Medicare Claims
Processing
Centers for Medicare & Medicaid Services
(CMS)
Transmittal 2034 Date: August 24, 2010
Change Request 7038
NOTE: This Transmittal is no longer sensitive and is being re-communicated November 16, 2010. The
Transmittal Number, date of Transmittal and all other information remain the same. This instruction
may now be posted to the Internet.
NOTE: Transmittal 2013, dated July 30, 2010 is being rescinded and replaced by Transmittal 2034 dated
August 24, 2010 to indicate the new waiver of coinsurance and deductible for Preventive Services as
enacted by 4104 of the Affordable Care Act. Business Requirement 7038.11 and the Claims Processing
Manual, Pub. 100-04, Chapter 9, sections 120 and 150 have been updated to reflect the above policy
changes. All other material remains the same.
“This policy is discussed in the CY 2011 physician fee schedule proposed rule published on July 13, 2010
and may change based on analysis of public comments. This advance notice is provided so contractors can
begin making the necessary systems changes for the policy to go in effect January 1, 2011.”
SUBJECT: Affordable Care Act (ACA) Mandated Collection of Federally Qualified Health Center
(FQHC) Data and Updates to Preventive Services Provided by FQHCs
I. SUMMARY OF CHANGES: The ACA provides the statutory framework for development and
implementation of a prospective payment system (PPS) for Medicare FQHCs in 2014. The ACA grants the
Secretary of HHS the authority to require FQHCs to submit such information as may be required in order to
develop and implement a PPS for Medicare FQHCs. The ACA mandates the collection of the data begins no
later than January 1, 2011. ACA also expands the definition of FQHC preventive services. NOTE: The
original section 110.1 is being deleted from Chapter 9. Sections 110.2 and 110.3 have been re-numbered to
110.1 and 110.2.
EFFECTIVE DATE: January 1, 2011
IMPLEMENTATION DATE: January 3, 2011
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized
material. Any other material was previously published and remains unchanged. However, if this revision
contains a table of contents, you will receive the new/revised information only, and not the entire table of
contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.
R/N/D CHAPTER / SECTION / SUBSECTION / TITLE
R 9/Table of Contents
R 9/100/General Billing Requirements
R 9/110/FQHC Affordable Care Act (ACA) Requirements
R 9/110.1/Reporting of Specific HCPCS Codes for Hospital-Based FQHCs
R 9/110.2/Billing for Supplemental Payments to FQHCs Under Contract with
Medicare Advantage (MA) Plans
R 9/120/General Billing Requirements for Preventive Services
R 9/150/Initial Preventive Physical Examination (IPPE)
R 9/160/Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
R 9/181/Diabetes Self-Management Training (DSMT) Services Provided by RHCs
and FQHCs
R 9/182/Medical Nutrition Therapy (MNT) Services
III. FUNDING:
For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers:
No additional funding will be provided by CMS; Contractor activities are to be carried out within their
operating budgets.
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is
not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
IV. ATTACHMENTS:
Business Requirements
Manual Instruction
*Unless otherwise specified, the effective date is the date of service.
Attachment - Business Requirements Pub. 100-04 Transmittal: 2034 Date: August 24, 2010 Change Request: 7038
NOTE: This Transmittal is no longer sensitive and is being re-communicated November 16, 2010. The
Transmittal Number, date of Transmittal and all other information remain the same. This instruction may
now be posted to the Internet.
NOTE: Transmittal 2013, dated July 30, 2010 is being rescinded and replaced by Transmittal 2034 dated
August 24, 2010 to indicate the new waiver of coinsurance and deductible for Preventive Services as enacted by
4104 of the Affordable Care Act. Business Requirement 7038.11 and the Claims Processing Manual, Pub. 100-
04, Chapter 9, sections 120 and 150 have been updated to reflect the above policy changes. All other material
remains the same.
“This policy is discussed in the CY 2011 physician fee schedule proposed rule published on July 13, 2010 and
may change based on analysis of public comments. This advance notice is provided so contractors can begin
making the necessary systems changes for the policy to go in effect January 1, 2011.”
SUBJECT: Affordable Care Act (ACA) Mandated Collection of Federally Qualified Health Center
(FQHC) Data and Updates to Preventive Services Provided by FQHCs
Effective Date: January 1, 2011
Implementation Date: January 3, 2011
I. GENERAL INFORMATION
A. Background:
Section 10501(i)(3)(A) of ACA amended section 1834 of the Social Security Act (the Act) by adding a new
subsection (o), Development and Implementation of Prospective Payment System. This subsection provides the
statutory framework for development and implementation of a prospective payment system for Medicare
FQHCs. Section 1834(o)(1)(B), as amended by the ACA, addresses collection of data necessary to develop and
implement the new Medicare FQHC prospective payment system. Specifically, the ACA grants the Secretary
of Health and Human Services the authority to require FQHCs to submit such information as may be required in
order to develop and implement the Medicare FQHC prospective payment system, including the reporting of
services using Healthcare Common Procedure Coding System (HCPCS) codes. The ACA requires that the
Secretary impose this data collection submission requirement no later than January 1, 2011.
Section 10501(i)(2) of the ACA amended the definition of FQHC services as defined in section 1861(aa)(3)(A)
of the Act by removing the specific references to services provided under section 1861(qq) and (vv) and by
adding preventive services as defined in section 1861(ddd)(3), as amended by the ACA. The ACA establishes a
new Medicare FQHC preventive services definition by referencing preventive services as defined in section
1861(ddd)(3) of the Act, as amended by the ACA. In accordance with 1833 (a)(3) of the Act, preventive
services listed in 1861(ddd)(3) are paid in the manner as all other Medicare FQHC services (with the exception
of 1861(s)(10) services, i.e., pneumococcal and influenza vaccines and administration which are paid at 100%).
B. Policy:
This policy is subject to change based on analysis of public comments of the final rule to Payment Policies
under the Physician Fee Schedule for Calendar Year (CY) 2011. Any changes will be reflected in the
implementation of this Change Request before issuance.
Beginning with dates of service on or after January 1, 2011, when billing Medicare, FQHCs must report all
pertinent services provided and list the appropriate HCPCS code for each line item along with revenue code(s)
for each FQHC visit. The additional line item(s) and HCPCS code reporting are for informational and data
gathering purposes only, and will not be utilized to determine current Medicare payment to FQHCs. Until the
FQHC prospective payment system is implemented in 2014, the Medicare claims processing system will
continue to make payments under the current FQHC interim per-visit payment rate methodology.
Also, beginning with dates of service on or after January 1, 2011, ACA revised the list of preventive services
paid for in the FQHC setting. Effective January 1, 2011,the professional component of the following preventive
services will be covered FQHC services when provided by an FQHC: (1) Initial preventive physical
examination (IPPE); (2) The following screening and other preventive services: (A) Pneumococcal, influenza,
and hepatitis B vaccine and administration under subsection (s)(10); (B) Screening mammography as defined in
1861(jj); (C) Screening pap smear and screening pelvic exam as defined in 1861 (nn).; (D) Prostate cancer
screening tests as defined in 1861(oo); (E) Colorectal cancer screening tests as defined in 1861 (pp); (F)
Diabetes outpatient self-management training services as defined in 1861 (qq)(1); (G) Bone mass measurement
as defined in 1861 (rr); (H) Screening for glaucoma as defined in 1861 (uu); (I) Medical nutrition therapy
services as defined in 1861 (vv); (J) Cardiovascular screening blood tests as defined in 1861 (xx)(1); (K)
Diabetes screening tests as defined in 1861(yy); (L) Ultrasound screening for abdominal aortic aneurysm as
defined in 1861(bbb); (M) Additional preventive services (as defined in 1861 (ddd)(1); (3) The personalized
prevention plan services as defined in Section 1861(hhh)(1) of the Act.
This CR does not impact claims for supplemental payments to FQHCs under contact with Medicare Advantage
Plans.
II. BUSINESS REQUIREMENTS TABLE
Use“Shall" to denote a mandatory requirement
Number Requirement Responsibility (place an “X” in each
applicable column)
A
/
B
M
A
C
D
M
E
M
A
C
F
I
C
A
R
R
I
E
R
R
H
H
I
Shared-
System
Maintainers
OTH
ER
F
I
S
S
M
C
S
V
M
S
C
W
F
7038.1 For all Medicare fee-for-service claims on TOB 77x
with dates of service on or after 01/01/2011, Medicare
systems shall require all service lines contain a valid
HCPCS code except for revenue codes that do not
permit HCPCS code reporting, i.e. revenue code 025x.
X
7038.1.1 For all Medicare fee-for-service claims on TOB 77x
with dates of service on or after 01/01/2011, Medicare
systems shall return to provider all FQHC claims that
X X X
Number Requirement Responsibility (place an “X” in each
applicable column)
A
/
B
M
A
C
D
M
E
M
A
C
F
I
C
A
R
R
I
E
R
R
H
H
I
Shared-
System
Maintainers
OTH
ER
F
I
S
S
M
C
S
V
M
S
C
W
F
contain service line (s) without a valid HCPCS code(s).
7038.2 For all Medicare fee-for-service claims on TOB 77x
with dates of service on or after 01/01/2011, Medicare
systems shall accept all service lines with valid revenue
codes except for the following revenue codes: 002x-