Federally Qualified Health Center Billing Examples

During a visit with a physician at a federally qualified health center (FQHC), a new patient received an examination and venipuncture. Medicare pays 80% of the lesser of the FQHC charge or the FQHC prospective payment system (PPS) rate for the specific payment code.

An established patient has an encounter visit with a FQHC provider for a sinus infection and venipuncture. Later that day, the patient returns with a cut on their hand. Medicare pays 80 percent of the lesser of the FQHC charge or the FQHC PPS rate for the specific payment code for both visits.

For additional examples refer to CMS IOM Pub.100-04, Medicare Claims Processing Manual, Chapter 9.   

References

• CMS IOM Pub.100-02, Benefit Policy Manual, Chapter 13
• Federally Qualified Health Center (FQHC) Pricer