RHCs and FQHCs are paid an all-inclusive rate (AIR) or national prospective payment system (PPS) rate for any service that is defined as a visit to their facility.  A visit may be with a physician, non-physician practitioner (NPP), psychologist or social worker.

There are some differences in RHC and FQHC rules, but in general, a service identified by a CPT^® code is submitted with a revenue code and is paid at the AIR/PPS rate for each type of organization.  All of the services performed are listed on the claim form, but the payment is based on the HCPCS code that identifies the type of visit. Links to the CMS fact sheets for each type of service are listed at the end of this post, as well as FAQ about these services.

Wellness visits in an RHC and FQHC—additional payment in a FQHC

Medicare developed HCPCS codes for three services generally considered wellness visits. These are:

• G0402 for the welcome to Medicare visit,
• G0438 for an initial annual wellness visit and
• G0439 for a subsequent annual wellness visit.

There are resources on CodingIntel that describe patient eligibility and the service requirements for each.

When one of these wellness visits is performed in an RHC, it is paid the same as for any other service defined as a visit.  However, when a wellness visit is provided in an FQHC, it is paid at 134% of the PPS rate.  This provides an incentive to provide the wellness visits in an FQHC.