Staying current with Medicare billing regulations is essential for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). This comprehensive guide clarifies the billing and payment policies for specific preventive services—HCPCS codes G0101 and Q0091—under the All-Inclusive Rate (AIR) system, and provides crucial updates regarding the Medicare Additional Documentation Request (ADR) response timeframe. We’ve consolidated the latest official CMS guidance to ensure your practice remains compliant and optimizes reimbursement.

Medicare Payment for G0101 and Q0091 in RHCs and FQHCs

Provider Types Affected

This information is vital for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) authorized to bill under the All-Inclusive Rate (AIR) system. This includes facilities submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Key Billing Updates for G0101 & Q0091

The Centers for Medicare & Medicaid Services (CMS) has designated Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) as billable visits when furnished by an RHC or FQHC practitioner to an eligible patient. These services are recognized as essential preventive care.

It is important that your billing staff are aware of these guidelines, which became effective for dates of service on or after January 1, 2014, as outlined in Change Request (CR) 8927. For detailed guidance, refer to the Medicare Claims Processing Manual, Chapter 9, Sections 100.1 (for RHCs) and 110.1 (for FQHCs).

Background and Payment Specifics

• HCPCS codes G0101 and Q0091 are payable as a stand-alone encounter/visit.
• These services are paid based on the All-Inclusive Rate (AIR) for RHC and FQHC claims utilizing 71X and 77X Types of Bills (TOBs).
• A significant benefit for beneficiaries: Deductible and coinsurance are NOT applied to G0101 or Q0091.
• For FQHCs billing under the Prospective Payment System (PPS), G0101 and Q0091 qualify as visits when billed with FQHC payment HCPCS codes G0466 or G0467.

Defining Risk and Payment Frequency

Medicare coverage for G0101 and Q0091 varies based on the patient’s risk profile for cervical or vaginal cancer:

• Annual Payment: For women identified as “high risk” for developing cervical or vaginal cancer, or women of childbearing age who have had an abnormal Pap test within the past 3 years. According to National Coverage Determination (NCD) 210.2.1, high-risk factors include a history of cervical or vaginal cancer, being immunosuppressed, or having been exposed to diethylstilbestrol (DES) in utero.
• Biennial Payment (Every 2 Years): For women classified as “normal risk.”

Important Note on Same-Day Billing

A critical rule for RHCs and FQHCs is that if other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid. This means that if a patient receives a preventive screening (G0101 or Q0091) and also has a separate, distinct medically necessary evaluation and management (E/M) service on the same day, only one of these services will be reimbursed as an RHC/FQHC encounter. Providers must determine which service best represents the primary reason for the visit to ensure correct billing under the AIR system.

MACs will not automatically search for claims denied prior to the implementation of CR8927. However, they will adjust any claims that you bring to their attention for review.

Medicare Additional Documentation Request (ADR) Response Guidelines

Provider Types Affected by ADRs

This section applies to all physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, for services rendered to Medicare beneficiaries. Adhering to these guidelines is crucial for all Medicare participating entities.

What You Need to Know: The 45-Day Deadline

Based on Change Request (CR) 8583 (revised November 18, 2014), Medicare review contractors (MACs and Zone Program Integrity Contractors (ZPICs)) are required to issue pre-payment review Additional Documentation Requests (ADRs) that explicitly state a 45-calendar-day deadline for providers and suppliers to respond. Failure to submit the requested documentation within this 45-day timeframe will result in the denial of the claim(s) associated with the ADR. Ensure your billing and administrative staff are fully aware of this strict deadline.

Understanding the ADR Process

In instances where CMS review contractors (including MACs, ZPICs, Recovery Auditors, the Comprehensive Error Rate Testing (CERT) contractor, and the Supplemental Medical Review Contractor) cannot make a claim determination based solely on the information initially submitted, an ADR will be issued. The purpose of an ADR is to solicit further medical documentation from the provider or supplier to facilitate an accurate claim review.

Common reasons for receiving an ADR include:

• Lack of clear medical necessity for the billed service.
• Insufficient or incomplete documentation to support the billed service.
• Discrepancies between the billed code and the documentation.
• Requests for specific patient demographic or historical information.
• Services that trigger automated review due to high cost or utilization patterns.

Responding to an ADR: A Provider Checklist

To ensure compliance and maximize your chances of claim approval, follow these actionable steps when responding to an ADR:

1. Review the Request Immediately: Understand precisely what documentation is being requested.
2. Gather All Relevant Documentation: This typically includes, but is not limited to:
   • Medical records (physician orders, progress notes, hospital records).
   • Test results (lab, imaging, pathology).
   • Consultation reports.
   • Therapy notes.
   • Discharge summaries.
   • Operative reports.
3. Organize and Legibilize: Ensure all documentation is clearly legible, well-organized, and directly relevant to the services under review. Highlight or annotate key sections if permissible and helpful.
4. Complete Within 45 Days: Submit all requested documentation within the 45-calendar-day deadline from the date of the ADR.
5. Proof of Submission: Always send documentation via a method that provides proof of delivery, such as certified mail with return receipt or an electronic submission portal if available.
6. Keep Copies: Maintain a complete copy of all submitted documentation for your records.

Legal Basis and Current Guidance

The authority for Medicare contractors to collect medical documentation is rooted in the Social Security Act, Section 1833(e). This section mandates that no payment shall be made for services unless necessary information is furnished to determine the amounts due.

Current Medicare policy regarding ADRs is detailed in the Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Section 3.2.3.2, titled “Verifying Potential Errors and Tracking Corrective Actions.” This manual explicitly states that MACs and ZPICs must notify providers that documentation is to be submitted within 45 calendar days of the request, and claims will be denied if documentation is not received by day 46.

This article was revised on November 18, 2014, to clarify ADR requirements related to pre-payment review, and the core 45-day rule has remained a consistent guideline in subsequent CMS publications.