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October 14, 2015

Federally Qualified Health Centers (FQHCs) Top Billing Error – Reason code W7088

Current data analysis reveals Reason code W7088, “FQHC PPS TOB 77X IS SUBMITTED AND AT LEAST ONE OF THE SPECIFIC PAYMENT CODES G0466, G0467, G0468, G0469 OR G0470 IS NOT PRESENT” as one of the top J15 Part A billing errors. Ensure your Medicare billing staff is aware of the error and is familiar with the FQHC claim submission rules.

Reminder: In accordance with Section 1834(o)(1)(A) and 1834(o)(2)(C) of the Social Security Act, CMS established specific payment codes that FQHCs MUST use when submitting a claim for FQHC services for payment under the FQHC PPS. Detailed HCPCS (Healthcare Common Procedure Coding System) coding with the associated line item charges listing the visit that qualifies the service for an encounter-based payment and all other FQHC services furnished during the encounter are also required.

Refer to the following CMS references:

Review the CGS Part A claims Top Billing Errors Web page often to help you keep track of your claim submission issues.

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