Site-level lookups
Registration
- New to the clinic but seen at a sister site two years ago is established; the reverse error is just as common
FixOrg-wide three-year check
Guide · Medicare FQHC PPS
FQHC PPS new patient add-on: the 34 percent most centers leave at the front desk
The rule, the arithmetic, and the registration, scheduling and coding fixes that capture it.
Short answer: Medicare pays the geographically adjusted FQHC PPS rate plus 34.16% for a new patient, an IPPE or an AWV, once per day. The add-on is automatic when G0466, G0468 or G0469 is on the claim and invisible when registration defaults to G0467.
G0466 · new patientG0468 · IPPE or AWVG0469 · new patient mental healthx 1.3416 · after the GAF
Edition
Oct 2026
Focus
Medicare FQHC PPS
Audience
Front desk · Coding
Metric
Add-on capture rate
Codes
G0466 · G0468 · G0469
Length
7 min read
Where the 34.16 percent is won or lost
The G code is chosen downstream of three decisions that nobody owns. Each miss produces a G0467 that should have been something else.
- 1RegistrationThree-year lookup across every site and service line; dated new-patient flag on the encounter
- 2SchedulingIPPE in the first 12 months of Part B, AWV recall every 12 months, visit type pre-set to G0468
- 3VisitMedical or mental health visit; same-day second visit only for a new illness or a mental health or IOP visit [3]
- 4CodingG code driven by the flag and visit type; pre-bill edit when a new-patient flag meets a G0467
- 5ClaimLesser-of test: Medicare pays 80% of the lower of the charge or the adjusted rate [2]
- 6RemittancePaid amount compared to base x GAF x 1.3416 on every adjusted line
Decision owner
Front desk: org-wide history, AWV recall list
Code chosen
Coder: G0466 / G0468 / G0469 or G0467
Cash check
Billing: charge above adjusted rate, short-pay audit
Front desk and schedulingCoding decisionBilling and remittance
Per-visit PPS amount at a GAF of 1.000, before Medicare's 80 percent
CY 2026 final and CY 2027 proposed, dollars per qualifying visit
Base rate x GAF first, then x 1.3416 [1]. CY 2027 is proposed, not final [7].
Established visit, G0467 / G0470CY 2026 final
$207.72baseline, 100%
Adjusted visit, G0466 / G0468 / G0469CY 2026 final
$278.68+34.16%, add-on $70.96
Established visit, G0467 / G0470CY 2027 proposed
$212.91+2.5% market basket
Adjusted visit, G0466 / G0468 / G0469CY 2027 proposed
$285.64+34.16%, add-on $72.73
$0$100$200$300
Established, no adjustmentNew patient, IPPE or AWV adjusted
$7,100Roughly what every ten points of missed flags costs per 1,000 qualifying Medicare visits a year, GAF 1.000, before the 80 percent and sequestration
One per dayA new patient with an AWV the same day gets one adjustment, not two [1]
No deductibleCoinsurance waived on the preventive visit; Medicare pays 100 percent of covered preventive services [2]
Decisions the registration screen has to make
A new patient has not been treated by the FQHC's organization within the previous three years, including all of its sites [2].
| Scenario | New for PPS? | Why |
|---|---|---|
| First visit ever to any site of your organization | Yes | No service in three years [2] |
| Seen at your dental site 18 months ago, first medical visit today | Depends | The rule counts professional medical or mental health services from any practitioner in the organization [5] |
| Seen at a different, unaffiliated FQHC six months ago | Yes | New to your FQHC [1] |
| Last visit to your organization 37 months ago | Yes | Outside the three-year window [2] |
| Medical and mental health visits on the same first day | One visit only | New for one of the two visits; the other takes the established code [5] |
Five leaks, five fixes
AWV never scheduled
Scheduling
- G0468 pays the add-on and waives coinsurance; an unworked recall list is a quality miss and a payment miss
Fix13-month no-AWV report
Flag not carried to coding
Coding
- Registration knows the patient is new; the coding queue defaults to G0467
FixPre-bill edit on flag + G0467
Charge below the adjusted rate
Charge master
- Medicare pays 80 percent of the lesser of the charge or the rate [2]; a flat charge master caps the add-on
FixRe-price every January
Same-day double adjustment
Claim
- G0466 and G0469 together on a first visit triggers an edit; one adjustment per day [1]
FixBill one adjusted, one established
What to change and how to test it
| Desk | Fix | How to test it |
|---|---|---|
| Registration | Three-year lookup across every site and service line of the organization, stored as a dated flag on the encounter | Pull 50 G0467 claims; count how many patients had no visit in three years |
| Scheduling | IPPE within the first 12 months of Part B, then AWV recall every 12 months, with the visit type pre-set to G0468 | Count Medicare patients with no AWV in 13 months |
| Coding | G code driven by the registration flag and the visit type, with a pre-bill edit when a new-patient flag meets a G0467 | Weekly add-on capture rate: adjusted codes billed divided by qualifying visits |
| Charge master | Encounter charges priced above the adjusted PPS rate for your locality, re-priced every January | List encounter lines where charge is below base x GAF x 1.3416 |
| Remittance | Compare paid amount to expected adjusted rate on every G0466, G0468 and G0469 line | Short-paid adjusted visits by month |
Takeaway
Measure it as a rate, not an anecdote: adjusted codes billed divided by visits that qualified. It is KPI 6 in our FQHC revenue cycle scorecard.
Six checks before the next Medicare batch
Pull 50 G0467 and G0470 claimsCheck three-year history across every site; count the new patients billed as established.
Run the 13-month no-AWV listEvery Medicare patient without an AWV in 13 months gets a recall call with the visit type set to G0468.
Add the pre-bill editNew-patient flag plus G0467 stops the claim before it leaves.
Price the charge masterEvery encounter line above base x GAF x 1.3416 for your locality; see the FQHC PPS rate 2026 guide for the GAF table.
Audit remittancesPaid versus expected on every adjusted line; short-pays by month.
Hold CY 2027 rates until finalLoad $212.91 only when the final rule publishes; see CY2027 PFS FQHC provisions. The FQHC RCM toolkit has the registration script and audit sample template; our FQHC billing services run the flag, edit and remittance check as one workflow.
Frequently asked questions
How much more does Medicare pay for a new patient visit at an FQHC?
CMS's FQHC PPS FAQ says the adjusted PPS rate is increased by 34.16 percent when a patient is new to the FQHC or an IPPE or AWV is furnished. The increase is applied after the geographic adjustment, only one adjustment can be applied per day, and the percentage is the same for every FQHC.
Who counts as a new patient for G0466?
Under 42 CFR 405.2462(e)(2), a new patient is one who has not been treated by the FQHC's organization within the previous three years, including all sites that are part of the FQHC. The FAQ adds that a patient seen at an unaffiliated FQHC six months earlier is still new to yours. The lookback is organizational, not by clinic.
Can we bill G0466 and G0469 for the same new patient on the same day?
No. CMS's payment code definitions say that if a new patient is also receiving a mental health visit on the same day, the patient is considered new for only one of these visits. Bill the add-on code on one visit and the established code on the other.
What is the CY 2027 FQHC PPS base rate?
Not final yet. The CY 2027 PFS proposed rule published July 16, 2026 would update the CY 2026 base rate of $207.72 by a proposed 2.5 percent FQHC market basket update to $212.91, with the final figure to reflect data through the second quarter of 2026. Confirm against the final rule, expected in November 2026, before loading it.
- CMS, FQHC PPS Frequently Asked Questions: new patient, IPPE and AWV adjustments; lesser-of rule; sequestration
- 42 CFR 405.2462, Payment for RHC and FQHC services (eCFR)
- 42 CFR 405.2463, What constitutes a visit (eCFR)
- CMS MLN Matters MM14309: FQHC PPS and IOP payment rates, CY 2026 update (December 5, 2025)
- CMS, Specific Payment Codes for the FQHC PPS, G0466 to G0470 definitions (grandfathered tribal FQHC edition, January 1, 2016)
- CMS fact sheet: Calendar Year 2027 Medicare Physician Fee Schedule proposed rule (July 14, 2026)
- Federal Register: CY 2027 PFS proposed rule, 91 FR 43842 (July 16, 2026), RHC and FQHC provisions
Checked October 25, 2026. Rules change, and proposed rules are not final until CMS publishes them; confirm against the source before relying on them.
How many of your Medicare visits qualified and were billed as established?
We pull a sample of your G0467 and G0470 claims, check the three-year history across your sites and your AWV recall, and show you the add-on capture rate with the dollars attached.