Step Outside Your Coding Bubble into FQHC Services

Step Outside Your Coding Bubble into FQHC Services

Compare coding and billing for FQHCs to that of provider- and facility-based organizations.

Federally qualified health centers (FQHCs) account for less than 10 percent of designated organizations, but as coding professionals we should understand the differences between FQHCs and physician- or facility-based organizations.

Note: Medicare, Medicaid, and commercial carriers do not all process FQHC claims the same. This article is based on Medicare rules. You should check with your other payers regarding their requirements.

Requirements Differ

Like rural health centers (RHCs), FQHCs provide healthcare services in underserved areas; the rules, regulations, reimbursement models, and requirements for these facility types differ, however. For example, an RHC is required to have a non-physician provider (NPP) — such as a nurse practitioner (NP), physician assistant (PA), or certified nurse specialist (CNS) — onsite 50 percent of operating hours. There is no such requirement for FQHCs.

Reimbursement Includes Bundled Services

The biggest difference between FQHCs and other healthcare providers is the reimbursement model. Beginning in 2017, the FQHC prospective payment system (PPS) rate is updated annually by the FQHC market basket. The Centers for Medicare & Medicaid Services (CMS) issues a base rate of payment to which the geographic index is applied. From Jan. 1, 2019, through Dec. 31, 2019, the FQHC PPS base payment rate is $169.77 per CMS-billed encounter (geographic variations apply) (up 1.9 percent from last year).

If you are a physician- or facility-based organization, you may be thinking, “Wow! That sounds great! How do we sign up?” But you should note that many services are inclusive in this rate (i.e., bundled).

To qualify as a FQHC, an organization must provide all preventive health services (exams, labs, and screenings), as well as prenatal and perinatal care, family planning, and dental services. These are just a few of the services bundled into the FQHC all-inclusive rate. This helps to explain why the reimbursement per encounter rate is dramatically different than that of other providers.

Many professional services provided in a FQHC-designated facility are also included in the PPS payment. How does this affect ancillary services? The Medicare PPS payment rate is inclusive of the professional component reimbursement of most ancillary services. For example, if a patient presents for a complaint of chest pain, and an EKG and chest X-ray are provided, the professional portion of these tests are not reimbursed by Medicare in addition to the encounter because they are included in the PPS reimbursement.

Although office-based procedures do not have technical and professional components, these services are professional in nature (meaning: payers are reimbursing for the professional service provided to the patient). The FQHC PPS payment rate includes office-based procedures performed by the provider. For example, laceration repair and wart removal are not paid in addition to the encounter base rate.

In a FQHC setting, specialty does not matter. For example, if a patient presents for dental services at a FQHC as a new patient and returns at a later date for medical intervention, such as the flu, that patient is still an established patient because they were previously seen by that FQHC.

Commercial Payer Rules Vary

Most commercial carriers (and some Medicaid programs) vary in their reimbursement model for FQHC-designated organizations. In many cases, FQHCs code claims and submit bills to the payer in the same manner as any other facility-based organization.

Your provider, coder, and biller must be cognizant of who the payer is, and they must know the payer’s specific policies for coding, billing, and bundled services. They must also be aware of what services are recognized by traditional CPT® coding, and what services may not be paid in a FQHC-designated facility.

Let’s review an example by first discussing services provided to Medicare patients who do not comply with traditional CPT® coding designation. The office-based services in a FQHC use G codes recognized by CMS. These include:

G0466 FQHC visit, new patient:

A medically-necessary, face-to-face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit

G0467 FQHC visit, established patient:

A medically-necessary, face-to-face encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a FQHC visit.

G0468 FQHC visit, initial preventive physical examination (IPPE) or annual wellness visit (AWV):

A FQHC visit that includes an IPPE or AWV and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV.

G0469 FQHC visit, mental health, new patient:

A medically-necessary, face-to-face mental health encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental health visit.

G0470 FQHC visit, mental health, established patient:

A medically-necessary, face-to-face mental health encounter (one-on-one) between an established patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental health visit.

Although these G codes are used for Medicare patients, they may not translate to commercial and Medicaid patients, which causes additional administrative burdens for these organizations.

Non-covered Services

Services not covered in a FQHC include chronic care management (CCM). When these services and new coding were released, and CMS announced coverage of these services, there was a caveat that CCM was considered part of the existing reimbursement model and not separately reportable.

In 2017, CMS provided reimbursement to FQHC organizations for CCM services. Just one year later, CMS released a new G code for CCM and provided an option of mental health treatments in association with these reportable services. Again, rules vary depending on FQHC designation, so always confirm payer policy.

Although we have addressed only a few of the differences of an FQHC, you can see how stepping outside your “bubble” will make you a more valuable coder and auditor, as you move forward with your career path.


Resource

MLN Matters Number MM10990: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10990.pdf

Shannon DeConda

Shannon DeConda, CPC, CPMA, CEMA, CEMC, CMSCS, CMPM, founded NAMAS 11 years ago to launch a program to train and certify auditors and investigators. She is committed to providing valuable education by ensuring misconceptions about the rules and guidelines are separated from the facts to create a standardization of efforts on both sides. DeConda is a member of the Melbourne, Fla., local chapter.

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