Wiki Federally Qualified Healthcare Centers


Oakland, CA
Best answers
Since FQHC's don't always bill a traditional CPT code, do they still have to follow the CPT guidelines when obtaining HPI? Example: FQHC's will bill Medi-Cal an "01", this is an office visit. They do not use a 99211-99215 as most traditional offices. So, when it comes to meeting all the of the components as outlined by CPT, are they still held to the same rules? I say yes, however I would like to hear what others know about this. And, does anyone know where I can find written instruction on where the guidelines are for FQHC on this topic?
I would request guidance from your Medi-Cal provider rep or search their manual since this is Medi-Cal's billing rules, but I would guess that, yes, you must comply with CPT E/M documentation guidelines. In other states like Indiana, FQHC's are required to bill with the appropriate CPT E/M plus a "T" code from HCPCS II that designates an FQHC service. Also, national Medicare rules require all CPT codes for the services be included on the claim even though billing/payment is determined by the prospective payment rules.
In MA, we have several payers that require T1015 as an all-inclusive code instead of EM codes or CPT codes. My providers still document and code as if we submitted EM codes; the billers manually 'correct' the codes prior to submission. Because the providers are not doing anything different, they still follow all the EM documentation guidelines. I don't know if the payers have issued a directive on this, but I feel that the documentation still needs to support the visit and charges (even though we get paid an encounter rate regardless of what charges we attach to the claim).
Even though you may not be required to use a cpt code when billing it affects your bottom line when you don't. Everything that goes on in a visit should be recorded because it affects your cost (overhead) and that is part of what they use to determine your payment amount.