Wiki FQHC E/M for VFC encounter

[sankoe@keystoneruralhealth.com]

I have a question. Our provider wants to bill an office visit 99212 when administering VFC vaccines such as the flu shot. We brought up the issue of medical necessity and also that a 99212 is a problem focused e/m and the patients only coming in for the vaccine with no problem. He just wants paid the encounter rate, but yet doesn't want to have to see the patient either. I do not believe this is allowed red flag for fraud and abuse. Can some clarify. I feel it's not allowed. If he wants the encounter rate so bad then he needs to see the patient and counsel them on the vaccine and document what he counseled and do a physical exam on the patient.

 

[angeleve]

You cannot bill an E&M for a nurse visit, you will have to submit you will only get paid admin fee. you cannot add an E&M if patient did not have a face to face with provider.

 

[Pathos]

Medical Necessity is always key when reporting E/M codes. 99212 is considered a regular provider visit and, as the previous poster mentioned, the provider must see the patient and perform the E/M components as a regular E/M visit.
If the provider is thinking they can bill a 99211 visit, then there are some special rules on which requirements are needed for documentation. However, from the example you are giving, the provider should bill the injection admin + drug codes for the visit, and not include any E/M codes. I see no "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service ", that would justify an E/M, and the provider will get in trouble due to submitting a False Claim.

I can probably find some more material on this, but this seems pretty straightforward (see what I did there? ;o) ).

 

[Chelle-Lynn]

The FQHC guidelines can be difficult for the providers to understand as they feel that they are not getting paid for services rendered in their office. However we use this as an opportunity to remind the providers about the yearly cost report and ability to be "made whole" as an FQHC provider. So while the services are not paid as an individual claim as they are non-core; there is a dollar value at the end of the reporting year.

Hope this helps!