FQHC MC Billing

[varga1195@yahoo.com]

I work for a primary care office and we split bill for our Medicare (CPT office level with G code goes to A) and (Procedure, injectable etc. goes to B). My question is if a procedure is performed for a Medicare patient, can I just bill the procedure without an office level CPT?

tvarga@owensvillepc.com

 

[hperry10]

Hi there,

I work for an FQHC as well. Medicare no longer allows FQHC's to submit claims that do not have an associated G code. Procedures are not separately billable any more. I have included the link to the FAQ'S.


From page 7:Q8. How do I bill for procedures if no other service is furnished?

A8. Except for certain preventive services, procedures are not separately billable. If the procedure is
furnished on the same date of service as a qualifying visit, the charges for the procedure would go on the
claim with the payment code and qualifying visit code, and the FQHC would be paid the lesser of the
total charges or the adjusted PPS rate. If there is no qualifying visit associated with the procedure, no
claim is submitted and no payment is made.

The only way to get Medicare accept a procedure is to attach a qualifying visit, such as an E/M code but we know as coders that we can't just slap an E/M code on the claim to get it paid, there has to be a separate and identifiable reason for the E/M code. Stand alone procedures have to be written off. The PPS system has cost our clinic lots of money and unfortunately we have had to reduce the number of services we provide.

 

[lyncaldwell]

Careful before you write off that procedure!

My org specializes in healthcare economics and reimbursement. We work with many folks who aren't always able to put their hands on available resources when needed. I've attached a document periodically published by Myers and Stauffer (CPAs who work and audit for CMS) that we use as a resource in managing fee schedules for our clients. Per MS, these procedures are considered "encounters". Depending on your offerings, some or all codes should be configured and managed as encounters in your EMR/PMS. They will need to be aligned with the encounter code for government payers and should not be forgotten when filing for the periodic wrap/supplemental payments from traditional Medicare and Medicaid based on your MCOs' reimbursement. These codes would be linked to commercial fee schedules as well.

For the procedures you're writing off, hopefully, your adjustment (write-off) codes have an actionable process flow that allows for optimal, financial reporting of your non-covered charges in accordance with your financial policies and guidelines.

Good luck...

 

[Kellyj0h]

Billing procedure codes to Medicare Part A for FQHC

Where is this list from and what Medicare G-codes do these procedure codes correspond to for billing?

 

[rsager1985]

How are FQHCs supposed to bill secondary insurances after Medicare pays? We're getting a lot of denials because the insurance companies don't seem to understand the PPS system, and they are claiming the PPS codes aren't covered services.