Wiki How FQHC coding is different than other coding?

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rbandaru

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Can any one give an overview on FQHC coding and how it is different from other coding? Appreciate any help thanks much in advance.

Regards
Dr.Ramnath Bandaru, CCS, CPC
American Medical Services LLC
http://amshealth.com/
Twitter: @HospitalCoders
 
Is the FQHC an IHS facility? I have coded for an IHS clinic in Southern California that billed Medicare part A to NGS which required use of G codes. IHS FQHC facilities tend to have MOA's with local medicaid.


Kimberly
 
An FQHC is a Federally Qualified Health Center, which means you have to bill based on specific Medicare Guidelines that are set up for FQHCs. I have been coding/billing for an FQHC for a long time.

Everything is based on encounters with the physician/clinician. Certain services are not-billable unless there is a face-to-face encounter with the clinician. Visits/encounters must be billed along with a G-code and Medicare pays on the G-code based on the rate set up for your geographical area (GAF). These are billed to Medicare Part A and paid as part of the FQHC. Many services that are provided along with the visit (urinalysis, A1c, PFT, etc.) are split off of the visit/encounter and billed separately to Medicare part B and paid fee-for-service.

The practice I work for is an FQHC and we are set up to bill as an FQHC with Medicare, Medicaid, and the Marketplace/Exchange plans. We bill commercial payers as a normal or non-FQHC services.

There are some good resources out there. Here is one I use: https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html

Also, it is good to get in touch with other FQHCs in your area.

Best of luck!
 
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Billing procedure to Part B for FQHC

I have not been able to find anything that states you can bill procedures to Part B if you are an FQHC. Everything I have come across states these services are included in the All inclusive visit and not separately billable. How are you able to bill the PFT, and other procedures to Part B without issue? I know you can bill certain labs and technical components of tests to Part B. But PFT's, Medications (Jcodes) and other procedures are inclusive per the guidelines. Please help me to understand.
 
Kellyj0h said:
I have not been able to find anything that states you can bill procedures to Part B if you are an FQHC. Everything I have come across states these services are included in the All inclusive visit and not separately billable. How are you able to bill the PFT, and other procedures to Part B without issue? I know you can bill certain labs and technical components of tests to Part B. But PFT's, Medications (Jcodes) and other procedures are inclusive per the guidelines. Please help me to understand.
Click to expand...

I currently have the same problem. One of our newest MDs specifically blocks out a day of the week just to do surgical procedures like lesions excisions, biopsies, etc. but since we are an FQHC, these procedural codes don't count as qualifying codes to get reimbursed the PPS rate. So would these encounters be billed using an E/M code?
 
j_oania@yahoo.com said:
I currently have the same problem. One of our newest MDs specifically blocks out a day of the week just to do surgical procedures like lesions excisions, biopsies, etc. but since we are an FQHC, these procedural codes don't count as qualifying codes to get reimbursed the PPS rate. So would these encounters be billed using an E/M code?
Click to expand...

These visits have to be written off unfortunately. You can only add an E/M code if it is warranted. My boss actually spoke with our contact person at CMS and asked what we do about patients who need procedures. The woman from CMS told her we would have to refer the patient elsewhere or perform the procedure and write it off. CMS documentation for FQHCs provides this same information. Our clinic has stopped performing some procedures and has decided against bringing in additional specialists. It's unfortunate because our patients need these services but we cannot pay the providers if we are writing off their charges.

Heather CPC
 
I agree with Heather. We are an FQHC facility and have confirmed the same information with CMS as well as with National Government Services (our administrator). If only a procedure is performed the visit is not billable.
 
Thanks, everyone. This makes more sense now.

So what happens when we bill for only venipuncture, injections, vaccines as a "nurse visit"? How would be handled these when billing to Medicare/Medicaid vs commercial payers? Would we need to change the revenue code?
 
j_oania@yahoo.com said:
Thanks, everyone. This makes more sense now.

So what happens when we bill for only venipuncture, injections, vaccines as a "nurse visit"? How would be handled these when billing to Medicare/Medicaid vs commercial payers? Would we need to change the revenue code?
Click to expand...

Hi Jasmin,

I can't speak for the venipuncture but the injections and vaccines billed as nurse visits are not written off but are added to the cost report for reimbursement for Medicare. We bill them to Medicaid as we would a commercial payer, some are paid, some are not and we have to write them off.

Heather CPC
 
smontague said:
An FQHC is a Federally Qualified Health Center, which means you have to bill based on specific Medicare Guidelines that are set up for FQHCs. I have been coding/billing for an FQHC for a long time.

Everything is based on encounters with the physician/clinician. Certain services are not-billable unless there is a face-to-face encounter with the clinician. Visits/encounters must be billed along with a G-code and Medicare pays on the G-code based on the rate set up for your geographical area (GAF). These are billed to Medicare Part A and paid as part of the FQHC. Many services that are provided along with the visit (urinalysis, A1c, PFT, etc.) are split off of the visit/encounter and billed separately to Medicare part B and paid fee-for-service.

The practice I work for is an FQHC and we are set up to bill as an FQHC with Medicare, Medicaid, and the Marketplace/Exchange plans. We bill commercial payers as a normal or non-FQHC services.

There are some good resources out there. Here is one I use: https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html

Also, it is good to get in touch with other FQHCs in your area.

Best of luck!
Click to expand...


Does this apply to Medicare Advantage plans as well? As an FQHC, our EHR system with automatically separates our charges into two claims when there are non-FQHC services (like UA, drug screening, etc) rendered during the same encounter as an E/M code & venipuncture. One of our Advantage plans have been splitting these charges, but I wasn't sure if it is not Traditional Medicare exclusive.
 
So if a patient has Medicare/Medicaid and they had a nurse visits, how are you processing it with Medicaid? Do you get a remittance from Medicare with the $0 payment or do you use the RTP date to process the denied visit with Medicaid?
 
kbrooks15 said:
So if a patient has Medicare/Medicaid and they had a nurse visits, how are you processing it with Medicaid? Do you get a remittance from Medicare with the $0 payment or do you use the RTP date to process the denied visit with Medicaid?
Click to expand...

Does anyone have an answer to this. Also what are you doing with the Colposcopy's and Medicaid with your FQHC rate. We cannot bill an office visit if there is no medical necessity to do so, so are they written off?
 
If the service is a nurse only visit (non-core) service, then it is not payable by Medicare or Medicaid. Both carriers handle non-core services the same. So even if you had a denial from Medicare on the 99211 and attempted to bill it to Medicaid, Medicaid would deny as a non-core service.
 
hperry10 said:
These visits have to be written off unfortunately. You can only add an E/M code if it is warranted. My boss actually spoke with our contact person at CMS and asked what we do about patients who need procedures. The woman from CMS told her we would have to refer the patient elsewhere or perform the procedure and write it off. CMS documentation for FQHCs provides this same information. Our clinic has stopped performing some procedures and has decided against bringing in additional specialists. It's unfortunate because our patients need these services but we cannot pay the providers if we are writing off their charges.

Heather CPC
Click to expand...

Is this only for FQHC Medicare claims? Can an FQHC bill procedures only to commercial and Medicaid payers?
 
FQHC and Group Therapy

Hi There,

We are an FQHC with both a Mental Health and Substance Abuse program; both of which do Group Therapy sessions; this is a payable service under part B; however the Group Therapy does not qualify as a face to face for an FQHC for Part A payment. This may be a stretch, but since some lab and TC services are billable separately to Part B, does this also make the Group Therapy billable to Part B since Group Therapy IS listed in the Non-FQHC Service section of the FQHC Manual?

Thanks-Stephanie CPC
 
Last edited:
Unfortunately this is not billable to part B. Some FQHC sites will provide a group therapy session in addition to a private face to face time with the provider which would allow for a core service. However, in your case if there is no face-to-face then it is considered non-core and not separately billable to Part A or B.
 
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