Are you thinking about becoming and Federally Qualified Healthcare Center (FQHC)? Or would you like to know more about FQHC billing? If so, let us tell you the key things you need to know.
What is an FQHC?
FQHCs are community based organizations that were created in 1991. They provide primary and preventative care services to persons of all ages, regardless of their ability to pay or their health insurance status. FQHCs include community health and migrant health centers, health care for homeless facilities, public housing primary care centers and health center program “look-alikes”.
FQHCs are reimbursed by Medicare and Medicaid based on an all-inclusive model. There are only a few instances where the centers can bill for services separately. Although both Medicare and Medicaid get reimbursed using the all-inclusive rate, all services must be documented on a claim form using the appropriate CPT and HCPCS coding. There are substantial differences between how the Medicaid and Medicare Prospective Payment System (PPS) systems will function, which are discussed below.
Since 2011, State Medicaid agencies have been required to pay FQHCs based on the PPS guidelines. To appropriately bill for services to Medicaid, the provider will use the following HCPCS code:
- T1015 – Clinic visit/encounter, all-inclusive
Each claim that is billed using this code must also include the CPT code of all services rendered. These codes are used to track the Healthcare Effectiveness Data and Information Set (HEDIS) measures, which may affect total reimbursement or ongoing participation.
Medicaid will reimburse for the following services when reported in conjunction with HCPCS code T1015:
- Laboratory services
- Pharmacy services
- X-ray services.
The Affordable Care Act (ACA) established the FQHC PPS for cost reporting periods in October 2014. FQHCs are required to use PPS codes when billing to Medicare. To appropriately bill for services to Medicare, the provider must select a specific payment code for each encounter. Below is a list of the payment codes:
- G0466 – FQHC visit, new patient
- G0467 – FQHC visit, established patient
- G0468 – FQHC visit, Initial Preventative Physical Exam (IPPE) or Annual Wellness Visit (AWV)
- G0469 – FQHC visit, mental health, new patient
- G0470 – FQHC visit, mental health, established patient
Each of the PPS codes must be submitted with a qualifying code on a separate line. Refer to the following link for a list of qualifying visit codes: FQHC PPS Specific Payment Codes
There are certain services that can be billed for payment outside of the PPS rate. Services may include:
- Technical component of FQHC services
- Certain laboratory services
- Durable medical equipment
- Ambulance services
- Telehealth distant-site services
- Hospice services
- Group services.
See section 60.1 from the following link for a detailed list of exceptions. PPS Billing Exceptions
Non Medicaid/Medicare Billing
Other insurance carriers will follow their own payment system guidelines so it is important to research how claims should be billed to those carriers.
If you didn’t already know, FQHC billing is very different from physician practice billing. To be successful, it is important to have key billing personnel who understand this type of billing. Physician Services USA has FQHC knowledge and experience and can help if you have any questions.
Call us today and we’d be happy to answer your questions and/or set up a free practice consultation @ 800-599-7183 or email: firstname.lastname@example.org.