# FQHC Medicare Claims



## Asmith2284 (Mar 11, 2015)

We recently switched from AIR to PPS Medicare Rate.  We are were told that we cannot bill out Procedures (wart removal, ear wax removal, skin tag, etc) our supervisor wants us to switch them from procedures to an E/M visit. I need to know if any other FQHC is doing this?


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## ntreber (Apr 10, 2015)

I also work for an FQHC and this is our understanding. The new codes are for a medical necessary face to face visit. they are divided by New and Established patients. you need to list the appropriate "G" code with its pricing and then any CPT codes that apply to the visit and there pricing. you will be paid 80 % of the lesser of your "G" code rate or the PPS rate for your area. ( which ever is less) 
example for an established pt that has an excision for a benign lesion
G0467 - $$$
11400- $$$
hope this helps.


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## Asmith2284 (Apr 13, 2015)

are you getting paid for wart removals, blood draws, ear wax removals, A1c, and allergy shots.  if you are not than are you having the patient sign an ABN waiver what policies do you have in place for these services? We have billed out these services and rcvd denial stating they are not eligible for pymt. Any information would be helpful!


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## smontague (Jun 9, 2015)

We haven't started the PPS yet...we start July 1st, but I did want to respond to your notation about blood draws, etc.  As an FQHC you should not be billing those services unless they are done in conjunction with an E/M service.  Anything performed by a nurse is "non-billable" unless performed at the same time as a MD encounter.  As en example, if a patient came in and saw the nurse to have blood drawn only then you can't bill those services to Medicare.  If they saw an MD for a 99212 and also saw the nurse to have blood drawn then you would include the blood draw.  

You can still bill procedures (i.e. wart removals or lesion removals) and Medicare will cover them if they are medically necessary.  Allergy shots run along the same line as the blood draw.  If they are given in conjunction with a clinician encounter then they can be included on the claim.  If the patient sees the nurse only then they can not be billed.  

I'm not sure how all FQHC clinics work, but I know we have certain charges that are not included in our FQHC services but we can still bill them to Medicare but we have a separate NPI that they have to be billed under.  This is how we bill a lot of our diagnostic ancillary services (i.e. A1c testing, flu testing, urinalysis, PFTs, etc.)

I hope this helps.


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## tamil_u (Oct 16, 2015)

*Fqhc*

I work for an FQHC and you cannot bill out procedures alone, they must have one of the accepted codes (usually an E/M code) with the procedure. If the patient comes in and only has a lesion removed, Medicare will not pay this under the FQHC, however if there is an office visit level in addition to the procedure you can bill it. 

What I would like to know, is how do you explain the extra charges to a patient who thinks you are double billing or committing fraud by adding the PPS G codes onto the claim. Its impossible to explain in a way that people can understand.


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## amys2361 (Nov 2, 2015)

Would the blood draws, allergy shots be billed to the part B MAC?
I know technicals are to billed to the part B MAC?Example: the ekg technical 93005 vs.93010.


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## arrana (Mar 11, 2016)

Procedure codes don't "roll up" into any of the 5 G codes under Medicare PPS, so if the patient is coming in for the procedure only and there is no significant and separately identifiable service that warrants an E/M code in addition, you cannot bill the procedure. We tried all scenarios of submitting, none passed the Medicare edits - the claims were not accepted into their system. If you have a patient sign an ABN, and they select option A - that you will bill Medicare, the ABN is pointless because you cannot submit the claim. Unfortunately these services are adjusted off. We have a podiatrist who does mostly procedures, a dermatologist who is always removing something, and a couple of other providers who do a lot of joint injections and biopsies... We can't bill for any of it.

As for explaining to the patients who call upset about the charges, we do our best to tell them it is a new Medicare requirement, but Medicare is only paying on the G code. If they don't accept our answer, we advise them to call Medicare....

Oh the joys of FQHC!

Arrana


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## LeaHarris (Mar 17, 2016)

*More Information??*

Does anyone happen to have a link or know where to find on the CMS website about the guidelines of FQHC billing with Medicare?  It seems like everyone is having the same problems and I would like to learn more about them so I can educate my clinic.  We just transitioned to an FQHC in November.  Yikes!  It's like learning a whole new language!


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## arrana (May 3, 2016)

Check out this link... should tell you all you need to know about FQHC billing to Medicare.

https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html


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