Wiki Federally Qualified Healthcare Centers

[Nardajr]

Since FQHC's don't always bill a traditional CPT code, do they still have to follow the CPT guidelines when obtaining HPI? Example: FQHC's will bill Medi-Cal an "01", this is an office visit. They do not use a 99211-99215 as most traditional offices. So, when it comes to meeting all the of the components as outlined by CPT, are they still held to the same rules? I say yes, however I would like to hear what others know about this. And, does anyone know where I can find written instruction on where the guidelines are for FQHC on this topic?

 

[ckeeney]

I would request guidance from your Medi-Cal provider rep or search their manual since this is Medi-Cal's billing rules, but I would guess that, yes, you must comply with CPT E/M documentation guidelines. In other states like Indiana, FQHC's are required to bill with the appropriate CPT E/M plus a "T" code from HCPCS II that designates an FQHC service. Also, national Medicare rules require all CPT codes for the services be included on the claim even though billing/payment is determined by the prospective payment rules.

 

[arrana]

In MA, we have several payers that require T1015 as an all-inclusive code instead of EM codes or CPT codes. My providers still document and code as if we submitted EM codes; the billers manually 'correct' the codes prior to submission. Because the providers are not doing anything different, they still follow all the EM documentation guidelines. I don't know if the payers have issued a directive on this, but I feel that the documentation still needs to support the visit and charges (even though we get paid an encounter rate regardless of what charges we attach to the claim).

 

[khristinelouise]

Even though you may not be required to use a cpt code when billing it affects your bottom line when you don't. Everything that goes on in a visit should be recorded because it affects your cost (overhead) and that is part of what they use to determine your payment amount.