FQHC Billing Explained

Federally qualified health centers (FQHCs) were created in 1991 in order to provide access to health care services in both under-served rural and urban communities. Unlike Rural Health Centers (RHCs), FQHCs are required to provide primary care services across every stage of the life-cycle, offer preventive dental care or have an arrangement with another provider to do so, and have admitting privileges at a local hospital, or present a hospital plan that ensures continuity of care for their patients.

From a billing perspective, FQHCs are reimbursed on an all-inclusive model under Medicare and Medicaid, although they can bill certain services separately with the appropriate codes and documentation. Other FQHC requirements:

Collect the 20 percent coinsurance under Medicare where applicable (no Part B deductible applies). Must provide after-hours care, either within FQHC providers or through an after-hours arrangement. Use a sliding fee scale based on federal poverty guidelines. Even though FQHCs are reimbursed with an all-inclusive rate by Medicare and Medicaid, claim forms must be submitted with all the appropriate CPT and HCPCS codes or the claim will be automatically denied.

FQHC Billing Specifics

Let's look at some common FQHC billing scenarios and the billing guidelines that apply.

FQHC Encounters

A face-to-face encounter (defined as diagnosis, therapy, consultation, surgery) between a patient and physician, PA, nurse practitioner, nurse midwife, clinical psychologist, or clinical social worker in which a covered service is performed may be billed with the following caveats:

• The encounter must occur in an outpatient setting between the patient and a core provider. This includes a Part A stay in a skilled nursing facility.

• A CP or CSW may not bill for encounters with a patient's family members, only for services provided to the patient himself.

• Multiple encounters on the same day, or visits with more than one provider at the same location, are billed as one unit.

• Services provided by non-physician providers are billable if the provider is an employee of the clinic, the services are covered under Medicare if a physician provided them, and state law permits NPPs to perform them.

Preventive Services

A FQHC can bill for the following preventive services:

• Initial Physical Preventive exam to include screening ECG if needed, end of life planning, and patient counseling after results are received.

• Annual Wellness Visit to include vital signs, family history updates, and health risk assessment.

• Preventive Screenings to include prostate and colorectal cancer screen, diabetes screen, mammogram, screening pelvic exam, and Pap smear.

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Telehealth Services

FQHCs may bill for Telehealth services in lieu of face-to-face encounters for the following services if the system provides for real-time two-way communication:

• Office Visits

• Consultations

• Individual Psychotherapy

• Medication Management

• Neurological Status Exam

• Individual or Group Medical Nutrition Therapy

Diabetes Self Management Training and Medical Nutrition Therapy

Registered dietitians or registered nurses who can provide the appropriate credentials for certification in DSMT can provide these services, which are eligible services provided the following conditions are met:

• Cannot be billed if provided in a group setting; group services do not meet the criteria for a face-to-face encounter.

• Group DSMT and medical nutrition therapy sessions are included in the all-inclusive FQHC rate.

• Individual DSMT and medical nutrition therapy sessions can be billed as a separate item and payment is made in addition to a qualifying visit.

Services That Are Not Covered

The following products and services are not eligible for payment if provided by an FQHC (list is not comprehensive):

• Neck, Back, Arm, or Leg braces

• Prosthetics, Including arms, Legs, Eyes

• Services Provided in a Hospital

• Technical Components of mammograms, Bone density exams, or Other cancer screening tests