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Guidelines for FQHC Medical Billing

February 21, 2023

Federally qualified health centers (FQHCs) are funded by the government and provide necessary care to those who live in underserved areas, or for those with little to no insurance coverage. 

Accuracy is a key component of FQHC medical billing services to ensure the facility remains compliant and can continue providing valuable services that result in positive patient outcomes.  

What Is FQHC Medical Billing? 

FQHC medical billing is not that dissimilar to billing for an outpatient private practice, but certain stipulations are in place to ensure the facility remains compliant. 

FQHCs must collect Medicare coinsurance, provide after-hours access for patients, and use a sliding scale for the services offered in the facility. Reimbursement is based on services that are bundled together, so it’s imperative for FQHCs to follow the strict guidelines set forth by the Centers for Medicare and Medicaid (CMS) to avoid denied claims. 

Coronis health two fqhc medical workers going over paperwork

Additionally, the entire process of billing, from patient registration to collecting unpaid patient balances, needs constant attention to protect the facility from losing revenue or losing the ability to treat its patients. Hiring an expert billing team is the start of creating success for an FQHC.  

Understand the Billing and Coding Guidelines for FQHCs 

Medical billing for FQHCs is more involved than billing for standard private practices. The guidelines for billing and coding services for an FQHC are strict, if not set in stone. FQHC claims submitted to CMS with billing and coding errors, such as incorrect current procedural terminology (CPT) and healthcare common procedure coding system (HCPCS) codes, will not be paid. 

These guidelines are in place to ensure that coders review documentation with a fine-toothed comb and use current codes that apply to ICD-10. Billers must also focus on what services are billable. 

The following simple, but critical, guidelines must be followed for FQHCs: 

  • Face-to-face encounters – Only designated healthcare providers may render services to patients in an FQHC, and they must be in person in an outpatient setting. Encounters in a skilled nursing facility (SNF) where Medicare Part A applies are permitted. 
  • Mental health providers or social workers – may meet with family members, but may only bill for the services rendered to the patient 
  • Preventive services – Annual wellness visits (AWV), physicals, and screenings are billable through FQHCs. Additional services – screening electrocardiograms, end-of-life planning, and follow-up counseling related to test results – are also billable. 
coronis health fqhc healthcare worker talking on phone at computer

CMS also outlines specific codes for encounters, including time spent with the patient, amount of time counseling, if two billable encounters were completed on one day, or if the patient received advanced care planning (ACP) or chronic care management. 

Understanding the high level of specificity of billing and coding requires the attention of an expert who is always up to date on the latest changes with ICD-10 and HCPCS codes and billing regulations set forth by CMS.  

Stay Up to Date on Changes With FQHC Medical Billing Regulations 

FQHC billing regulations are in a constant state of flux. CMS uses the prospective payment system (PPS) for a more controlled rate of reimbursement for rendered services, but the rates within the PPS are updated annually to ensure they are in line with market variations and the cost of goods and services. FQHC billing experts understand the importance of these changes and how they can affect the accuracy of coding and claims submission. 

The CMS website has one full page dedicated to FQHCs and news related to billing and payments for everything from the pandemic to telehealth. Overall, these changes can significantly affect the outcomes of revenue cycle management for an FQHC.     

Use the Correct FQHC Billing Codes to Ensure Timely Reimbursements 

FQHC billing is quite different from the typical outpatient or hospital clinic as it requires a higher level of specificity that correlates with the PPS. The following are unique codes relate to patient encounters in an FQHC: 

  • G0466 – new patient 
  • G0467 – established patient 
  • G0468 – initial preventive physical exam (IPPE) or annual wellness visit (AWV) 
  • G0469 – new patient, mental health 
  • G0470 – established patient, mental health 

This is just a sampling of encounter codes, but claims must also include specific FQHC revenue codes with the appropriate HCPCS code. Timing for special visits such as Advanced Care Planning (ACP) also requires unique CPT codes and modifiers to designate how much time was spent with a patient. Additionally, “incident to” billing is allowable from an FQHC with appropriate coding for the services rendered by a non-physician provider, such as a nurse practitioner or physician assistant. From preventive medicine to telemedicine, all claims submitted by an FQHC must be accurate down to the modifier to avoid any delays in reimbursement.   

Tips for Reducing Denials and Improving Collection Rates 

FQHC medical billing can be complex, but you don’t want denials or problems with collections to turn that complexity into an impossibility. Claim denials and a reduced collection rate can easily spell disaster for the revenue cycle of an FQHC, but taking action with these tips can give you peace of mind and a path for improving both your denial and collection rates. 

Coronis health fqhc medical worker talking to patient
  • Focus on capturing accurate eligibility information – ensure your staff is well-versed in collecting accurate demographic and insurance information on each patient, and all benefits are verified prior to rendering services.  
  • Transition to automated tools – use electronic health records and electronic billing systems to create more efficiency in the clinic. 
  • Have open, informative conversations regarding financial responsibility with patients –  encourage them to use their patient portal to inquire about bills. 
  • Focus on your processes – make sure you have as much of your process automated as possible to save time and reduce errors on gathering patient information for registration, checking eligibility, and coding for an office visit. 
  • Ensure your coders and billers are always updated – ensure they stay abreast of compliance changes and regulatory updates with CMS to avoid potential claim denials. 

If your employees are bogged down with so much of the revenue cycle process that it affects collections and reimbursement, consider outsourcing your coding and billing to experts who can ensure that your claim denials disappear and your collection rates skyrocket.  

Why Choose Coronis Health As Your Revenue Cycle Management Partner 

FQHC billing experts understand the importance of coding specificity and billing regulations that result in a high rate of reimbursement, a low rate of claim denials, and an overall efficient revenue cycle management process. When you outsource your revenue cycle management to Coronis Health, you recognize that the most important mission of your clinic is caring for the patients. Give your team the freedom to focus on patients, and let Coronis Health take care of your coding, billing, financial reporting, and revenue cycle management process. Request your free financial checkup and get started today. 

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