Federally Qualified Health Centers (FQHCs) are paid a PPS rate for every visit, whether the visit is simple or complex. But, it is still important to select the correct level of E/M service based on medical decision making (or time) and documentation.
Most FQHCs also have some fee-for-service patients, as well, and revenue for those visits varies by the fee associated with the code. This presentation will describe code selection for E/M services using the new guidelines, with FQHCs in mind.
Recorded on June 24, 2021
Coding for services in Federally Qualified Health Centers (FQHCs) is different than coding for free-standing medical practices or health system clinics. Services provided to patients under the FQHC Prospective Payment System (PPS) are reported differently than to patients with private insurance, in the same clinic. This webinar will describe what constitutes a visit, who may perform an FQHC visit, and what services may be provided. This overview will describe coding, and will only briefly discuss billing.
After the presentation, participants will be able to:
- Describe a qualifying visit and who may perform it
- Explain the importance of diagnosis coding when an FQHC is part of an ACO
- Identify CPT, HCPCS and ICD-10-CM codes that relate to pay for reporting
Please note: AAPC requires a score of 70% correct or better to receive the CEU certificate.
*This program has the prior approval of AAPC for 1 continuing education credit. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.
Clinicians find doing minor office procedures easier than coding for these procedures. Sometimes, they do the procedure but find it too difficult to select the code. Sometimes, the documentation doesn’t support the service. This presentation will describe the key elements of frequently performed office procedures, and when to bill and when not to bill an office visit on the same day.
Preventive medicine services are important services done by FQHC pracititioners. This session describes the coding differences between problem-oriented visits, Medicare wellness visits, and CPT preventive services. The session also describes when to report both a problem-oriented visit and a preventive service, and how to document it.[mepr-show rule="24639"]
Correct diagnosis coding gets a claim paid in an FQHC. But, accurate and complete diagnosis coding also communicates the acuity of the patient and population of patients. This introduction to risk-based diagnosis coding describes the important principles and commonly diagnosed conditions in Federally Qualified Health Centers.
CMS has released guidance about paying for telehealth services in Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs). These payments were authorized by the CARES Act passed at the end of March, but CMS had yet to issue instructions for how RHC’s and FQHC’s could be paid for telehealth services.
For services provided using telemedicine (real-time, interactive, audio and visual) between Jan. 27, 2020 (the day the public health emergency was declared) and June 30, 2020, CMS says to add modifier 95, synchronous telemedicine services rendered via real-time interactive audio and visual video telecommunication system, on the claim.
CMS notes that RHCs will be paid at the all-inclusive rate (AIR) and FQHCs will be paid at the Prospective Payment System (PPS) rate. CMS states, in bold,
“These claims will be automatically reprocessed in July when the Medicare claims processing system is updated with the payment rate. RHCs and FQHCs do not need to resubmit these claims for the payment adjustment.”
This is somewhat puzzling to me. Any claims for telehealth services prior to this instruction probably were not submitted to CMS. It seems to me they would need to be resubmitted with modifier 95 appended. For services going forward via telehealth, until June 3, 2020, use modifier 95.
For telehealth services performed starting July 1, 2020 until the end of the public health emergency use HCPCS code G2025 to identify services that were furnished via Tele health in an RHC or an FQHC these claims will be paid at the $92 rate.
- The visit must use real-time, interactive, audio and visual telecommunication systems
- Practitioners can furnish these services from any location, including home
Although CMS says that RHCs and FQHCs can also bill on-line digital E/M codes, 99421—99423 and virtual communication code G2012 and G2010, these are reported with HCPCS code G0071. G0071 will be paid at $24.76 beginning March 1, an increase from the prior rate of $13.53.
MACs will automatically reprocess claims with G0071 for claims processed after March 1. The new rate is a blended rate, based on the payment rates of 99421—99423, and the two HCPCS codes for virtual communication, G2012 and G2010. There are articles about those services on CodingIntel.
RHCs and FQHCs are paid an all-inclusive rate (AIR) or national prospective payment system (PPS) rate for any service that is defined as a visit to their facility. A visit may be with a physician, non-physician practitioner (NPP), psychologist or social worker.
There are some differences in RHC and FQHC rules, but in general, a service identified by a CPT® code is submitted with a revenue code and is paid at the AIR/PPS rate for each type of facility. Links to the CMS fact sheets for each type of service are listed at the end of this post, as well as FAQ about these services.
Wellness visits in an RHC and FQHC—additional payment in a FQHC
Medicare developed HCPCS codes for three services generally considered wellness visits. These are:
- G0402 for the welcome to Medicare visit,
- G0438 for an initial annual wellness visit and
- G0439 for a subsequent annual wellness visit.
There are resources on CodingIntel that describe patient eligibility and the service requirements for each.
When one of these wellness visits is performed in an RHC, it is paid the same as for any other service defined as a visit. However, when a wellness visit is provided in an FQHC, it is paid at 134% of the PPS rate. This provides an incentive to provide the wellness visits in an FQHC.[mepr-show rule="24639"]
New patient visits
Payment for new patient visits in an FQHC are also paid an additional 34%.
G0071: virtual communication
CMS is paying for virtual communication services done in RHCs or FQHCs using code G0071. Beginning March 1, 2020, the rate of payment for that code is $24.76.
TCM in an RHC or FQHC
Transitional Care Management (TCM) services are services provided by a physician or NPP to help the patient transition from a facility (inpatient hospital stay, observation stay, nursing home, or partial hospitalization) to a non-facility setting (home, or independent living at an assisted living facility).
It requires a direct contact, such as a phone call, within two business days, a patient with moderate or high complexity, a face-to-face E/M service and non-face-to-face care. In an RHC or FQHC, it is billed on the day of the face-to-face visit, and paid at the same rate as a visit.
Unlike TCM services provided in a free standing physician office or provider based clinic, there is no additional reimbursement for TCM in these two settings.
Care coordination in RHCs and FQHCs
In recent years, CMS has paid primary care practices to coordinate the care of patients with chronic illnesses. In addition to TCM, noted above, CMS pays for coordination of care for patients with chronic illnesses.
And starting in 2017, using HCPCS codes, and transitioning to CPT® codes in 2018, CMS paid primary care practices for collaboration of care and behavioral health integration.
Recognizing that RHCs and FQHCs provide care coordination in underserved areas, CMS now pays for these services in those places of service, as well. If an RHC or FQHC provides these services, the health center does not use CPT® codes but instead uses HCPCS codes that CMS developed for use by them.
The face-to-face service requirement is waived when performing care management services.
The CMS frequently asked questions starts at the beginning. Care management services are considered RHC and FQHC services, but there is no requirement to bill them, and no special enrollment required in order to provide them.
CCM in an RHC or FQHC
Chronic care management (CCM) billing in an RHC and FQHC changed as of January 1, 2018. Code 99490, chronic care management) is no longer recognized.
Instead, CMS developed a HCPCS code, G0511 to encompass chronic care management and general behavioral health integration.
G0511 General Care Management Services: Minimum of 20 minutes per calendar month
This code, with a payment rate of $62.28, is used for all services that would have been billed with code 99490, chronic care management and code 99487, complex chronic care management. It may also be used for services represented by the new CPT® code 99484.
Service elements must include:
- All elements of CCM services billed previously under CPT® codes 99490 or 99487
- Initial assessment or follow-up monitoring, including use of applicable validated rating scales;
- Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;
- Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and
- Continuity of care with a designated member of the care team.
There is a second HCPCS code that correlates with CPT® code 99492 and 99493. Here, CMS has again developed only one HCPCS code, G0512, with a payment rate of $145.08.
G0512 – Psychiatric Collaborative Care Model services: Minimum of 70 minutes in the first calendar month of psychiatric CoCM services and at least 60 minutes in subsequent calendar months for CoCM services. Service elements provided by the members of the CoCM team must include:
- Outreach and engagement of patients;
- Initial assessment, including administration of validated scales and resulting in a treatment plan;
- Entering patients into a registry for tracking patient follow-up and progress;
- Participation in weekly caseload review with psychiatric consultant and modifications to treatment, if recommended;
- Provision of brief interventions using evidence-based treatments such as behavioral activation, problem- solving treatment, and other focused treatment activities;
- Tracking patient follow-up and progress using validated rating scales;
- Ongoing collaboration and coordination with treating FQHC and RHC providers; and
- Relapse prevention planning and preparation for discharge from active treatment.
These are services that are billed under the physician or NPP’s provider number, not under the behavioral health care provider’s NPI.
Both G0511 and G0512 require an initiating E/M service, which could be the welcome to Medicare visit or a wellness visit for new patients, or those not seen within the past year.
Excerpts from CMS FAQ
Unlike TCM, there is additional payment for G0511 and G0512 for both RHCs and FQHCs.
According to the FAQ CMS document,
“Except for TCM which is not separately payable if furnished on the same day as another billable visit, care management services are paid in addition to the RHC or FQHC billable visit.”
“Q18. If an RHC submits a claim for a billable visit and a care management service, is the total payment subject to the RHC payment limit? A18. Except for TCM, which is paid as an RHC visit, payments for G0511 and G0512 are not factored in to the RHC AIR. The RHC would be paid 80% of their rate for the billable visit, subject to the RHC payment limit, plus 80% of the rate for care management.
Q19. If an FQHC submits a claim for a billable visit and a care management service, would these be added together to determine the payment? A19. No. The FQHC would be paid 80% of the lesser of its charges or the fully adjusted PPS rate for the billable visit, plus 80% of the rate for G0511 or G0512 ($62.28 and $145.08 respectively).”
FQHCs have an added financial incentive to perform wellness visits.
Both FQHCs and RHCs can be paid for care coordination, if their health centers have staff in place to perform the services and systems in place to document the service.
Why not bill all 99213 visits in an FQHC? (Hint: it's a good way of telling everyone that they were pretty easy visits.)
Practitioners who work in Federally Qualified Health Centers (FQHCs) can get in the habit of billing all level three office visits, understanding that an FQHC is paid under the Prospective Payment System (PPS rate) for patients with Medicare and Medicaid. Whether the visit was a simple visit or the patient had a complex and time-consuming set of problems, the health center is paid the same rate for patients with Medicare and Medicaid. FQHCs are paid based on the visit, not by the number or complexity of visits performed. For patients paid under the PPS rate, there are only two types of medical services paid at a higher rate: new patient visits and Medicare wellness visits. Those are paid at 134% of the PPS rate.
When a practitioner uses mostly 99213 visits, they are telling the administrator, their medical director, and the payer that the patient visits are pretty easy. They are communicating that the disease burden of their patients is simpler than seen in other primary care practices. Of course, diagnosis coding also tells the story to administration and to payers about acuity. But level of service is important as well.
E/M frequency data
|New OV||Family Medicine||Internal Medicine||Established office visits||Family Medicine||Internal Medicine|
This CMS data from the entire country shows the level of service billed by internists and family physicians. It is not meant to be prescriptive, of course. But physicians, nurse practitioners, and physician assistants can compare their own distribution of new and established patient visits with those billed by their peers across the country. If their distribution is significantly different than this norm, they can ask themselves why. Are my patients really simpler and easier to care for the other patients or am I selecting a level of service incorrectly? Or, conversely, if their distribution shows more high-level visits, ask the opposite question.
No one expects that all clinicians will have the same distribution of office visit codes. A clinician may mostly do walk-in or same day appointments, and have more lower-level office visits. A practitioner may see the more complex patients in the practice with multiple chronic conditions, see fewer patients in a day, but each is complex. Practices vary.
Selecting a level of service
Office visit codes are selected based on either time or medical decision making, beginning in 2021. Selecting all level three visits because it is the easiest and most familiar can incorrectly communicate the level of work that they are doing. It sends this message: "My patients are not very sick. " “Today’s appointment schedule was a piece of cake.”
In addition, most FQHC's have some patients with private insurance. Private insurance can amount to 10%, 20%, or even 30% of the population of patients. It wouldn’t be compliant, and it doesn't make sense compliant to select the level of service based on the patient’s insurance. The reasonable course of action is to select the level of office visit based on either time or medical decision-making for all patients that are seen, as defined by CPT. Moving from using essentially all 99213 visits to some 99213 and some 99214 visits can provide immediate revenue (resources) for the FQHC from commercial payers. FQHCs are required to have a sliding fee scale for self-pay patients, so accurate coding doesn’t penalize those patients.
There are resources on CodingIntel that can help practitioners select the accurate level of service using the new 2021 E/M guidelines, as well as information from the American Academy of Family Physicians and the American College of Physicians. Not to mention the American Medical Association.
Selecting codes at the end of an encounter has two purposes (okay, three, if you can’t that it allows you to close the note and see the next patient). It gets the claim paid. And, it communicates to the payer the acuity of the patient and the panel of patients. Select the level of service with that in mind.