On our blog previously, we looked into the basics of what FQHC is. Today we will go through some of the challenges that most practices face when billing for an FQHC service. If you have not read our previous blog, you can read it here

Billing for a FQHC clinic can sometime become tedious and tiresome, specially when you are new to FQHC billing. The way claims are billed to Medicare, Medicaid and Commercial payers are mostly different and varies from State-to-State. This may cause billing confusion and also result in huge number of denials from the insurances. 

For example, when billing for an Evaluation and Management code to Medicare, you cannot bill just the E&M code alone, it should be billed along with a payment code, i.e. G codes. Similarly, you cannot bill only the payment code, i.e. G code, and not report the E&M (Qualifying Visit Code). You can find the complete list of qualifying visit codes and payment codes here

Unlike Medicare, which requires the G code for each encounter, several state Medicaid and Medicaid Managed Care Plans requires claims to be sent with CPT code T1015. Some state Medicaid wants T1015 only, whereas, few other state Medicaid may require you to submit CPT Code T1015 along with all the other procedures on the actual claim.

It is also important that you have a valid Revenue Code on each line item billed on a UB-04 claim. Payers like Medicare Part A will return claims back to your office if the revenue code is not set correctly.

The biller and the practice should know which CPT codes are considered part of more extensive services (bundled, inclusive) so that there are no unnecessary follow up with insurances. Most payers will only pay for either the Payment Code or the Qualifying Visit Code.

Initially, billing for services may be intimidating, because there are specific payer requirements for claims submission. Most of the payers will want these services billed on a UB-04, and non-qualifying visits on a CMS-1500 form: however, there may be times when a payer dictates for all services in an FQHC to be billed on the CMS-1500 form. Revenue codes and UB-type of bill codes can vary, as well, making it essential to have billing staff who can easily differentiate the claims submission process for each type of visit, to each type of payer, and for each type of service the facility is providing. Staff must be able to handle simultaneously traditional billing processes along with those of an FQHC.

How Can Total RCM Help:

We know how important each claim is for your practice and therefore, our priority is to ensure all claims are submitted without errors. The ability to set up EMR based on the State and Insurance requirement is a major challenge for several FQHC Healthcare Professionals, and this is where we excel in. With a vast experience in billing FQHC services, Total RCM can become a partner in success of your practice.