FQHC Billing for Behavioral Health and SUD Services

FQHC medical billing is similar to outpatient private practice billing, but certain restrictions apply to ensure the facility remains compliant. FQHCs must collect Medicare coinsurance, provide after-hours access for patients, and offer services on a sliding scale. As reimbursement is based on bundled services, it is critical for FQHCs to adhere to the strict guidelines established by the Centers for Medicare and Medicaid (CMS) to avoid denied claims.

Furthermore, the entire billing process, from patient registration to collecting unpaid patient balances, requires constant attention to keep the facility from losing revenue or the ability to treat its patients. Let’s have a look at the guidelines related to FQHC billing for behavioral health and SUD services:

FQHC Billing Guidelines for for Behavioral Health and SUD Services

Medical billing for FQHCs is more complex than billing for standard private practices. The billing and coding guidelines for a FQHC are strict if not set in stone. FQHC claims submitted to CMS with billing and coding errors, such as incorrect CPT and HCPCS codes, will be denied. These guidelines are in place to ensure that coders thoroughly review documentation and use current ICD-10 codes. Billers must also consider which services can be billed.

For FQHCs, the below-mentioned simple but critical guidelines must be followed:

  • Only designated healthcare professionals may provide services to patients in an FQHC, which must be done in person in an outpatient setting. Encounters are permitted in a skilled nursing facility (SNF) where Medicare Part A applies.
  • Mental health providers or social workers may consult with family members, but they may only bill for services provided to the patient.
  • FQHCs bill for preventive services such as annual wellness visits (AWV), physicals, and screenings. Additional services are billable, such as screening electrocardiograms, end-of-life planning, and test-result follow-up counseling.

CMS also specifies specific codes for encounters, such as the amount of time spent with the patient, the amount of time spent counseling, whether two billable encounters were completed on the same day, or whether the patient received advanced care planning (ACP) or chronic care management.

Understanding the high level of specificity of billing and coding necessitates the attention of an expert who is constantly up to date on the latest changes with ICD-10 and HCPCS codes, as well as CMS billing regulations.

FQHC Coding Guidelines 

FQHC coding differs from typical outpatient or hospital clinic coding in that it requires a higher level of specificity that corresponds with the PPS. The following are specific codes for patient encounters in a FQHC:

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

This is only a partial list of encounter codes; claims must include specific FQHC revenue codes and the appropriate HCPCS code. Timing for special visits, such as Advanced Care Planning (ACP), necessitates using unique CPT codes and modifiers to indicate the amount of time spent with a patient. Furthermore, “incident to” billing from an FQHC with appropriate coding for services rendered by a non-physician provider, such as a nurse practitioner or physician assistant, is permitted. To avoid reimbursement delays, all claims submitted by an FQHC must be accurate down to the modifier, from preventive medicine to telemedicine.

Tips for Correct FQHC Billing for Behavioral Health and SUD Services

FQHC medical billing and coding can be complicated, but you don’t want denials or collection issues to make that complexity impossible. Claim denials and a low collection rate can quickly spell disaster for an FQHC’s revenue cycle, but following these tips can provide you with peace of mind and a path to improving both your denial and collection rates.

  • Concentrate on capturing accurate eligibility information to ensure that your staff is proficient in gathering correct demographic and insurance information on every patient and that all benefits are verified before rendering services.
  • Change to automated tools and use electronic health records and billing systems to increase centre efficiency.
  • Engage patients in open, informative conversations about financial responsibility and encourage them to use their patient portal to inquire about bills.
  • Concentrate on your processes; ensure that as much of your process as possible is automated to save time and reduce errors when gathering patient information for checking eligibility, registration, and coding for an office visit.
  • Ensure that your coders and billers are always up to date to be aware of compliance changes and regulatory updates from CMS to avoid potential claim denials.

Stay up-to-date with 24/7 Medical Billing Services!

FQHC billing and coding regulations are constantly changing. CMS employs the prospective payment system (PPS) to provide a more controlled reimbursement rate for rendered services. Still, the PPS rates are updated annually to meet market variations. FQHC billing experts understand the significance of these changes and how they can affect coding and claim submission accuracy. That’s why contacting the 24/7 Medical Billing Services experts is recommended to stay up-to-date and ensure correct FQHC billing and coding to enhance reimbursements for behavioral health and SUD services.

Even the CMS website has an entire page dedicated to FQHCs medical billing and payment information ranging from the pandemic to telehealth. Overall, these changes can significantly impact a FQHC’s revenue cycle management outcomes.

See also: How To Ensure Accurate Medical Billing For Your Substance Use Disorder (SUD)


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