Priority Management Group – CHC Billing Experts

In a CHC wouldn’t the post partum be included in the delivery billing code since we billed the 59410 which is vaginal delivery with post partum care?

In short, yes. HOWEVER, if FQHC and the post partum occurs at the clinic site for Medicaid, they will normally want the T1015 for the postpartum so… would recommend billing 59409 for FQHC unless the state Medicaid program has more exacting instructions stating otherwise. Assuming we are not billing this for Medicare BUT could happen for SSI patient so in that case definitely use the 59409 and the UGS/NGS encounter rate would work for the office based post-partum encounter.

I have a question, can you bill for a visit to a family practice physician and a psychiatrist on the same day?

For UGS/NGS Medicare on a UB-04 claim the psych visit uses a 900 series revenue code with the appropriate behavioral health HCPCS (e.g., CPT code 90406) while the family practice doctor uses revenue code 521 with the appropriate medical service HCPCS (e.g., CPT code 99212). Full encounter rate payment is eligible less variable co-payments; i.e., the behavioral health component is near 50% while the medical is the standard 20% of charges.

Medicaid is similar to Medicare in this scenario, in nearly all states, except no co-payment. Commercial payers would also allow both to be paid due to two distinct provider specialties based on national board certification.

I have a question on billing out Nursing Visits (re: dressing changes, suture removals, etc) currently we enter these types of visits in our system but do not bill them to insurance companies.  As a FQHC can we bill these types of services to Medicare and Medicaid and if so, can you advise us on how what the guidelines would be as to who/what needs to be recorded in patients chart and if we would bill using the revenue code for Medicare or bill to NHIC, with Medicaid the T1015 or fee for service?

Thanks for the note. To be clear, there is distinction between Medicare and Medicaid on this topic. UGS/NGS Medicare payment is NOT available for nurse visits. This is incontrovertible. However, certain states (e.g., Vermont and Connecticut), have language within the Medicaid FQHC manuals which clearly affords payment opportunity for services rendered “incident to” a core provider.  The language for each state is unique so take a look yourself via the following URL. The T101, not fee for service, would be appropriate as this is what triggers encounter rate payment.

http://www.hrsa.gov/reimbursement/states/Vermont-Medicaid-Covered-Services.htm

According to CMS regulations, under Chapter 13 in the Medicare Benefit Policy Manual, 60.1, would fetal non-stress tests performed in the office setting fall under Incidental and Integral part of physician’s professional services, making it necessary for the physician to be on site in order to bill for the service?

In short, don’t think so.   CMS recognizes three levels of supervision: general, direct, and personal. General supervision means the billing.provider does not even need to be on-site; e.g., lab, ultrasound.  Direct means the billing provider needs to be in the office suite “within shouting distance;” e.g., residency supervision or “incident to” billing. Personal supervision means in the exam room with the patient; e.g., personal oversight of surgical resident if wanting to bill as attending. Thinking fetal stress testing (like ultrasound) falls under “general supervision” not requiring physical presence of the billing doctor.  

With exception of SSI patients, questioning how many OB services are rendered to Medicare patients.  Can research whether fetal stress tests definitely fall under “general” supervision, or not, if desired.

By Robert Skeffington, Partner, PMG, Inc.

Now that the celebrations have ended and the confetti has been cleared, it’s time to consider how the Patient Protection and Affordable Care Act will impact Federally Qualified Health Centers (FQHCs).

As one of the most effective federal programs, FQHCs are poised to continue their prominence. Nearly everyone agrees that covering more individuals with health insurance is a positive step forward, as is substantially growing the FQHC program. But what, if anything, will change in the revenue and/or billing process as a result of the new law? Patient revenues from Medicaid, Medicare and other payers make up more than 50 percent of an FQHC’s revenue. As such, this question requires further examination.But what, if anything, will change in the revenue and/or billing process as a result of the new law? Billing is more than half of the average FQHC’s annual revenue, so this question requires a closer look.

(more…)