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FQHC and Group Therapy Services Job Aid
Historically, federally qualified health center’s (FQHC’s) billing instructions have been the same. However, effective 1/1/2011, the billing requirements changed for this facility type. Beginning with dates of service on or after 1/1/2011, when billing Medicare, FQHCs must report services provided during the encounter/visit by listing the appropriate HCPCS code. The additional revenue lines with detailed HCPCS code(s) are for information and data gathering purposes in order to develop the FQHC Prospective Payment System (PPS). The additional data will not be utilized to determine current Medicare payments to FQHCs. The Medicare claims processing system will continue to make interim payments under the current FQHC interim per-visit payment rate methodology with final payments determined within the Medicare cost report.
Billing
It has been brought to National Government Services’ attention that FQHCs are submitting group therapy codes with a revenue code in the 52X series. Group therapy is not a payable benefit for FQHCs. The changes effective 1/1/2011, did not change the policy.
Currently, National Government Services rejects claims submitted with revenue code 0900 and group therapy codes. National Government Services will reject claims submitted with revenue 0521 or any code from the 52X series, when a group therapy code is submitted. Since these services are considered at cost report time, FQHCs are being instructed not to submit them on their claims for payment. The reason code applicable to this type of billing error is 7C935.
Only therapy between a patient and a physician, clinical psychologist or clinical social worker is billed to National Government Services. However, group therapy is covered and reimbursed through the Medicare cost report.
Related Content
The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 9, (215 KB) for billing information as it specifically relates to FQHCs. The UB-04 Specification Manual provides definitions of UB-04 fields which include, among other codes, revenue codes to assist providers with coding claims correctly. It can be purchased thorough National Uniform Billing Committee Web site: http://www.nubc.org/. It is called the NUBC Official UB-04 Data Specifications Manual. There is an annual fee for the manual. Providers also receive updates throughout the year.