Federally qualified health centers (FQHCs) act as a safety net for underserved areas or populations. These healthcare facilities are mostly funded. Federal insurance plans such as Medicare and Medicaid cover the medical and mental health services provided at these health centers. Moreover, some third parties, like Preferred Provider Organizations (PPOs), Health Maintenance Organizations (HMOs), and Managed Care Organizations (MCOs), provide FQHC coverage.
You can get your rightful reimbursements as long as you are a qualifying center. However, the medical coding requirements may overwhelm you. Therefore, we will discuss the most used HCPCS codes for FQHCs in this guide to help you stay on top of your coding game. So, without further ado, let’s get started!
Most Common FQHC HCPS Codes
Here are the most common HCPCS codes for FQHC:
HCPCS Code G0466 – FQHC Visit, New Patient
This FQHC ‘G’ Code covers a one-on-one (face-to-face), medically necessary encounter between an FQHC clinician and a new patient. This visit may include one or more FQHC services. Also, a standard services bundle would be provided to the Medicare beneficiary receiving medical service at the health center.
For the unversed, a new patient can be defined as someone who has not received any mental health or medical care services from any healthcare provider within the FQHC organization, including any sites within the organization, in the past three years before the service date.
Applicable Scenario for G0466
Here’s an example! Assume a new patient with a whooping cough arrived at the FQHC. The practitioner conducted a thorough examination of the Medicare-enrolled patient, requested a chest X-ray, and prescribed medication. He will bill FQHC HCPCS code G0466 to Medicare for the new patient encounter at an FQHC.
Note that if a patient receives a mental health and medical checkup on the same day, then the patient will be considered ‘new’ for only one of these encounters. You can use this code to report the medical encounter and G0470 to bill the mental health visit that follows for accurate reimbursements.
HCPCS Code G0467 – FQHC Visit, Established Patient
If a one-on-one (face-to-face), medically necessary encounter happens between a qualified FQHC healthcare provider and an established patient, the G0467 HCPCS code for FQHC will be used to report the visit. However, during this encounter, the physician must render one or more FQHC services and include a standard services bundle that would be provided to a Medicare beneficiary per diem.
Any person who has received mental health or professional healthcare services from any FQHC practitioner and at any site within the FQHC organization in the past three years before the service date may be referred to as an established patient.
Applicable Scenario for G0467
Consider an established patient with a history of diabetes and hypertension who visited an FQHC for a routine checkup. During the encounter, the healthcare provider charted the patient’s comprehensive medical history and performed a physical examination, including blood sugar level and blood pressure monitoring, and based on the findings, adjusted the medication.
The provider also counseled the patient on diabetes management. Since it was an established patient FQHC visit with multiple qualifying services, FQHC HCPCS code G0467 will be reported.
HCPCS Code G0468 – FQHC Visit, IPPE or AWV
If an FQHC visit with a standard Medicare service bundle includes an Annual Wellness Visit (AWV) or Initial Preventive Physical Exam (IPPE), then you must report FQHC ‘G’ Code G0468.
Applicable Scenario for G0468
Let’s assume a scenario! A long-time FQHC patient scheduled an AWV. The healthcare practitioner performed a comprehensive health assessment, reviewed the medical history, discussed current medications, and provided dietary counseling addressing the patient’s weight gain concerns during the encounter. Here, G0468 will apply for rightful reimbursements.
HCPCS Code G0469 – FQHC Visit, New Patient, Mental Health
You may report FQHC HCPCS code G0469 if one or more FQHC services are performed, including Medicare’s standard services bundle, and the face-to-face encounter between a qualified FQHC healthcare provider and a new patient is categorized as a mental health visit. The definition of the new patient remains the same.
However, note that the visit must include a qualified mental health service, such as psychotherapy or psychiatric diagnostic evaluation, to qualify as an FQHC mental health visit. Also, if the patient receives mental and medical health services on the same day, the patient is considered ‘new’ for only one of these visits. Thus, you must report FQHC ‘G’ codes G0469 and G0467 to bill for mental health and medical visits, respectively.
Applicable Scenario for G0469
A new patient encountered a qualified FQHC practitioner due to severe anxiety and difficulty sleeping. The clinician performed a psychiatric diagnostic evaluation to understand the reason behind the patient’s distress. Since it was the patient’s first mental health visit in the past three years, G0469 is applicable.
HCPCS Code G0470 – Mental Health, Established Patient, FQHC Visit
You may report the G0470 HCPCS code for FQHC to bill a face-to-face, medically necessary mental health visit between an FQHC clinician and an established patient during which one or more FQHC services are delivered, including Medicare’s standard services bundle. The established patient definition remains the same as discussed in the G0467 description.
Besides, if an established patient receives a mental health and medical visit on the same day, you are eligible to bill for two visits with G0467 for the medical visit and FQHC ‘G’ Code G0470 for the mental health visit. However, the mental health visit must include qualified mental health services, such as psychotherapy or psychiatric diagnostic evaluation.
Applicable Scenario for G0470
Assume an established patient with a history of depression returned for a scheduled therapy session at the FQHC. The therapist rendered a 45-minute psychotherapy to address the symptoms of depression and educate the patient on various coping strategies.
FQHC Billing Guidelines
Discussed below are the FQHC billing guidelines to help you ensure proper claim submission and faster reimbursements:
Verify Patient Eligibility
Verifying the patient’s insurance eligibility is key to ensuring timely reimbursements. Thus, we recommend that before you prepare the claim, first determine whether the patient is enrolled in a plan, like Medicare, Medicaid, or third-party payers, or whether the entire financial responsibility falls on the patient himself.
Ensure Accurate Coding
Understand the Medicare FQHC ‘G’ codes and identify the respective qualifying medical or mental health services. Also, determine whether the patient is new or established to ensure accurate medical coding. Errors in assigning codes may lead to underpayments, delayed payments, denials, or even financial penalties.
If you don’t have certified professional coders (CPCs) in-house, we recommend you outsource medical coding to a medical billing firm like MediBillMD.
Understand Bundled Services
Billing medical or mental health services for FQHC is tricky as it often involves more integrated care solutions or bundled services. As a result, you must educate and train your staff on accurate coding guidelines and service bundles to ensure they do not unbundle services unnecessarily. Unbundling services for higher reimbursements can lead to audits and lawsuits, jeopardizing your healthcare center’s reputation.
Establish Medical Necessity
As you may have already noted in every FQHC ‘G’ code description, the encounter between the patient (new or established) and qualified FQHC practitioner must be medically necessary. Thus, you must justify the medical necessity and appropriateness of the rendered mental health or medical care services with comprehensive documentation. If the insurance payer finds that the provided documentation is insufficient, they may reject the claim, resulting in an unsteady cash flow.
Bottom Line
This guide discussed in detail the most common HCPCS codes for FQHC. These included G0466 for a new patient, FQHC visit, G0467 for an established patient, FQHC encounter, G0468 for IPPE or AWV, G0469 for a new patient, mental health visit, and G0470 for an established patient, mental health encounter.
Besides, we shared the FQHC billing guidelines, including verifying patient eligibility, ensuring accurate coding, understanding bundled services, and establishing medical necessity. With all this information, if you still find it challenging to navigate the complex FQHC billing landscape, why not outsource FQHC billing services to professionals?
