ProviderBillingCommunication

FederallyQualifiedHealthCenterServices(FQHC)/RuralHealthClinic(RHC)
WellCareofGeorgiawillbepayingFederallyQualifiedHealthCenters(FQHC)andRuralHealthCenters (RHC)basedonaProspectivePaymentSystem(PPS)rateprovidedbytheDepartmentofCommunity Health. ThisupdateisbeingimplementedbasedonrecentcontractchangesfromtheDepartmentofCommunity HealthdirectingallCareManagementOrganizations(CMOs)toadjustcontractswithFQHCandRHC providerstoreimbursebasedonthePPSrate. BillingGuidelines CommonlyUsedModifiers FP=FamilyPlanning EP=ServiceprovidedaspartofMedicaidEPSDTprogram AJ=Clinicalsocialworkersrenderingservices PlaceofServiceCode WhenbillingCPTandHCPCScodes,theFQHC/RHCshouldbilltheappropriatePlaceofServiceCodeonthe claimform. EnterPlaceofServicecode50(FederallyQualifiedHealthCenter[FQHC])inBlock24B(Placeof Service)onCMS1500claimform. EnterPlaceofServicecode72(RuralHealthClinic[RHC])inBlock24B(PlaceofService)onCMS 1500claimform. PlaceofServicecodes11(Office)or99(OtherPlaceofservice)arenotacceptedwhenrendering serviceinaFQHC/RHC. RevenueCodes ProviderBased(HospitalBased)ruralhealthclinicsmustidentifyservicesprovidedontheUB92 formbyusingRevenuecode521forruralhealthservices,Revenuecode522forhomevisit servicesbyapractitionerandRevenuecode527forVisitingNurseservicestoamembershome wheninahomehealthstoragearea. Revenuecode636shouldbeusedforreportinginjectabledrugs.

Providers will receive the allinclusive Prospective Payment System (PPS) rate per FQHC/RHC visit. A service visit must be reported in order for a provider to be paid a PPS rate. Services and supplies incident to a service visit include those services commonly furnished in a physicians office and ordinarily rendered without charge or are included in the practices bill, such as laboratory/pathology services,radiologyservices,ordinarymedications,suppliesusedinapatientservicevisit.

CodingInstructions Multiple encounters with the same health professional on the same day at a single location constitute a single visit for billing purposes. If separate reimbursement is warranted and a denial is received, the providermustsubmitMedicalRecordsforpaymentreconsideration. NPInumbermustbereportedintheappropriatefieldontheCMS1500andUB04Form. CodesdeletedfromthepreviouseditionsoftheCPTManualarenotreimbursableandshould notbesubmitted. CodesdeletedforthepreviousICD9CMManualarenotreimbursableandshouldnotbe submitted. CodetothehighestlevelofspecificitywhenreportingICD9CMdiagnosticcodes. E(E8000E9999)andM(M8000M9970/1)arenotacceptablewhenreportingservices renderedintheFQHC/RHC. CodesforUnlistedProcedureswhichendsin99arenotacceptedandshouldnotbe submitted. NationalDrugCode(NDC)numberisrequiredalongwiththeinjectabledrugcodeontheclaim form. EvaluationandManagementServices
OfficeorOtherOutpatientServices NewPatient EstablishedPatient HospitalObservationServices HospitalObservationDischargeServices InitialHospitalObservationServices HospitalObservationorInpatientCareServices (IncludingAdmissionandDischargeServices) HospitalInpatientServices InitialHospitalCare SubsequentHospitalCare HospitalDischargeServices Consultations OfficeConsultations InitialInpatientConsultations EmergencyDepartmentServices NeworEstablishedpatient CriticalCareServices Adult(over24monthsofage) Pediatric Neonatal NursingFacilityServices InitialNursingFacilityCare SubsequentNursingFacilityCare OtherNursingFacilityservices 9920199205 9921199215

99217 9921899220

9923499236

9922199223 9923199233 99238

9924199245 9925199255

9928199285

9929199292 9947199472 9946899469

9930499306 9930799310 99318

 HomeServices NewPatient 9934199345 EstablishedPatient 9934799350 PreventiveMedicineServices(HealthCheckVisits) PleaserefertoHealthCheckManualAppendixCforproperbillingwithEPmodifier,whenappropriate NewPatient 9938199385 EstablishedPatient 9939199395 NewbornCare 9946099465 AntepartumandPostpartumCare: AntepartumCare 5942559426 PostpartumCare 59430 ServicesofClinicalPsychologistsandLicensedClinicalSocialWorkers: CentralNervousSystemAssessment/Test 96101,96102 PsychiatricDiagnosticorEvaluativeInterviewProcedures 90801,90802 PsychiatricTherapeuticProcedures 9080490814,90846,90853 OfficeorOtherOutpatientServices NewPatient 9920199205 EstablishedPatient 9921199215 VisionCareServices(Oneencounterpermemberperday): OphthalmologicalServices 92002,92004,92012,92014 OfficeorOtherOutpatientServices NewPatient 9920199205 EstablishedPatient 9921199215 PodiatryServices: OfficeorOtherOutpatientServices NewPatient 9920199205 EstablishedPatient 9921199215 OfficeorOtherOutpatientServices NewPatient 9920199205 EstablishedPatient 9921199215 PregnancyRelatedServices: 99342,99347,99348 PerinatalCaseManagement: T2022

FamilyPlanning ModifierFP(FamilyPlanning)shouldbeenteredinBlock24HontheCMS1500claimform. TheappropriatediagnosticcodeindicatingfamilyplanningserviceshouldbeenteredinBlock 24EontheCMS1500claimform. AppropriateCPTcodesforreportingfamilyplanningvisitsarelocatedwithintherangeof99201 99215. LaboratoryServices Laboratoryservicesarenotseparatelyreimbursable.Laboratoryservicesmustbelistedonthe claimforminconjunctionwiththeFQHC/RHCvisit. Centerscollectingspecimensandforwardingthemtoanindependentorpublichealthlaboratory maynotbillforthecollectingandhandling(99001)orforthetestproceduresaswell. LaboratoryproceduresrequiredtobesenttotheStatelaboratoriesarenotseparately reimbursableandmustperformedbytheStatelaboratory. ObstetricalServices ServicesforantepartumandpostpartumcaremustbereportedusingtheappropriateCPTcode indicatingtheservicesprovided.TheseserviceswillbereimbursedatthePPSrateforthe FQHC/RHCpervisit. GlobalOBCPTcodesshouldnotbebilledbytheFQHC/RHC. TheFQHC/RHCwillbereimbursedattheFeeforServiceratefortheapplicabledeliveryonlyCPT code. RadiologyServices Radiologyservicesarenotseparatelyreimbursable.Radiologyservicesmustbelistedonthe claimforminconjunctionwiththeFQHC/RHCvisit. HealthCheckVisits ToreportHealthCheckvisits,usetheappropriateCPTcodeslistedwithintherangeof99381 99385and9939199395. ModifierEP(ServiceprovidedaspartofMedicaidEPSDTprogram)mustbereportedinBlock 24HontheCMSclaimform HealthcheckcodesarereimbursableatthePPSrateforeachvisit HealthCheckCodesSeparatelyBillableatFeeforServices(FFS)Rate Listed below are the Interperiodic Vision Only and Hearing Only Procedure Codes that are separately reimbursableoutsideofanEPSDTservice.(SeeAppendixDintheHealthCheckManual) Service CPTDescription CPT4
Screeningtestofvisualacuity, quantitative,bilateral Screeningtest,puretone,aironly Puretoneaudiometry(threshold);air only Puretoneaudiometry(threshold);air andbone Speechaudiometrythreshold Speechaudiometrythreshold;with speechrecognition Screeningtestofvisualacuity,quantitative,bilateral Screeningtest,puretone,aironly Puretoneaudiometry(threshold);aironly Puretoneaudiometry(threshold);airandbone Speechaudiometrythreshold Speechaudiometrythreshold;withspeechrecognition 99173 92551 92552 92553 92555 92556

 Listed below are Immunization, Tuberculin Skin Test, and Blood Lead Level Screening Procedure Codes thatareseparatelyReimbursablewithaHealthCheckvisit.(SeeAppendixEintheHealthCheckManual)