Specialized Medical Coding Expertise Matters for Maximizing CHC Reimbursements
Common CHC and FQHC Coding Challenges
- Financial impact of undercoding: FQHC self-pay patients pay according to a sliding fee schedule, so undercoding, and not accounting for everything during a visit, only hurts a facility’s reimbursement, and doesn’t fully capture the complexities of a patient’s condition.
- Lack of specialized training: Not recording accurate data (CPT, ICD, HCPCs) affects a CHC’s resource allocation, budgeting, and financial planning .
Outsourcing Medical Coding Provides Specialized Solutions
Here are just a few examples where specialized knowledge is required for CHC and FQHC coding:
1. PPS Codes for Medicare and Medicaid
FQHCs require specific Prospective Payment System (PPS) codes, such as G0466, G0467, G0468, G0469, and G0470 for Medicare. Medicaid often uses the PPS code T1015.
2. Qualifying Services and State-Specific Programs and Rules
While Medicare rules for FQHCs are consistent across all states, Medicaid programs vary significantly. It’s important to know the appropriate PPS codes and understand the qualifying services that support them.
FQHCs often have special programs necessitating additional modifiers, including provider and program-specific modifiers. CodeEMR will develop an SOP (Standard Operational Procedures) guide or Job Aide tailored to specific Medicaid plans and unique contracts.
3. Payment Methodologies
FQHCs can opt for different payment methodologies to ensure they receive at least their PPS rate of reimbursement.
For FQHCs receiving PPS rates for Medicare, the definition of a new patient differs from AMA guidelines, and allows you to receive a higher rate for new patients.
It’s also important to accurately capture and report the necessary data (CPT/ICD) for cost reports, which directly impacts payment rates.
4. MIPS and ACOs
Coders need to be knowledgeable about the Merit-based Incentive Payment System (MIPS), and how it influences payments based on quality measures, cost measures, health IT use, and practice improvement activities.
Know how to work with Accountable Care Organization (ACO) programs to ensure accurate risk adjustment, which adjusts Medicare or Medicaid capitation payments according to patient diagnoses.
5. CPT II Codes for Quality Measures
Ensure CPT Category II codes are accurately applied for HEDIS measures that can provide additional payments from some insurances.
6. Fee-For-Service
While FQHCs may use alternative payment methods, fee-for-service remains relevant. It takes specialized knowledge and experience to ensure every service delivered is appropriately coded and reimbursed.
Count on CodeEMR
CodeEMR is a proud sponsor of the National Association of Community Health Centers, partnering with CHCs and FQHCs to establish best practices that optimize reimbursements, increase profits and foster growth. For more information, fill out this brief form, and we will get back to you.
