Medical Coding for prenatal care in Federally Qualified Health Centers (FQHCs) can be complex due to the unique nature of these healthcare facilities, especially when it involves dual insurance, such as commercial and Medicaid.
Here are some specific challenges and potential solutions:
● Dual Insurance Coordination Challenge: Coordinating medical billing and coding processes for patients with both commercial and Medicaid coverage can be complex.
● Solution: Establish clear workflows and communication channels between clinical staff, outpatient coders, inpatient coders, and billing teams to ensure proper coordination. Develop protocols for identifying dual-coverage patients early in the process.
Billing Restrictions for Global Delivery
● Challenge: Medicaid may not allow billing for global delivery, even if the same provider offers both prenatal care and delivery. Commercial insurers usually want global delivery codes.
● Solution: Implement a mechanism, such as attaching a charge ($.00) to prenatal Evaluation and Management (E&M) levels, to prevent individual prenatal visits from being billed to the commercial payer.
Notification of Pregnancy-Ending Events
● Challenge: Clinical staff must notify outpatient coders if a patient with commercial insurance has a pregnancy-ending event. If the patient was seen three times or less, then individual E&M codes, with full price, need to be added to each visit and billed out.
● Solution: Develop a system for clinical staff to promptly communicate relevant information to outpatient coders, allowing them to code individual prenatal visits appropriately with E&M codes.
Transitioning to Medicaid Coding
● Challenge: Transitioning from commercial to Medicaid coding after delivery can lead to potential errors or delays.
● Solution: Establish a notification system to inform both outpatient and inpatient coding teams of commercial payments. This should trigger the transition to Medicaid coding. Provide training to ensure coding teams are well-versed in the specific requirements of each insurance type
Adjusting Global Delivery Codes
● Challenge: Inpatient coders need to change global delivery codes to ‘delivery-only’ codes for Medicaid.
● Solution: Implement a clear process for inpatient coders to adjust global delivery codes when transitioning from commercial to Medicaid billing.
Coding Individual Prenatal Visits for Medicaid
● Challenge: Outpatient coders will need to code individual prenatal visits or use antepartum care codes for Medicaid billing.
● Solution: Ensure outpatient coders are notified so they can update prenatal visit coding.
Special Contracts for Prenatal Care with Medicaid
● Challenge: FQHCs may have special contracts with Medicaid for prenatal care which require specific coding details.
● Solution: Establish a process for sharing contract details with coding teams to ensure accurate medical coding and billing are in alignment with the terms of the contract and Medicaid regulations.
Consistent communication, comprehensive staff training, and implementation of standardized workflows is crucial for addressing prenatal care coding challenges effectively in an FQHC setting. Keeping abreast of changes in coding guidelines and payer policies is also essential for maintaining compliance and optimizing reimbursement.
Contact CodeEMR today to learn more about how FQHCs nationwide are benefitting from Code EMR’s comprehensive and specialized medical coding services.