The most common FQHC billing mistakes are: non-qualifying encounters billed as PPS visits, incorrect visit consolidation when multiple services occur on the same day, missing or incorrect G-codes, failure to capture all sliding fee scale documentation, and inadequate documentation supporting the qualifying provider's face-to-face encounter.
For Medicare FQHC PPS reimbursement, a qualifying visit requires a face-to-face encounter with an eligible FQHC provider (physician, NP, PA, CNM, clinical psychologist, or LCSW) and must include a medical, mental health, dental, or preventive service. The encounter must be coded with an appropriate visit CPT code and the relevant HCPCS G-code for the visit type.
FQHC billing refers to the specialized revenue cycle management for Federally Qualified Health Centers. It differs from standard medical billing in that FQHCs receive a Prospective Payment System (PPS) reimbursement rate from Medicaid and Medicare — a fixed all-inclusive rate per visit rather than fee-for-service — requiring unique coding, encounter documentation, and cost reporting practices.
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