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Clarification of Mental Health Billing and Services in an FQHC Setting

Attn: Licensed professional counselors (LPC), licensed mental health counselor (LMHC), and licensed marriage and family therapists (LMFT) billing mental health services in federally qualified health centers (FQHC)

We are conducting a medical review on FQHC claims in which mental health services are provided to Medicare beneficiaries. We would like to clarify mental health billing and who can perform mental health services in an FQHC setting. Several providers are receiving denials for services/visits provided by professionals that are not considered to be core providers in an FQHC. Core providers include:

  • Physicians
  • Nurse practitioners
  • Physician assistant (PA)
  • Certified nurse midwife
  • Clinical psychologist (CP)
  • Clinical social worker (CSW)

The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual Publication (IOM) 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 40 (614 KB) discusses what is considered to be a billable visit in an FQHC setting and states:

An RHC or FQHC visit is a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more RHC or FQHC services are rendered.

The criteria for CP and CSWs can be found in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 150 (614 KB) which states:

A CP is an individual who:

    • Holds a doctoral degree in psychology, and
    • Is licensed or certified, on the basis of the doctoral degree in psychology, by the state in which he or she practices, at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals.

A CSW is an individual who:

    • Possesses a master’s or doctor’s degree in social work;
    • After obtaining the degree, has performed at least 2 years of supervised clinical social work; and
    • Is licensed or certified as a clinical social worker by the state in which the services are performed; or, in the case of an individual in a state that does not provide for licensure or certification, meets the requirements listed in 410.73(a)(3)(i) and (ii).

Services may include diagnosis, treatment, and consultation. The CP or CSW must directly examine the patient, or directly review the patient’s medical information. Except for services that meet the criteria for authorized care management services, telephone or electronic communication between a CP or CSW and a patient, or between such practitioner and someone on behalf of a patient, are considered CP or CSW services and are included in an otherwise billable visit. They do not constitute a separately billable visit. CSWs are statutorily authorized (1861(hh)(2) of the Act) to furnish services for the diagnosis and treatment of mental illnesses only.

Services provided by licensed counselors are not considered to be payable in the FQHC setting as these professionals are not considered to be Core Providers and are not able to provide services incident to a CP or CSW. CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 15, Section 15.4.4 (2.52 MB) discusses Individual practitioners that can enroll in the Medicare Program. LPC, LMHC and LMFT, to name a few, are not listed providers that can enroll in Medicare.

A mental health visit is a medically necessary face-to-face encounter between a patient being treated at and FQHC and an FQHC practitioner during which time one or more FQHC mental health services are rendered. Mental health services qualify as a stand-alone billable visit in an FQHC as listed in the FQHC qualifying list in the CMS Specific Payment Codes for the Federally Qualified Health Center Prospective Payment System (FQHC PPS) (323 KB). The services furnished must also be within the practitioner’s state scope of practice.

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 170 – Mental Health Visits (614 KB) states:

Medicare-covered mental health services furnished incident to an RHC or FQHC visit are included in the payment for a medically necessary mental health visit when an FQHC practitioner furnishes a mental health visit. Group mental health services do not meet the criteria for a one-one-one, face-to-face encounter in an FQHC or RHC.

Therefore, mental health services may only be billed and paid when provided by an FQHC core provider in the FQHC setting.

Clarification of Mental Health Billing and Services in an FQHC Setting
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