Billing

Reporting Multiple Qualifying Visits on the Same Date of Service for FQHC Reimbursement

FQHC providers are reimbursed based on a PPS, which pays the facility for all services provided during a qualifying visit. In addition to reporting the appropriate payment code and qualifying visit HCPCS/CPT code to identify the billable encounter, all services performed incident to such an encounter must also be included on a single claim. This claim generates a single PPS reimbursement payment for the FQHC.

The only exceptions to guideline occurs when there are multiple qualifying visits that occur on the same date of service:

  • There is a qualifying medical visit that is provided on the same date of service as a qualifying mental health visit.
  • There is a qualifying medical visit that is provided on the same date of service as another qualifying medical visit, when the patient, subsequent to the initial medical visit, suffers an illness or injury that requires additional diagnosis or treatment.

With either of these exceptions, both visits need to be reported on a single claim. Each visit should be represented by an appropriate payment code and qualifying visit HCPCS/CPT code to identify the billable encounter, and all services performed incident to each encounter. In the case of two separate medical visits, the second payment code should be reported with modifier XE to identify the return visit is separate and medically distinct from the initial visit. These types of claims would generate two PPS reimbursement payments for the FQHC.

What happens when an FQHC submits a separate claim for the mental health visit/subsequent medical visit that were performed on the same date of service as an initial medical visit?

The second claim will be RTP as a duplicate or overlapping claim. This RTP claim is not reimbursed. Additional provider action is required.

How does an FQHC address a subsequent medical visit/mental health claim that qualifies to receive a PPS reimbursement once the claim has been RTP?

Do not attempt to correct the RTP claim. Doing so will not address the duplicate/overlapping claim error.

Do not submit an appeal. The appeals process only applies to claims that have been DENIED (status/location D B9997). Submitting an appeal for a claim that has been RTP is not appropriate.

In a situation where the initial claim for the medical visit has already been submitted, an FQHC would adjust the initial claim to add the mental health visit or subsequent medical encounter.

  1. Wait for the initial claim to process. Once processed, the claim will be in P B9997 status/location.
  2. Adjust the processed claim to add the mental health visit or subsequent medical encounter.

    • FISS users: report claim change reason code D2 (changes to revenue/HCPCS/HIPPS rate codes) and adjustment reason code OT (other change)

  3. Include all services provided incident to the mental health visit or subsequent medical encounter.
  4. Resubmit the adjusted claim.
  5. The adjusted claim will reprocess and generate two PPS reimbursement payments for the FQHC.

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Posted 6/21/2022