TMPPM 2010 > Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook > Titles V, X, and XX Family Planning Services > Services/Benefits, Limitations and Prior Authorization > Title V and XX Family Planning Office or Outpatient Visits > FQHC Reimbursement for Title V and XX Family Planning Office or Outpatient Visits

5.3.2.1 FQHC Reimbursement for Title V and XX Family Planning Office or Outpatient Visits

To receive the encounter rate for a general family planning visit FQHCs must use the most appropriate E/M procedure code for the complexity of service provided as indicated previously in the tables in Section 4.5.3.

FQHCs may be reimbursed for 3 family planning encounters per client per year regardless of the reason for the encounter. The 3 encounters may include any combination of general family planning encounters, an annual family planning examination, or procedure code J7300 or J7302.

The new patient procedure codes will be limited to one new patient E/M procedure code 3 three years following the last E/M visit provided to the client by that provider or a provider of the same specialty in the same group. The annual examination must be billed as an established patient visit if E/M services have been provided to the client within the last 3 years.

Reimbursement for services payable to an FQHC is based on an all-inclusive rate per visit.

A general family planning office or outpatient visit (billed without modifier FP) will not be reimbursed when submitted with the same date of service as an additional E/M visit. Providers may appeal denied claims using modifier 25 if the reason for the additional visit was for a separate, distinct service from the family planning visit. Documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client's medical record and made available to Texas Medicaid upon request.

Refer to: Section 3, "Federally Qualified Health Center" in the Outpatient Services Handbook, (Vol. 2, Provider Handbooks) for more information about FQHC services.