TMPPM 2007 >21.3 Benefits and Limitations

Medicaid coverage is limited to services provided by the center that are covered by the Texas Medicaid Program and are reasonable and medically necessary.

When furnished to a client of the FQHC, medically necessary services include the following:

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Other ambulatory services included in Medicaid such as family planning, Texas Health Steps (THSteps), birthing center, and maternity service clinic (MSC).

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Services and supplies necessary for services that would be covered otherwise, if furnished by a physician or a physician service.

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Visiting nurse services to a homebound individual, in the case of those FQHCs located in an area with a shortage of home health agencies.

A visit is a face-to-face encounter between an FQHC client and a physician, PA, NP, certified nurse-midwife (CNM), visiting nurse, qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exists:

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After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment.

A medical visit is a face-to-face encounter between an FQHC client and a physician, physician assistant, NP, CNM, or visiting nurse.

An other health visit includes, but is not limited to, a face-to-face encounter between an FQHC client and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a THSteps medical check up.

All services provided that are incident to the encounter should be included in the total charge for the encounter and are not billable as a separate encounter. For example, if an office visit was provided at a charge of $30 and a lab test for $15, the center would bill TMHP procedure code 1-T1015 for $45 and would be reimbursed at the center's encounter rate.

Reminder: An encounter is defined as a face-to-face meeting between an FQHC client and a physician, PA, NP, CNM, visiting nurse, qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist.

All services (except for family planning, THSteps medical, THSteps dental, immunizations, and case management for high-risk pregnant women and infants) provided during an encounter must be billed using procedure code 1-T1015.

Laboratory and radiology services or the services of a licensed vocational nurse (LVN), registered nurse (RN), nutritionist, or dietitian are not considered an encounter, because they are incidental to an encounter with one of the above-mentioned health-care professionals. Providers should continue to include the cost associated with these services on their cost report (they are allowable but do not constitute an encounter).

When an FQHC sees a client younger than 21 years of age for immunizations that are not part of a THSteps check up, the FQHC should bill for the administration of the immunization on the UB-04 CMS-1450 or CMS-1500 claim form using their FQHC provider identifier and the appropriate Medicaid procedure code. If the client is seen only for immunizations, an encounter should not be billed. There is no change in the billing procedures for those services noted as exceptions. The total billed amount for the service should be the total charge for all services provided during the encounter or incident to the encounter.


Services	Claim Form
CPW case management services	UB-04 CMS-1450 or CMS-1500 claim form
THSteps dental services	American Dental Association (ADA) claim form
THSteps medical services	CMS-1500 claim form.

Services provided by a health-care professional require one of the following modifiers with procedure code 1-T1015, to designate the health-care professional providing the services: AH, AM, SA, TD or TE with place of service (POS) 2, or U7.

If more than one health-care professional is seen during the encounter, the modifier should indicate the primary contact. The primary contact is defined as the health-care professional who spends the greatest amount of time with the client during that encounter.

If the encounter is for antepartum care or postpartum care, the modifier TH must be indicated.

The electronic format or the paper claim form allows for multiple modifiers; therefore, if the antepartum or postpartum care or delivery is provided by a CNM, then modifier SA must be indicated on the claim in addition to the appropriate modifier above.

If a physician of the FQHC provides a service in the hospital such as delivery, the FQHC may elect to bill for that service using the physician's provider identifier, if the contract with the physician indicates this occurrence. If the service is billed using the physician number rather than the FQHC's provider identifier, the costs associated with the service must be excluded from the cost report and will not be considered during the cost settlement/encounter rate setting process.

After-hours care for FQHCs and RHCs is defined as care provided on weekends, on federal holidays, or before 8 a.m. and after 5 p.m. Monday through Friday. After-hours care provided by FQHCs and RHCs do not require a referral from the client's primary care provider. FQHCs and RHCs that provide after-hours services to PCCM clients must submit claims with modifier TU.