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O.3 Reimbursement
WHP noninstitutional professional services are covered by the Texas Medicaid Program (Title XIX) and considered for payment on an existing reimbursement schedule based on provider type. Services are also on a fee-for-service basis, even in areas with managed care.
FQHCs are paid according to the existing prospective payment system (PPS). Up to three encounter rates per calendar year per client may be reimbursed to FQHCs for WHP visits when only family planning services occurred during the visit. To obtain the encounter rate, FQHCs must bill family planning services provided during a WHP visit using one of the following procedure codes: 1-99204 with modifier FP, 1-99214 with modifier FP, or 1-J7300. These procedure codes must be submitted in conjunction with the most appropriate informational procedure codes for services that were rendered.
For any family planning service other than an intrauterine device or an annual exam with a new patient, FQHCs should bill code 1-99214 with modifier FP with the claim so FQHCs can receive an encounter rate reimbursement. This includes family planning services that are not annual exams and visits where only a contraceptive injection is provided. FQHCs are only reimbursed for procedure codes 1-99204, 1-99214, and 1-J7300. All other procedure codes are marked as "informational." Procedure codes 1-99204 and 1-99214 must be billed with modifier FP.
Hospital-based ambulatory surgical centers and free-standing ambulatory surgical centers may be reimbursed for procedure codes F-58600, F-58615, F-58670, and F-58671.
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