Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 4. Federally Qualified Health Center (FQHC) : 4.2 Services, Benefits, Limitations, and Prior Authorization

4.2 Services, Benefits, Limitations, and Prior Authorization
The services listed in the tables below may be reimbursed to FQHCs using the National Provider Identifier (NPI). Any additional services must be submitted for reimbursement using the provider’s Medicaid provider identifier.
Refer to:
Subsection 6.3.5, “Modifiers” in Section 6, “Claims Filing” (Vol. 1, General Information) for a definition of modifiers.
Section 4, “Texas Health Steps (THSteps) Dental,” and Section 5, “THSteps Medical,” in Children’s Services Handbook (Vol. 2, Provider Handbooks).
Section 3, “Women’s Health Program (Title XIX Family Planning),” and Section 4, “Department of State Health Services (DSHS) Family Planning Program Services,” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks).
Section 4, “Vision Care Professionals,” in Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks).
Section 4, “Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC),” in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Subsection 8.2.60.1.2, “Preventive Care Visits” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Section 6, “Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers,” in Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Subsection 6.12.2.2, “Managed Care Organization (MCO) Copayments” in Section 6, “Claims Filing” (Vol. 1, General Information).
Medicaid coverage is limited to FQHC services that are covered by Texas Medicaid and are reasonable and medically necessary. When furnished to a client of the FQHC, medically necessary services include the following:
Types of FQHC visits are defined in 1 TAC §355.8261. A visit is a face-to-face encounter between an FQHC client and a physician, PA, NP, CNM, visiting nurse, qualified clinical psychologist, clinical social worker, other health-care professional for mental health services, dentist, dental hygienist, or optometrist. Encounters that take place on the same day at a single location with more than one health-care professional or multiple encounters with the same health-care professional constitute a single visit, except where one of the following conditions exists:
The FQHC client has a medical visit and an other health visit such as 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 checkup.
All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. They are not billable as a separate encounter.
Registered nurses may not be the sole provider of a medical checkup in an FQHC. If immunizations are given outside of a THSteps medical checkup, procedure codes given in the THSteps section of this manual should be used. These procedure codes are informational only, and are not payable.
To be reimbursed for Case Management for Children and Pregnant Women, an FQHC must be approved as a case management services provider by the DSHS Case Management Branch.
An annual family planning examination is allowed once per state fiscal year (September 1 through August 31), per client, per provider. An FQHC may be reimbursed for up to three family planning encounters per client, per year, regardless of the reason for the encounter. The three encounters may include any combination of general family planning encounters, an annual family planning examination, or intrauterine devices. Family planning services must be submitted with the most appropriate E/M procedure code and one of the following family planning diagnosis codes:
Procedure code 58300 must be submitted on the same claim as J7300 and J7302. Procedure code 58300 will process as informational only. Only the annual family planning examination requires modifier FP. All other family planning visits do not require the FP modifier. Claims filed incorrectly may be denied.
FQHC providers may receive Title XX reimbursement for WHP wrap-around services that are rendered during a visit where the primary purpose of the visit is not related to contraception and is not reimbursed by the WHP.
FQHC providers may receive Title XX reimbursement for the following services that are rendered to WHP clients when the primary diagnosis is not related to contraception:
Follow-up Pap tests. To receive Title XX reimbursement, DSHS contractors must file a separate Title XX claim with diagnosis code 6229. DSHS contractors may be reimbursed for the Pap test, an appropriate counseling code, and the appropriate visit code.
Follow-up visits for sexually transmitted disease/infection (STD/STI) testing. To receive Title XX reimbursement for a visit that is strictly for the purposes of STD/STI testing for a WHP client, DSHS contractors must file a separate Title XX claim with a diagnosis code of V016. DSHS contractors may be reimbursed for STD/STI tests and STD/STI-related services.
Pregnancy-test-only visits. To receive Title XX reimbursement for a visit that is for a pregnancy test only, DSHS contractors must file a separate Title XX claim with diagnosis code V7240.
Claims that are submitted by FQHC providers for wrap-around services but are considered part of a WHP encounter will be subject to retrospective review as these claims are not eligible for Title XX reimbursement. Any wrap-around services that are determined to have been paid in error may be recouped.
Refer to:
Section 3, “Women’s Health Program (Title XIX Family Planning),” and Section 4, “Department of State Health Services (DSHS) Family Planning Program Services,” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks).
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 previously-mentioned payable 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).
Per federal regulations, the provider cannot submit claims to Medicaid or bill the client for vaccines obtained from the Texas Vaccine for Children (TVFC) Program.
Refer to:
Section 5, “THSteps Medical,” in Children’s Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.