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December 2016 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
The services listed in the tables below may be reimbursed using the FQHC’s National Provider Identifier (NPI). Any additional physician services must be submitted for reimbursement using the physician’s Medicaid provider identifier. Hospital services are not considered for reimbursement to FQHC providers, and cannot be billed using the facility provider number assigned to the FQHC.
 
 
 
 
 
 
* Procedures cannot be performed by Psychologist. Mental health services must be submitted using one of the appropriate modifiers AH, AJ, AM, U1, or U2.
 
 
THSteps medical services must be submitted using modifier EP in addition to one of the appropriate modifiers AM, SA, or U7.
Note: Procedure code 99420 is a benefit for Texas Medicaid clients who are 12 through 18 years of age and is limited to once per lifetime.
 
 
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 the Children’s Services Handbook (Vol. 2, Provider Handbooks).
Subsection 2, “Healthy Texas Women (HTW) Program Overview” in the Women’s Health Services Handbook (Vol. 2, Provider Handbooks).
Section 3, “Health and Human Services Commission (HHSC) Family Planning Program Services,” in the Women’s Health Services Handbook (Vol. 2, Provider Handbooks).
Section 4, “Vision Care Professionals,” in the 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 the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Subsection 9.2.56.1.2, “Preventive Care Visits” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Section 6, “Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers,” in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks).
Subsection 8.8.2.2, “HMO Copayments” in “Section 8: Third Party Liability" (Vol. 1, General Information) for information about HMO copayments.
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 evaluation and management (E/M) procedure code and one of the following family planning diagnosis codes:
 
Procedure code 58300 must be submitted on the same claim as J7297, J7298, J7300, and J7301. 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.
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 the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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