Why not bill all 99213 visits in an FQHC?

Why not bill all 99213 visits in an FQHC? (Hint: it’s a good way of telling everyone that they were pretty easy visits.)

Practitioners who work in Federally Qualified Health Centers (FQHCs) can get in the habit of billing all level three office visits, understanding that an FQHC is paid under the Prospective Payment System (PPS rate)  for patients with Medicare and Medicaid. Whether the visit was a simple visit or the patient had a complex and time-consuming set of problems, the health center is paid the same rate for patients with Medicare and Medicaid.  FQHCs are paid based on the visit, not by the number or complexity of visits performed. For patients paid under the PPS rate, there are only two types of medical services paid at a higher rate: new patient visits and Medicare wellness visits. Those are paid at 134% of the PPS rate.

When a practitioner uses mostly 99213 visits, they are telling the administrator, their medical director, and the payer that the patient visits are pretty easy. They are communicating that the disease burden of their patients is simpler than seen in other primary care practices. Of course, diagnosis coding also tells the story to administration and to payers about acuity. But level of service is important as well.

E/M frequency data

New OV	Family Medicine	Internal Medicine		Established office visits	Family Medicine	Internal Medicine
99201	0.00%	0.00%		99211	2.40%	2.29%
99202	7.80%	4.39%		99212	2.19%	2.38%
99203	38.33%	24.57%		99213	33.33%	32.42%
99204	48.21%	55.73%		99214	58.05%	57.32%
99205	5.65%	15.32%		99215	4.03%	5.59%

Data above is from 2021, released in late 2022.

This CMS data from the entire country shows the level of service billed by internists and family physicians. It is not meant to be prescriptive, of course. But physicians, nurse practitioners, and physician assistants can compare their own distribution of new and established patient visits with those billed by their peers across the country. If their distribution is significantly different than this norm, they can ask themselves why. Are my patients really simpler and easier to care for the other patients or am I selecting a level of service incorrectly? Or, conversely, if their distribution shows more high-level visits, ask the opposite question.

No one expects that all clinicians will have the same distribution of office visit codes. A clinician may mostly do walk-in or same day appointments, and have more lower-level office visits. A practitioner may see the more complex patients in the practice with multiple chronic conditions, see fewer patients in a day, but each is complex. Practices vary.

Selecting a level of service

Office visit codes are selected based on either time or medical decision making, beginning in 2021. Selecting all level three visits because it is the easiest and most familiar can incorrectly communicate the level of work that they are doing. It sends this message: “My patients are not very sick. ” “Today’s appointment schedule was a piece of cake.”

In addition, most FQHC’s have some patients with private insurance. Private insurance can amount to 10%, 20%, or even 30% of the population of patients. It wouldn’t be compliant, and it doesn’t make sense compliant to select the level of service based on the patient’s insurance. The reasonable course of action is to select the level of office visit based on either time or medical decision-making for all patients that are seen, as defined by CPT.  Moving from using essentially all 99213 visits to some 99213 and some 99214 visits can provide immediate revenue (resources) for the FQHC from commercial payers. FQHCs are required to have a sliding fee scale for self-pay patients, so accurate coding doesn’t penalize those patients.

There are resources on CodingIntel that can help practitioners select the accurate level of service using the new 2021 E/M guidelines, as well as information from the American Academy of Family Physicians and the American College of Physicians. Not to mention the American Medical Association.

Selecting codes at the end of an encounter has two purposes (okay, three, if you can’t that it allows you to close the note and see the next patient). It gets the claim paid. And, it communicates to the payer the acuity of the patient and the panel of patients. Select the level of service with that in mind.

CodingIntel members: there are additional FQHC coding resources in the FQHC section of our specialty page.

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