Federally Qualified Health Centers (FQHC) – Are Your Medical Records Compliant?

November 15, 2017

In 1991, Federally Qualified Health Center(FQHC) benefits were added as a benefit under the Medicare Program, specifically under the Social Security Act. An FQHC is an all-encompassing program, specifically designed to provide comprehensive primary care medical services in underserved urban and rural communities.

  • FQHCs provide a full range of primary care and other specialty services, including Dental, Optometry, Chiropractics, Podiatry, PT, OT, Visiting Nurse, Mental Health, Well Child Care, Pre and Post Natal services, Preventive Care and Vaccinations.

Due to the varying types of services performed at FQHCs, it is vitally important that the documentation and coding of the medical records is complete and accurate. The coding requirements for an FQHC are unlike a traditional facility and professional billing. There are specific payment codes, which represent multiple visit types and services. Patient encounters must be coded with the correct payment code for appropriate payment to be received.

Each service provided by an FQHC has specific documentation guidelines required by the Centers for Medicare and Medicaid Services (CMS). Although EMRs assist with proper medical record documentation, auditors will often find deficiencies and missing information that may impact compliant claim submission.

Utilization of NPPs in the FQHC setting must be closely monitored for billing compliance. CMS provides general guidelines and the individual state where the FQHC is located may have a specific set of regulations pertaining to these services. This is an area of vulnerability for many organizations and should be reviewed to ensure adherence to the guidelines and reduce any potential risk.

Although most FQHCs have an in-house Compliance Department performing internal audits, it is always best practice to bring an outside compliance firm to review a random sample of services to validate coding and compliance practices. An external review will identify any potential issues and/or validate provider documentation, EMR templates and overall operational workflow.

By Susan Genrich, CMM, CPC

Consultant, RR Health Strategies