Billing update for FQHCs and RHCs

FQHCs and RHCs submitting claims for GHP Kids (CHIP) and GHP Family (Medicaid) should be aware of an important billing rule affecting the use of T1015 – Clinic Visit/Encounter, All-Inclusive. As of Sunday, March 1, claims that include T1015 without any qualifying service code may be denied.

The T1015 code is an all-inclusive encounter code and is not intended to be billed alone. For a claim to be considered complete and billable, the encounter must include a qualifying evaluation and management (E/M) CPT code or HCPCS code that describes the actual service(s) provided during the visit. This requirement ensures accurate documentation of patient encounters and aligns billing with encounter-based reimbursement guidelines for FQHCs and RHCs.

How denials will appear on remittance advice

Claims submitted with T1015 without a qualifying service code will deny using the following messages:

• Claim denial explanation code: KPV
  Deny – billed in error – provider should include all services in an encounter on a claim
• CARC Code: 129
  Prior processing information appears incorrect.
• RARC Code: 130
  Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is un-processable. Please submit a new claim with the complete/correct information.

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