Federally Qualified Health Centers (FQHCs) must be on top of many changes coming out of the Centers for Medicare and Medicaid Services or CMS - and many of these relate to specific kinds of care and categories of treatment and evaluation. So often, CMS is updating codes, protocols, or reimbursement details for a given range of medical services, and the individual change becomes a snowflake in a blizzard of transmittals and notices, so that it's difficult for administrators to track everything that they need to optimize revenue.
One example is the recent 2018 CMS code changes to Chronic Care Management or CCM services. CCM has become a major part of ongoing treatments in community centers, as providers put together care plans for an aging patient base with chronic diseases such as diabetes and heart disease. This increasing population of patients who suffer from long-term, chronic illness need ongoing care, and new CMS models change the ways that this ongoing care is tracked and monitored. The rising occurrences of chronic conditions, as well as the increasing demand for self-care and remote monitoring, are signiﬁcant factors driving the growth of CCM. Centers that keep pace and add care delivered by telephony can not only reduce costs, but can also leverage it to create new services and offer existing ones to more patients than they could from inside their own four walls.
New CCM Rules for Centers
One of the big new changes is a "general code" that FQHCs and RHCs must use to bill certain CCM services under CMS reimbursement rules.
Part of the context for this new code is the integration of behavioral health services into the CCM model. In fact, one eligible way to use the code, G0511, is to include at least 20 minutes of behavioral health services under the code. The other option is to use G0511 to provide at least 20 minutes of CCM services.
The new G0511 code is specific for FQHCs and RHCs replacing CPT code 99490, which is part of a range of codes describing CCM services that are used for plans outside of Medicare and greatly increases the reimbursement. As a "general code," G0511 offers a new more flexible way to bill as a stand-alone or in addition to other payable FQHC/RHC services, but may only be billed once per month per beneficiary. The rate is updated annually based on the PFS amounts and coinsurance applies and is currently $62.28 per visit.
In addition to allowing the billing of general CCM services and behavioral health services under G0511, CMS is also changing the reporting burden and oversight requirements for state Medicare providers, which can make CCM care easier to bill. Part of the reason is that new models, like ACO models, anticipate the key role of CCM is helping with management of chronic disease - like preventative care, government offices are considering CCM as a pillar of medical support for communities. These changes allow care providers new ways to get reimbursed, and, in some cases, enhance reimbursement rates.
Taking Advantage of new CCM Rules
Of course, to benefit from the new CCM changes, FQHCs and RHCs will need tools that are built with CMS provisions in mind. However, adding patient services that require expensive software, new processes and additional staff can be a barrier to taking advantage of these new care models.
Partnering with a vendor like Altrius offers centers a way to get started without the financial burden of staffing and purchasing software or the lengthy process of developing and implement best practices. Having a partner that can provide these services in a turn-key manner and knows the billing requirements for FQHCs and RHCs is important.