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2018 PFS Final Rule: RHC and FQHC Care Coordination

Posted by Chantelle Marcelle

Nov 21, 2017 11:46:37 AM

The 2018 Medicare Physician Fee Schedule Final Rule has several adjustments that support RHC and FQHC care coordination service delivery and billing for increased reimbursement. Find out more on the CareSync healthcare blog for physicians and providers.RHC and FQHC care coordination services and payment are receiving more robust support from the Centers for Medicare and Medicaid Services following the release of the 2018 Medicare Physician Fee Schedule Final Rule.

Since Chronic Care Management and care coordination payments to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) began on Jan. 1, 2016, providers have sought ways to realize CCM benefits for patients of these healthcare facilities. The healthcare providers who serve these patients are often stretched thin, and particularly in rural areas, access to care resources can be minimal. Patient populations of FQHCs and RHCs with complex medical conditions could greatly benefit from Chronic Care Management and care coordination services.

History of RHC and FQHC Care Coordination in 2017 and Previous Years

Previously, RHC and FQHC care coordination services were only eligible for reimbursement under one reimbursement code, original CCM code CPT 99490. Payment for additional costs associated with certain specific RHC and FQHC care coordination services were not included in the RHC AIR or FQHC PPS rate. Other codes, such as complex CCM code CPT 99487 or general BHI code G0507, were not available for RHC and FQHC care coordination payment.

The release of the 2018 Medicare Physician Fee Schedule Final Rule by the Centers for Medicare and Medicaid Services (CMS) signifies marked increase in potential for RHCs and FQHCs to expand care coordination services and increase CCM-related payments, though.

The goals of changes implemented in the 2018 Medicare Physician Fee Schedule Final Rule are to provide an avenue for “less burdensome” reporting, expanded care management codes for reimbursement, and greater consistency with RHC and FQHC payment methodology.

CY 2018 Medicare Physician Fee Schedule Final Rule has impacted RHC and FQHC care coordination with new Chronic Care Management codes, including 2 new G codes for reimbursement for RHC and FQHC billing.

FQHCs and Care Coordination

In the U.S., there are over 6,000 FQHC sites under an umbrella of about 1,000 health centers. California has more FQHCs than any other U.S. state or territory. These centers serve tens of millions of patients in this country.

The definition for FQHCs includes meeting the following criteria:

  • Qualifies for enhanced reimbursement from Medicare and Medicaid, as well as other benefits
  • Serves an underserved area or population - urban or rural
  • Offers services to all persons, regardless of ability to pay
  • Offers a sliding fee scale, which adjusts patient cost based on income
  • Provides comprehensive services, including:
    • Preventive health services
    • Dental services
    • Mental health and substance abuse services
    • Transportation services necessary for adequate patient care
    • Hospital and specialty care
  • Has an ongoing quality assurance program
  • Has a governing board of directors, with patient representation

A recent survey of CEOs at FQHCs across the country found that some top concerns among these healthcare leaders are revenue diversification and financial sustainability.

RHCs and Care Coordination

Read more about new CCM opportunities for RHCs and FQHCs.

The Rural Health Clinic (RHC) program is intended to increase access to primary care services for Medicare and Medicaid patients in rural communities.

RHCs can be public, nonprofit, or for-profit healthcare facilities, however, they must be located in rural, underserved areas. RHCs are reimbursed by Medicare via an All Inclusive Rate (AIR), where basically total costs are divided by total visits.

Similar to FQHCs, RHC patient populations can greatly benefit from care coordination services. Some common challenges faced by RHCs include:

  • Patients in rural areas live an average of 6 miles away from rural health clinics, making it difficult or inconvenient for many to get to the RHC provider.  
  • There are only 39.8 primary-care physicians for every 100,000 people in rural areas, compared to 53.3 physicians per 100,000 people in urban areas.
  • There is a higher percentage of Medicare patients who are 65 years old and older in rural areas than urban (18% vs 12%).
  • Average per capita income in rural areas is $9,242 lower than the average per capita income in the United States.
  • Rural areas have a more frequent occurrence of diabetes and coronary heart disease than urban areas.

Changes for RHC and FQHC Care Coordination Through PFS Final Rule 2018

Some changes for RHC and FQHC care coordination services and reimbursements include the expansion of the following four services:

  • Transitional Care Management (TCM)
  • Chronic Care Management (CCM)
  • General Behavioral Health Integration (BHI)
  • Psychiatric Collaborative Care Model (CoCM)

RHC and FQHC care coordination services for CCM code CPT 99490 will be paid through Dec. 31, 2017. Care management service claims will be denied on CCM code CPT 99490 starting Jan. 1, 2018.

In 2018, FQHC and RHC providers will transition to use of two new G codes. The first is a new general care management G code GO511, with an average reimbursement rate of $61.37. The second is a psychiatric CoCM code.

Care management codes can be billed alone or along with other payable services during an RHC or FQHC patient visit. Only one RHC and FQHC care coordination service can be billed in one month.

Support for RHC and FQHC Care Coordination Service Delivery

The direct supervision requirements for auxiliary personnel have been waived for TCM, CCM, general BHI, and psychiatric CoCM services furnished by RHCs and FQHCs. These services can be furnished by auxiliary personnel under general supervision of the RHC or FQHC practitioner.

General supervision does not require the RHC or FQHC practitioner to be in the same building or immediately available, but it does require the services to be furnished under the RHC or FQHC practitioner’s overall supervision and control.

CareSync is compliant with all these requirements.

We provide ongoing support for RHCs and FQHCs looking to successfully provide care coordination services to patient populations with minimal demand on available resources and maximum reimbursement.

To view full changes to be expected to RHC and FQHC care coordination, please visit the CMS website. CMS-hosted educational events, such as webinars, can be found on the MLN Calls & Webcasts page.

For a discussion more personalized to your needs, as well as other information about changes that RHC and FQHC providers can expect in 2018, please contact us at 800-501-2984 or sales@caresync.com.

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