Background

Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) have specific rules related to coding for service in their clinics. Both submit claims on a UB claim form that shows a revenue code and also includes the specific HCPCS/CPT codes that were performed. RHCs (generally) are paid an all-inclusive rate for services done on a single day and FQHCs are paid based on the Prospective Payment System (PPS) rate. The rate does not vary by the complexity of the patient or intensity of the service. The rate paid to FQHCs is increased by 34% for new patients, the welcome to Medicare visit and annual wellness visits.

Additional practitioners may provide services in 2024

Visits are defined as a face-to-face encounter between a patient and a physician, NP, PA, certified nurse midwife, clinical psychologist or clinical social worker.  Beginning January 1, 2024, a visit may also be performed by a marriage and family therapist (MFT) and Mental Health Counselor (MHC). You can read about that benefit in more detail in CodingIntel’s article about the requirements for these clinicians and enrollment.

CMS will update its manual definitions of what constitutes a visit to include these two types of professionals.

Consolidated Appropriations Act, 2023 (CAA)

The CAA passed December 29, 2022 extends the ability for RHCs and FQHCs to continue to provide services via telehealth until December 31, 2024.

Behavioral health services

MFTs and MHCs will be able to provide their services via telehealth, consistent with the rules for behavioral health services.

In the 2022 Physician Fee Schedule rule, CMS said that behavioral health services could continue to be performed via audio/visual, two-way communication or audio only services, even after the PHE expired. For audio only, they required an in-person visit within 6 months prior to furnishing these services and every 12 months after that, unless the practitioner and patient agree that the risks and benefits of an in-person visit outweigh the benefits of that visit. Or, if the beneficiary is unable or unwilling to be seen in person.  The CAA, 2023 delayed the in-person requirement for mental health services via audio only telehealth through December 31, 2024.  “That is, for RHCs and FQHCs, in-person visits will not be required until January 1, 2025.” p. 447

MFTs and MHCs would be able to report code G0323, behavioral health integration service, established in 2023.

Supervision via two-way, audio/visual technology

CMS defines direct supervision of a service (such as a diagnostic test or for incident to services) as the supervising physician or non-physician practitioner being in the suite of offices when the service is performed, immediately available to provide assistance. During the PHE, this supervision could be provided via two-way, audio/visual technology. CMS is proposing in its 2024 rule to extend this flexibility through Dec. 31, 2024. They are soliciting comments about this during the comment period, but it seems likely to be implemented.

General supervision for behavioral health services

“General supervision” means the that the procedure or service is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. The CY 2023 PFS Final Rule amended the incident to requirements to allow behavioral health services to be furnished under general supervision of a physician or non-physician practitioner when these services are provided via auxiliary personnel. This was only allowed for services payable under the PFS, which are not applicable to services in an RHC or FQHC.  Currently, behavioral health services furnished in RHCs and FQHCs require direct supervision. CMS is proposing to allow behavioral health services in those locations to be furnished under general supervision starting in CY 2024.

Remote physiological monitoring (RPM)/remote therapeutic monitoring (RTM)

Currently, in RHCs and FQHCs there is no separate payment for RPM or RTM. RPM includes codes 99453, 99454, 99457, 99458, and 99091. RTM includes codes 98975, 98976, 98977, 98980, and 98981.

CMS is proposing to add these codes to the list of service that can be reported with HCPCS code G0511. RHCs and FQHCs are considered non-facility in the PFS, and services are paid at the non-facility rate. G0511 has a total non-facility RVU value of 2.30, which translates to a national payment rate of approximately $78. CMS is proposing that for RPM and RTM services performed after January 1, 2024, report HCPCS code G0511 either alone or with other payable services.