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.
2025 FQHC and RHC update
There were significant changes in the physician fee schedule final rule for CY 2025 for RHCs and FQHCs. The most significant news? RHCs and FQHCs can continue using telehealth with pandemic waivers intact for all of 2025.
Care management services
- Starting 1-1-2025, FQHCs and RHCs can provide and bill for care management services with CPT® codes in place of HCPCS code G0511
- For the first six months of 2025, health centers have the option to continue to use code G0511 rather than using the more specific care management codes
- Reporting G0512 is unchanged (code for psychiatric Coordination of Care Management, 60 minutes)
- Health centers can also report Advanced Primary Care Management codes; however, either report APCM or individual care management services
HCPCS definition: G0511 Rural health clinic or federally qualified health center (rhc or fqhc) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm), per calendar month
G0511 consists of care management services defined by specific CPT® and HCPCS codes when 20 minutes of general care management or behavioral management is performed in a calendar month. Over the years, CMS added services to the definition of this code. In 2024, Remote physiological monitoring (RPM) codes and remote therapeutic monitoring (RTM) codes were added to the bundle of codes in G0511. FQHCs and RHCs who performed any of the services included in this list were paid at a single rate, for 20 minutes of clinical staff time in a calendar month.
Beginning January 1, FQHCs and RHCs may report individual care management codes and monitoring services in place of G0511, and after a six-month transition period, must report the CPT codes in place of G0511 Until July 1, 2025, health centers can continue to use G0511 or report the individual care management codes. You can download the table from the Final Rule that lists the individual care management codes here, Table 28, page 842 from the rule, Table 28, page 842 from the rule. Some of these have lower payments and some higher payments than G0511. You can report the care management codes on a claim with a visit or on a separate claim. Payment for the care management services will be at the national, non-facility rate, not adjusted for location.
“Payment for these services would be the national non-facility PFS payment rate when the individual code is on an RHC or FQHC claim, either alone or with other payable services and the payment rates are updated annually based on the PFS amounts for these codes.” PFS Final Rule, CY 2025, p. 841 display copy.
- Report the care management codes alone on a claim or with other payable services.
Don’t forget to obtain consent for care management services. Consent can be verbal or written, but must be documented in the medical record. Consent may be obtained by auxiliary staff. The consent should describe the service to the patient (what will be done), tell them they may revoke consent and stop receiving the service, and that there may be cost sharing for care management services.
Before reporting any of the individual care management codes, download CodingIntel’s care management services guide.
No change to reporting G0512
HCPCS definition: G0512 Rural health clinic or federally qualified health center (rhc/fqhc) only, psychiatric collaborative care model (psychiatric cocm), 60 minutes or more of clinical staff time for psychiatric cocm services directed by an rhc or fqhc practitioner (physician, np, pa, or cnm) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month
G0512 will continue to be used for Psychiatric Collaborative Care Management Services. It allows payment for clinical staff time, including service furnished by a behavioral health care manager, under the direction of a physician, nurse practitioner, physician assistant or clinical nurse midwife. These are time based codes with a long list of required elements, including establishing a registry and weekly consultation with the psychiatric consultant. The code is for the time in a calendar month, not 30-day period. This is based on CPT® codes 99492—99494. For more detailed information about the rules, see our article on those codes.
The MLN matters article on behavioral health integration services is here.
Telehealth
FQHCs and RHCs will continue to be allowed to use telehealth until Dec. 31, 2025, whether or not Congress passes an end of year bill in December, 2024.
Advanced Primary Care Management (APCM)
FQHCs and RHCs can perform Advanced Primary Care Management caring for patients with chronic conditions. There are three new HCPCS codes to report them. This is a monthly payment for primary care practitioners who are providing care management and oversight for patients in their practice. It is a monthly payment for a bundle of services, and there is a list of care management services APCM replaces and these cannot be reported in addition to the HCPCS APCM codes. RHCs and FQHCs will need to look at the two options: participating in APCM or reporting individual care management services in place of G0511. Patients are stratified into three levels: one or fewer chronic conditions, two or more chronic conditions, and Qualified Medicare Beneficiaries with two or more chronic conditions. Practices who report these codes will be required to do performance reporting at the end of the year. You can read a summary of the requirements in our CMS HCPCS update, with more detail to follow.
And, CMS has posted a summary page about APCM.
CodingIntel’s January and February webinars address each of these topics. Members can register for these webinar as part of their member benefit.
- January – Advanced Primary Care Management Codes
- February – Overview of FQHC Coding (registration opening soon)
2024 FQHC and RHC update
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)
As of 2024, 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 in 2024, 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.
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