CMS finalized their proposal to grant RHC’s the opportunity to bill for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services, as well as general care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN), beginning January 1, 2024)
On November 2nd, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2024 Medicare Physician Fee Schedule (MPFS) Final Rule and the CY 2024 Medicare Outpatient Prospective Payment System (OPPS) Final Rule, finalizing several Rural Health Clinic (RHC) specific policy proposals.
Extreme gratitude to our advocates at the National Association of Rural Health Clinic (NARHC) for submitting comments in September during the rule making process timeline as to how CMS proposals may impact the RHC community. Much appreciation to NARHC for the suggested changes submitted to ensure that safety net providers are able to take full advantage of the expanded benefits. Thank you! We encourage you to join NARHC’s Washington, D.C. team for a webinar on December 11th, 2023, where they will discuss the final rule and answer questions about implementation of these various policy proposals. Register for the webinar here. If you are unable to attend rest assured, we will be in attendance.
Background
Since 2016, RHCs have been able to bill for Chronic Care Management (CCM) services through this consolidated care management code. G0511 pays a consolidated fee schedule amount, $77.24 in 2023, which is the average of the Physician Fee Schedule (PFS) rates for CCM and principal care management (PCM) services, as well as codes newly added in 2023: Chronic Pain Management and General Behavioral Health Integration. For several years, NARHC has been advocating for CMS to extend Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) billing privileges to RHCs.
CMS Proposed
In the 2024 MPFS proposed rule, CMS extended RPM and RTM billing opportunities to RHCs and FQHCs under the general care management code of G0511. CMS also proposed entirely new care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN) services, all through the G0511 code. Additional details on the specific codes and services in the RPM, RTM, CHI, and PIN categories can be found here. Currently, G0511 reimburses at the average of the PFS rates for all services captured (and equally weighted) in the consolidated code. Beginning in 2024, CMS is proposing to use a weighted average of the services billable under G0511. However, because RHCs bill using a consolidated code, there is no utilization data on the various CCM services provided in RHCs. Therefore, in their proposed weighted average, CMS uses utilization data from non-RHC physician offices. Under the proposed methodology, the 2024 G0511 reimbursement amount would be $72.98. While this is a decrease from the 2023 reimbursement rate, it is not as significant as the decrease would have been simply using the true average methodology.
NARHC Comments
NARHC commended CMS for creating a mechanism for RHCs to provide and bill for RPM/RTM services and the creation of the new CHI and PIN codes in acknowledgment of the care and social services provided by auxiliary members of a care team, such as Community Health Workers and Peer Specialists.
NARHC conveyed that Medicare Claims Processing Manual Chapter 9 states “HCPCS code G0511 or G0512 can only be billed once per month per beneficiary and cannot be billed if other care management services are billed for the same time period.” Therefore, if an RHC patient is already enrolled in a clinic’s CCM program, regardless of whether they may benefit from additional services like RPM, CHI, etc.; the RHC will only be eligible for one G0511 reimbursement for that patient each month. This differs from fee-for-service flexibilities, in that FFS providers can bill RPM, CCM, CHI, and PIN all for the same patient, in the same month, so long as time and services are not duplicative.
NARHC asked CMS to change their policy to allow multiple G0511 services per month, or consider a different approach overall, to ensure that safety-net providers and their patients are not disadvantages by this special payment rule. We provided three different solutions to the issue, including potential pros and cons for each, such as:
1. Allowing for multiple G0511 payments per month distinguished by modifiers;
2. Creating several sets of G-codes to represent distinct care management services;
3. Allowing RHCs to bill the full suite of care management codes similar to how traditional fee-for-service providers bill for such services.
Regarding the proposed payment methodology revision, NARHC agreed with a weighted average methodology revision. NARHC emphasized that CMS must consider other care management reimbursement structures altogether to ensure that RHCs are not limited to one billable care management service per patient per month while traditional fee for service offices can bill many different care management services together.
CMS Finalized
CMS finalized their proposal to add RPM and RTM services, as well as two new codes for each CHI and PIN (G0019, G0022, G0023, and G0024, respectively) all to G0511. Most importantly, they clarified that an RHC may bill G0511 multiple times in a calendar month so long as they are: “medically reasonable and necessary, meet all requirements, and not be duplicative of services paid to RHCs and FQHCs under the general care management code for an episode of care in a given calendar month.” We are very pleased by this clarification and look forward to seeing RHCs expand their care management services to expand these services to eligible patients.
While certainly a positive step forward, we still have many questions as to the details of expanded G0511 implementation. In response to NARHCs suggested options listed, CMS stated: “We appreciate the commenter’s recommendations on how to operationalize and track HCPCS code G0511 when billed multiple times in a calendar month. We did not propose these options in the CY 2024 PFS proposed rule; however, we will take these options into consideration for future rulemaking.”
Based on interpretation of the various services, especially complex patients may theoretically benefit, without double counting of services/minutes, from CCM, RPM, CHI, and PIN in a single month. However, given that these will all be billed as G0511 without the requirement for any sort of modifier, determining the “reasonableness” of these multiple G0511 claims may be challenging.
Other questions include whether multiple of the five distinct codes in the RPM service list (i.e., device set-up and collection and interpretation of the data) can also be billed concurrently by the RHC. Based on the language in this final rule, it is unclear to us what exactly the parameters are regarding multiple G0511 codes per patient per month.
NARHC believes CMS will need to revise various guidance documents and provide clear direction to the Medicare Administrative Contractors (MACs) in order to ensure that the policy is implemented uniformly and that claims with multiple G0511s are not unnecessarily denied. Finally, CMS finalized the proposal to change the G0511 payment methodology to the weighted average of all included codes. This is estimated to be approximately $73.00 in 2024, however CMS will post the final 2024 payment rate soon.
Please contact Melissa Jones, CRHCP
Rural Health Clinic Senior Associate, Burrows Consulting at melissa@burrowsconsulting.net with any questions.
Reference Sarah Hohman, 11/07/2023 <https://www.narhc.org/News/30193/CMS%2DFinalizes%2D2024%2DRegulatory%2DUpdates>
