Health Center Federal Policy

Items of Interest to Health Centers in CMS Medicare Physician Fee Schedule Proposed Rule

We’re getting a lot of questions about the proposed rule on CY 2019 Medicare Physician Fee Schedule  issued by the Centers for Medicare and Medicaid Services (CMS).  This rule has drawn a lot of attention, as CMS is proposing major changes in the way Medicare reimburses providers paid on the Physician Fee Schedule.

This is an annual proposed rule from the federal agency  and it is generally used to update policies and reimbursements for providers paid on the Physician Fee Schedule, and other Medicare Part B policies.   Because this is an annually required rule, other provisions are sometimes included in the rule. As in years past, (see our previous post), this proposed rule includes some important provision for health centers.

Here’s a summary of key provisions specific to health centers.

Payment for Care Management Services

Since 2016, CMS has reimbursed FQHCs for Chronic Care Management.  Beginning January 2018, FQHCs are reimbursed for two Healthcare Common Procedure Coding System (HCPCS) codes:

  • General Care Management: G5011 (which includes CPT codes 99490, 99487, 99484) for at least 20 minutes of general care management.
  • Psychiatric Collaborative Care Management: G0512 (which includes CPT codes 99492 and 99493), for at least 70 minutes of collaborative care management.

In this proposed rule, CMS is proposing to add a new CPT code 994X7 (which corresponds to 30 minutes or more of CCM furnished by a physician or other qualified health care professional, similar to CPT codes 99490 and 99487) to the calculation of G5011.

Communication Technology-Based Services and Remote Evaluations

CMS is proposing to add a new payment for two new services:

  • Communication technology-based service – When a provider does a “virtual check in” with their patients – a non face-to-face visit, using communication technology, as long as it is not related to a face-to-face visit within the last 7 days or does not lead to a visit within 24 hours (or the soonest available appointment) with the patient.
  • Remote evaluation – Providers can receive reimbursement for the evaluation of recorded video and/or images, as long as it is not related to a face-to-face visit within the last 7 days or does not lead to a visit within 24 hours (or the soonest available appointment) with the patient.

For remote evaluation, CMS is waiving the “face-to-face” requirement typically required to trigger payment at an FQHC. The payment rate for each of these services and operational details for these new G codes have not yet been announced. It will not be the full Medicare PPS amount, but will likely be similar to the payment that providers paid on the Physician Fee Schedule will receive for the same services.

NACHC commented on the proposed rule(see attached documents). We expect the rule to be finalized later this fall. Stay tuned for more detail about if and how these provisions are finalized and what you need to know to start providing these important services to your health center Medicare patients.

Questions?  Send them to state@nachc.org.

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