What's New for RHCs in 2019?

Nathan Baugh, Director of Government Affairs


What is New for RHCs in 2019?

Calendar year 2019 is here, and with it comes a flurry of new benefits and policies for Rural Health Clinics to keep track of. The following is a quick summary and update of what has changed and what is new for RHCs in 2019:

RHC Medicare Upper Payment Limit Raised 1.5% to $84.70

Link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4145CP.pdf

Every year CMS announces the RHC Upper Payment Limit, which is increased in accordance with the Medicare Economic Index (MEI). The RHC Upper Payment Limit is commonly referred to as the “cap” and applies to independent RHCs and RHCs that are provider-based to hospitals with more than 50 beds.

NARHC is advocating that Congress increase this upper payment limit to a more reasonable amount. The MEI adjustment methodology has simply not kept up with actual RHC expenses and the average capped RHC has a cost-per-visit roughly $30-$40 greater than this cap. The Policy Committee continues to promote legislation on Capitol Hill to address this issue.

Chronic Care Management Reimbursement Increased to $67.03

Link: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10175.pdf

Updated FAQ: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf

RHCs that have been providing Chronic Care Management (CCM) services will be happy to see that the payment for those services is going up by almost five dollars. For those of you that were thinking about starting a CCM program, it is definitely something that we (at NARHC) recommend you consider.

RHCs bill for CCM services with a different code than our fee-for-service peers. Fee-for-service (FFS) providers have four different CCM codes that they can bill for, but RHCs can only bill one CCM code: G0511. The payment rate for G0511 is set at the average of the four codes on the fee-for-service and for 2019 will be $67.03.

In 2018, there were only three CCM codes on the FFS side and the average payment between those three was $62.28. A new code was created for FFS providers in 2019: CPT code 99491 (30 minutes of CCM services provided by an RHC practitioner). RHCs cannot bill for this new CCM CPT code, but its creation did slightly increase the amount of money RHCs receive when they bill G0511 because payment for G0511 is based on the average of the CCM codes available for fee-for-service providers.

New Virtual Communication Services Covered by Medicare

FAQ: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/VCS-FAQs.pdf

Effective January 1, 2019, RHCs can provide and bill Medicare for a new type of service called “Virtual Communication Services.” This is a new type of health care service whereby the RHC practitioner provides at least 5 minutes of advice or counseling to a patient through some type of communications technology.

For instance, if a patient calls the RHC, and the RHC practitioner (not the nurse or receptionist) spends five minutes listening to the patient describe their condition and recommends that they schedule a visit with a specialist not associated with the RHC, then the RHC can bill for and get paid by Medicare for the five minutes of advice they gave to the patient.

Another scenario that might qualify as a billable virtual communication service could involve a patient emailing the RHC practitioner about a new condition they are experiencing. If your practitioner spends at least 5 minutes responding via email and advising the patient on what to do, and this condition is not related to an RHC service provided within the last 7 days (i.e. a follow-up), then this too would be considered a billable virtual communication service.

Similar to how CCM billing works for RHCs, virtual communication services performed in an RHC are billed using a different code than our FFS peers. The code for RHCs is G0071 and will be paid at $13.69 in 2019. FFS providers have two different codes that are paid at slightly different rates. RHCs, on the other hand, have the one code which is paid at the average of the two FFS codes.

It should be noted that unlike CCM services, the patient must initiate any virtual communications service. However, like CCM services, coinsurance and deductibles do apply. If you provide virtual communications services, be prepared to explain to patients why they are getting a bill for $2.74.

CMS Releases and Updated Medicare Benefit Policy Manual Chapter 13

Link: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf

CMS released a new version of the Medicare Benefit Policy Manual Chapter 13 in December to address and clarify how RHCs can provide these new kinds of services. If you do not already have this link saved on your computer, I would highly recommend that you save it now.

This document is typically the best place to start if you have a question about RHCs. This latest version contains a lot of new language surrounding care management services and virtual communications services.