RHCs Excluded from Principal Care Management Benefit in 2020


Conflicting Statements from CMS in 2020 Final Rule

In 2020, Rural Health Clinics may not bill for Principal Care Management.

Principal Care Management (PCM) is a new benefit that Medicare will cover in 2020. It is very similar to the
chronic care management (CCM) benefit, except for the fact that patients can qualify for principal care management services with only one chronic condition, whereas CCM services can only be provided to patients with at least two chronic conditions.

The 2020 Medicare Physician Fee Schedule contained conflicting language that at one point stated that Rural Health Clinics could bill for PCM services using our CCM or “care management” G-code G0511, and then at another point stated that RHCs could not bill for PCM. NARHC and others pointed out these conflicting sections to CMS and they issued a correction on January 2nd which clarified that RHCs may not bill for Principal Care Management with our G0511 code or any other code.

While we were disappointed that CMS clarified that we could not bill for PCM, due to the way CMS prices the reimbursement for G0511, if CMS had allowed RHCs to bill for PCM services it may have lowered reimbursement
for G0511.

NARHC believes that CMS should expand PCM services to RHCs and we will be asking CMS to expand that benefit for 2021. We will also be pressing that CMS find a way to expand the PCM benefit to RHCs without hurting G0511 reimbursement.

While most Medicare beneficiaries can qualify for CCM by having at least two chronic conditions, it makes no sense that Medicare beneficiaries with only one chronic condition may not receive this service simply because their clinician works in a rural health clinic.

We will be working with CMS to fix these issues in 2021, but in the meantime, make sure that all your care management patients have at least two chronic conditions.

Nathan Baugh
Director of Government Affairs
National Association of Rural Health Clinics