CMS Proposes to Expand Principal Care Management to RHCs in 2021
In 2021, Rural Health Clinics should be able to bill for Principal Care Management (PCM) through the G0511 code.
Back in January, we had to clarify that RHCs were excluded from being able to provide PCM in 2020 due to confusing language in the final physician fee schedule rule. At that time, we asked CMS to allow RHCs to provide PCM in 2021, and we are glad to report that they have now proposed to do exactly that.
Principal Care Management is very similar to Chronic Care Management (CCM) but Principal Care Management services can be provided to Medicare patients with only one (instead of two) chronic conditions.
As most of you already know, rural health clinics are paid for Chronic Care Management services through a single G-code (G0511). We do not use different codes or receive different payments based on the type of care management service provided like our fee-for-service peers do.
CMS is simply proposing to include Principal Care Management services into the G0511 bundle which they will now base on the average of six codes instead of four.
In 2020, the payment rates for the two PCM codes were $92.03 (for G2064) and $39.70 (for G2065). The average of those two codes is $65.87 which means that their inclusion in the calculation for the 2021 valuation of G0511 will not dramatically impact the rate of G0511 which is currently $66.77.
While we understand that most Medicare patients do have two chronic conditions, and were thus already eligible for Chronic Care Management, if you did have those relatively healthy Medicare patients with only one chronic condition, you should be able to offer those patients Principal Care Management services in 2021.
Key sections from the proposed rule:
HCPCS code G2064 is for at least 30 minutes of PCM services furnished by physicians or non-physicians during a calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
HCPCS code G2065 is for at least 30 minutes of PCM services furnished by clinical staff under the direct supervision of a physician or non-physician practitioner with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
A national stakeholder organization representing rural health clinics has requested that RHCs be allowed to furnish and bill for PCM services. [I think it is fair to say that this is NARHC] We agree that there can be significant resources involved in care management for a single high risk disease or complex chronic condition, and that the requirements for the new PCM codes are similar to the requirements for the care management services described by HCPCS code G0511. These are services that do not currently meet the requirements for an RHC or FQHC billable visit, and they provide an array of care management services that are not generally included in the RHC AIR or the FQHC PPS. Therefore, we are proposing to add HCPCS codes G2064 and G2065 to G0511 as a comprehensive care management service for RHCs and FQHCs starting January 1, 2021. The payment rate for HCPCS G0511 is the average of the national non-facility PFS payment rate for the RHC and FQHC care management and general behavioral health codes (CPT codes 99490, 99487, 99484, and 99491), and we propose that these 2 new codes be added to the calculation of the G0511 payment rate.