2021 Physician Fee Schedule Final Rule Released

CMS Finalizes Principal Care Management for Rural Health Clinics


The Centers for Medicare and Medicaid Services (CMS) released their 2021 Physician Fee Schedule final rule on December 1st and as expected, Rural Health Clinics will be able to bill for Principal Care Management services beginning in 2021.

Principal Care Management (PCM) services are very similar to Chronic Care Management (CCM) services with the key distinction being that PCM services can be provided to Medicare beneficiaries with only one (instead of two) chronic condition. Beginning January 1, 2021 RHCs will be able to provide PCM services and bill for them using the G0511 code.

Because care management services do not meet the definition of an encounter, CMS created a special code (G0511) to allow RHCs to provide and bill for care management services beginning in 2016. This code is only used by RHCs and FQHCs and CMS sets the reimbursement for G0511 at the average of the care management codes available for our fee-for-service peers. With the inclusion of PCM services in 2021, the reimbursement for G0511 will be based on the average of 6 codes instead of 4.

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 should not dramatically impact the rate of G0511 which is currently $66.77.

Key section of the 2021 PFS Final Rule:

In consideration of these public comments, we are finalizing the proposal to add the PCM HCPCS codes, G2064 and G2065, to the general care management code, G0511, as a comprehensive care management service for RHCs and FQHCs, starting January 1, 2021 as proposed. We are also finalizing that when RHCs and FQHCs furnish PCM services, they will also be able to bill the services using HCPCS code G0511, either alone or with other payable services on an RHC or FQHC claim for dates of service on or after January 1, 2021. The payment rate for HCPCS code G0511 will be the average of the national non-facility PFS payment rates for the RHC/FQHC care management and general behavioral health codes (CPT codes 99484, 99487, 99490, and 99491) with the addition of HCPCS G2064 and G2065. That is, the PCM services will be added to G0511 to calculate a new average for the national non-facility PFS payment rate. The payment rate for HCPCS code G0511 will be updated annually based on the PFS amounts for these codes.

Evaluation and Management Coding Simplification and Revaluation

One of the major changes in this year’s final rule is the formal adoption of new coding guidance for Evaluation and Management Services. Coders and billers should familiarize themselves with the new framework that will be effective in 2021. These new guidelines were adopted by the American Medical Association’s CPT Editorial Panel and you can find out more about their rationale for these changes here.

Notably, for our fee-for-service peers, the updated E/M codes will pay more in 2021. While these code revaluations will not affect Medicare RHC reimbursement, they do help underscore the need to update the RHC cap.

CMS Expands List of Telehealth Services but Legislative Solution Still Needed for RHCs

In conjunction with the release of the final rule, CMS issued a press release entitled “Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and Improved Payment for Time Doctors Spend with Patients.” In this press release there is a section on finalizing telehealth expansion and improving rural health, which at first glance seems like it could be a major victory for the Rural Health Clinic community considering our efforts to improve and permanently solidify telehealth policy for RHCs.

However, the changes CMS finalized in this rule do not allow RHCs to provide distant site telehealth services beyond the Public Health Emergency.

CMS is permanently expanding the list of CPT codes that can be provided through a telehealth visit but they are not permanently expanding who may provide those telehealth visits. As a result, absent Congressional action, when the Public Health Emergency (PHE) ends, Medicare telehealth policy will revert back to the pre-COVID era rules wherein RHCs are not authorized distant site providers and patients still have to drive to official originating site locations to receive telehealth visit services.

This final rule simply allows more types of services to be provided in the pre-COVID style of telehealth. RHCs would be able to serve as the originating site for these telehealth visits, but RHCs would not be able to provide distant site services after the PHE.

CMS does note in their press release that they do not have the statutory authority to allow for more meaningful expansion such as allowing Medicare beneficiaries to receive telehealth in their home outside of the Public Health Emergency.

CMS also maintains that they do not have the statutory authority to allow RHCs to be distant site providers outside the public health emergency, a position NARHC wholeheartedly disagrees with, but nevertheless a position that prevents RHCs from being distant site providers absent Congressional action.

If you are interested in helping the RHC community keep and improve our ability to provide telehealth visits stay tuned to NARHC news and check our official communications webpage to see the latest developments. Grassroots advocacy will be necessary if we are to emerge out of the Public Health Emergency with a good Medicare telehealth policy. Please feel free to contact me at Nathan.Baugh@narhc.org if you are interested in helping the RHC community in this endeavor.

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