CLIENT ALERT: The 2019 Medicare Physician Fee Schedule Final Rule: How It Affects FQHCs

By Published On: November 15, 2018

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year 2019 Medicare Physician Fee Schedule final rule (CY2019 PFS Final Rule). The regulation sets forth how physicians and other Medicare Part B practitioners will be paid under Medicare in 2019; it will be published in the Federal Register on November 23, 2018.

Federally-qualified health centers (FQHCs) are classified as Part A providers under Medicare, and therefore normally are not paid under the Physician Fee Schedule, but instead under a distinct FQHC Prospective Payment System (PPS) rate. However, the CY2019 PFS Final rule impacts FQHC payment in several respects. Each of the additions or updates to FQHC payment contained in the regulation has the potential to enhance FQHCs’ ability to furnish comprehensive services and care management to their Medicare patients. Each, also, builds on a trend evident in recent years toward Medicare paying FQHCs for certain new types of care through discrete payments similar to what physicians would receive, outside of the Medicare FQHC PPS rate.

Virtual Check-Ins and Remote Evaluation Services

Effective January 1, 2019, Medicare will pay FQHCs for two new types of communication technology-based services: brief communication technology-based services (or “virtual check-ins”) and remote evaluation services.

FQHCs will be able to bill Medicare for a “virtual check-in” when a physician or non-physician practitioner has a brief (5-10 minute) non-face-to-face contact with a patient to assess whether the patient needs an office visit. Notably, FQHCs will be authorized to bill for a virtual check-in only where the medical discussion is for a condition that is not related to an evaluation and management (E/M) service provided during the previous seven days and does not lead to an E/M service within the next 24 hours.

FQHCs will be authorized to bill Medicare for a remote evaluation service when a physician or non-physician practitioner evaluates patient-transmitted information that has been transmitted by “store-and-forward” video or image technology, including interpretation with verbal follow-up with the patient. The same time limitations will apply to the remote evaluation service as to the virtual check-in: the remote evaluation service may not be associated with an E/M visit during the prior seven days or subsequent 24 hours.

CMS proposes to use one G code, HCPCS code G0071, to pay for both virtual check-ins and remote evaluation services. FQHCs may bill Medicare for these services on an FQHC claim, either alone or with other payable services, and the payment rate will be set at the average non-facility Physician Fee Schedule (PFS) payment rate for these two codes. Medicare coinsurance will apply to these claims.

CMS has amended the Medicare regulations on FQHC payment rates to take into account the new communication technology-based services. The regulations at 42 C.F.R. § 405.2464 will be amended to state that FQHCs other than grandfathered tribal FQHCs are paid under the FQHC PPS rate, except with respect to care management services, communication technology-based services (“virtual check-ins”), and remote evaluation services.

Care Management Services

The 2019 PFS Final Rule also updates payment to FQHCs for chronic care management (CCM) and other care management services in Medicare. CCM services encompass physician or non-physician practitioner care related to management of chronic diseases. CCM includes maintaining a comprehensive electronic care plan, managing transitions of care, and coordinating and sharing patient health information within and outside the practice.

CMS began to pay Part B suppliers for CCM in 2014. Since 2016, FQHCs, as well, have been authorized to bill Medicare for CCM according to the national average non-facility payment rate for CCM. To receive the payment, an FQHC must provide at least 20 minutes of qualifying CCM services during a calendar month to a patient with multiple chronic conditions that are expected to last at least 12 months, and which place the patient at significant risk. Medicare makes only one CCM payment per beneficiary, per month.

Beginning in 2018, CMS expanded the care management codes used to pay FQHCs to encompass not only CCM, but also Behavioral Health Integration (BHI) and psychiatric Collaborative Care Management (CoCM) services furnished in FQHCs. The services are paid for using two G codes: HCPCS G0511 (General Care Management, including CCM and BHI); and HCPCS G0512 (CoCM). FQHCs bill Medicare for these services on an FQHC claim. FQHC claims for CCM, BHI or CoCM can be billed on their own or on the same claim as an FQHC visit.

Effective January 1, 2019, CMS will add a new CPT code to the bundle of codes that form HCPCS code G0511. The added code, CPT 99491, corresponds to 30 minutes or more of CCM furnished by a physician or other qualified health care professional. This will result in a higher payment for General Care Management services (approximately $67) than would otherwise have applied.

Additional Payment to FQHCs for Opioid Disorder Treatment

Section 6083 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 provides for additional payments to FQHCs for services furnished for the treatment of opioid use disorders by practitioners meeting certain requirements. Specifically, under federal law,  physicians who meet certain requirements may obtain a waiver of the separate registration requirements of the Narcotic Addict Treatment Act in order to treat opioid dependency with Schedule III, IV, or V controlled substances that have been approved by the Food and Drug Administration. The SUPPORT for Patients and Communities Act Section 6083 amends Section 1834(o) of the Social Security Act to authorize CMS to make one-time payment to FQHCs for the purpose of training physicians to receive this type of waiver.

CMS states in the CY2019 PFS Final Rule that forthcoming guidance will address the implementation of this provision.

For questions about any of the changes described above, please contact Susannah Vance Gopalan at sgopalan@ftlf.com.

Ms. Gopalan will also be hosting a webinar, Telehealth Payments for FQHCs: The Legal and Policy Landscape, on January 9, 2019 at 1:00 PM ET. For more information on this training, please contact learning@ftlf.com.


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