The Centers for Medicare and Medicaid Services (CMS) recently released an update to the Policy Manual for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). The update included policy changes made previously by CMS through the 2022 and 2023 Final Physician Fee Schedules, but had not yet been incorporated officially into the FQHC/RHC policy manual. To understand the impact of the policy changes, it’s first important to note that under permanent law, FQHCs and RHCs are not eligible distant site providers of telehealth services. Section 1834(m) of the Social Security Act only allows FQHCs/RHCs to be originating site providers, and lists only physicians and practitioners as eligible distant site providers excluding entities such as FQHCs/RHCs from the list. During the COVID-19 emergency, FQHCs and RHCs have temporarily been allowed to be distant site providers, and will continue to be allowed, thanks to the Consolidated Appropriations Act, 2023, until December 31, 2024.
However, beginning January 1, 2025, permanent policy kicks in and FQHCs/RHCs will again be excluded as distant site providers unless legislation is enacted beforehand to change this. To remedy the exclusion of FQHCs/RHCs as distant site providers in law, in the 2022 Physician Fee Schedule CMS took administrative action, modifying for these two entities the definition of a mental health visit in its permanent regulatory policy to specify that it could be conducted through video telecommunications technology or audio-only interactions. Although in practicality, these modalities may be the equivalent to typical telehealth live video and telephone modalities providers are currently using during the PHE (and up until Dec. 31, 2024), from a policy perspective they are considered separate from the term ‘telehealth’ because as noted previously, the law only allows CMS to reimburse physicians and practitioners for ‘telehealth’. The catch will be that after Dec. 31, 2024, in order for video telecommunications technology or audio-only interactions to be reimbursable for mental health to FQHCs/RHCs, there will need to have been an in-person visit paid by Medicare with the provider (or another provider in their same group practice) within 6 months of an initial visit and every 12 months thereafter. There is an exception from the subsequent visit requirement if the patient and practitioner agree that the risks and burdens associated with an in-person service outweighs the benefits of an in-person visit. This same requirement will also be applicable to telehealth-delivered mental health services for physicians and practitioners after Dec. 31, 2024 if the interaction does not meet the geographic and site requirements. Note that as the policy stands now, non-mental health telehealth visits will not be reimbursable at all after that date for FQHCs/RHCs, and would only be reimbursed for physicians and practitioners when patients are located in specific types of rural originating sites, with certain narrow exceptions.
The specific changes incorporated into the updated FQHC/RHC Policy Manual include:
- Defines a mental health visit as a face-to-face encounter OR an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for purposes of diagnosis, evaluation or treatment of a mental health disorder.
- Specifies that the in-person visit requirement for mental health telehealth services and visits furnished by RHCs and FQHCs begins on January 1, 2025.
- FQHCs and RHCs are instructed to append modifier 95 for mental health services furnished using audio-video communication technology and modifier 93 for audio-only communication.
Two additional clarifications are also provided in the new manual update for care management services, including:
- Clarifies Medicare pays for general care management services which includes: Chronic Care Management (CCM), Principal Care Management (PCM), Chronic Pain Management (CPM) and general Behavioral Health Integration (BHI) services. The services are paid at the average of the national non-facility physician fee schedule payment rate for CPT codes 99490, 99487, 99484, 99491, 99424, and 99426 when general care management HCPCS code G0511 is on an RHC or FQHC claim, either alone or with other payable services.
- Clarifies that as of January 1, 2022, RHCs and FQHCs can bill for care management and transitional care management services and other care management services (outside of the RHC All Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS) payment) for the same patient during the same service period.
The allowance for general care management (which can include non-face-to-face telecommunication elements) to be reimbursed for RHCs and FQHCs separately is noteworthy because there are some other types of virtual communication services that are reimbursable under fee-for-service Medicare, such as remote physiologic monitoring and interprofessional internet consultations, that are considered bundled into an FQHC/RHC’s PPS or AIR rate for physician services and not separately billable. During the COVID-19 PHE, FQHCs have been able to be reimbursed for a synchronous virtual check-in and remote evaluation of pre-recorded video through billing HCPCS code G0071, however there is no indication at this point that this will continue when the PHE expires.
Additional non-telehealth related changes were also made in the FQHC/RHC Manual update. To review them all, see CMS’ summary of FQHC/RHC manual changes, or review the full manual in its entirety. New changes are marked with red text. If you are an FQHC and have a billing question, CCHP has set up a technical assistance email box for FQHCs to ask their telehealth billing questions. This service is only for FQHCs. You can send your FQHC billing questions to FQHCquestions@cchpca.org