New Code G0511 Helps Expand Chronic Care Management at FQHCs

As QPP and MIPS become the standard for the majority of Medicare providers, expansion of programs into Federally Qualified Health Centers (FQHCs) is necessary. However, FQHCs are not like other providers. They have a high percentage of Medicaid patients and a completely different pay structure. How then, can FQHCs implement quality initiatives, like Chronic Care Management (CCM)? Through creating a new code, G0511, Centers for Medicare & Medicaid Services has enabled FQHCs to offer CCM on a much larger scale. Learn about the latest updates to G0511 in the CMS Final Rule here.

Saving Money and Expanding Care at FQHCs

A 2016 study of 13 states showed that the majority of FQHCs demonstrated Medicaid savings when compared to other primary care settings. FQHCs did this through lowering Emergency Department use and general decreases in spending.⁽¹⁾ One of the keys to controlling spending is that providers are paid a flat salary and they do not code for higher levels of service.⁽²⁾ As of January 1, 2018, CMS has extended this method of billing for CCM with the creation of billing code G0511.⁽³⁾

As discussed in our September post, “Implementing Chronic Care Management at FQHCs: Changes for 2018,” billing G0511 will be initiated on January 1, 2018. Like other FQHC codes, G0511 incorporates multiple codes to keep costs down. The three CPT codes that fall under the G0511 umbrella are 99490, 99487, and 99484. This means that reimbursement for all chronic care management and collaborative care management for behavioral health is the same rate.

In the 2024 PFS Final Rule, G0511 has been updated to include the new CHI and PIN programs along with CCM, PCM, RPM, and RTM. The Final Rule states FQHCs and RHCs can bill the code multiple times in a calendar month if requirements are met for the underlying services.

G0511 Recognizes the Role of Primary Care Providers in Behavioral Health Management

Not only is CMS trying to lower overall costs for CCM, they are also recognizing the often overlooked reality of Primary Care Providers. Often, PCPs are the front lines of behavioral health services for many patients. For a significant number of patients, PCPs are the first and last resource for addressing behavioral health conditions. As such, they are frequently called upon to provide plans of care and treatment coordination.⁽⁵⁾ Now, CMS is recognizing this role and shoring up continuity of care by offering a code for PCPs to charge. With G0511, FQHCs can recoup the costs associated with long-term behavioral health care and coordination.

Staying Competitive and Delivering Quality for FQHCs with G0511

These changes could not have come at a better time. It’s no secret that FQHCs infrequently track profit and have difficulty with revenue diversification.⁽⁶⁾ Coupled with these trends is the rise in competition. Not only do FQHCs compete amongst themselves for low-income patients, they face stiff competition from new sources. ⁽⁷⁾ There has been a marked increase in the number of urgent care centers and retail-based clinics in low-income neighborhoods in the past decade. These alternate treatment sources have larger economies of scale and can weather fluctuations of income better than FQHCs.⁽⁸⁾ Although these new resources are sorely needed, they are not required to take indigent patients, which gives them another edge on FQHCs.

The implementation of G0511 will help FQHCs diversify revenue while offering a beneficial service to their patients. Through CCM, FQHCs can give their patients something that urgent care centers, hospitals, and retail-based clinics cannot, continuity of care. With Chronic Care Management, FQHC administrators are not only protecting their bottom line, they are giving their organizations a valuable tool. Competitive, quality care that low-income patients cannot find anywhere else, will help FQHCs remain viable in this fluctuating market. CCM adds value to an organization, and it adds value to patient care.

Closing Gaps in Social Care: Doing the Work for Underserved Populations

The reality is that many FQHC providers are currently furnishing their patients with some form of care coordination. This stems from the recognition that social detriments strongly affect patient health. Addressing these issues is part-and-parcel of good patient care for low-income populations.⁽⁹⁾ However, prior to G0511, this time could not be captured in the billing to Medicare and Medicaid.

Utilizing Chronic Care Management strategies, like those developed by CareHarmony, allows FQHCs to provide much needed services to low-income patients. In this way, the creation of G0511 supports strengthening connections to patients and diversification of funding. By capitalizing on this unique area of competitiveness, FQHCs ensure their long-term viability.

References

1. Nocon, Robert S., et. al., “Health Care Use and Spending for Medicaid Enrollees in Federally Qualified Health Centers Versus Other Primary Care Settings,” American Journal of Public Health, 2016 November. [Online: December 15, 2017] http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303341
2. Laff, Michael, “Study Finds Savings at Federally Qualified Health Centers,” AAFP News, [Online: November 10, 2017] https://www.aafp.org/news/practice-professional-issues/20161010healthcenters.html
3. CMS used GCCC1 as a placeholder during the creation and feedback stages of the 2019 Physician Fee Schedule. Centers for Medicare & Medicaid Services, HHS, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program,” Federal Register, 82.219 (2017) [Online: November 20, 2017]. https://www.federalregister.gov/d/2017-23953
4. Hutchings, Chuck, “It’s the Most Wonderful Time of the Year! CMS Guidance for 2018,” FQHC Germane, 2017, November 27. [Online: December 18, 2017]. https://www.fqhc.org/blog/2017/11/27/cms-guidance-for-2018-ccm-behavioral-health-aco-assignment
5. AIMS Center, “Cheat Sheet on CMS Medicare Payments for Behavioral Health Integration Services in Federally Qualified Health Centers and Rural Health Clinics,” Updated: November 14, 2017 [Online: November 20, 2017]. http://aims.uw.edu/sites/default/files/CMS_FinalRule_FQHCs-RHCs_CheatSheet.pdf
6. Staff, “FQHCs Feel Pressure as They Evolve Into Business-minded Organizations,” Business Insider: 2017, September 12. [Online: October 17, 2017]. http://markets.businessinsider.com/news/stocks/FQHCs-Feel-the-Pressure-as-They-Evolve-Into-Business-minded-Organizations-1002362375
7. Stainton, Lil H. “Federal Health Centers Face Fiscal Cliff, Plus New Challenges,” NJ Spotlight: 2017, September 18. [Online: September 21, 2017]. http://www.njspotlight.com/stories/17/09/17/federal-health-centers-face-fiscal-cliff-plus-new-challenges/
8. Belliveau, Jacqueline, “Federally Qualified Health Centers Troubled by Rising Competition,” RevCycle Intelligence: 2017, September 13. [Online: September 21, 2017]. https://revcycleintelligence.com/news/federally-qualified-health-centers-troubled-by-rising-competition
9. Laff, Michael, “Study Finds Savings at Federally Qualified Health Centers,” AAFP News, [Online: November 10, 2017] https://www.aafp.org/news/practice-professional-issues/20161010healthcenters.html