2024 MPFS Proposes Expansion of Services Billable as G0511

RHCs Eligible for Remote Patient Monitoring and Other Care Management Reimbursement

Sarah Hohman, Director of Government Affairs

The CY 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule vastly expanded the care management related services billable in RHCs under the general care management code of G0511, beginning January 1, 2024.

Since 2016, RHCs have been able to bill for Chronic Care Management (CCM) services through this consolidated care management code. G0511 pays a consolidated fee schedule amount, $77.24 in 2023, which is the average of the Physician Fee Schedule (PFS) rates for CCM and principal care management (PCM) services, as well as codes newly added in 2023: Chronic Pain Management and General Behavioral Health Integration.

In this proposed rule, CMS is granting RHCs the opportunity to bill for Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) services, as well as establishing new care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN), all through the G0511 code.

1-Remote Patient Monitoring and Remote Therapeutic Monitoring

Remote Patient Monitoring and Remote Therapeutic Monitoring services are intended to help providers monitor their patients’ conditions remotely through various digital technologies. The descriptions of RPM and RTM codes can be found in the tables below and are also included on pages 459-460 of the MPFS proposed rule. As you can see, the services include device set-up, educating patients on the monitoring, as well as the monitoring of the collected data.

TABLE 20: RPM HCPCS Codes and Descriptors

HCPCS Code	Short Description	Official Long Description
99453	Rem mntr physiol param setup	Remote monitoring of physiologic parameter(s) (e.g. Weight, blood pressure, pulse oximetry, respiratory flow rate) initial set-up and patient education of use of equipment
99454	Rem mntr physiol param dev	Remote monitoring of physiologic parameter(s) (e.g. Weight, blood pressure, pulse oximetry, respiratory flow rate) initial device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
99457	Rem physiol mntr 1st 20 min	Remote physiologic monitoring treatment services, clinical staff/physician/other qualified health care professionals time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458	Rem physiol mntr ea addl 20	Remote physiologic monitoring treatment services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (list separately in addition to code for primary procedure)
99091	Collj & interpj data ea 30 d	Collection and interpretation of physiologic data (e.g. Blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.

 

TABLE 21: RTM HCPCS Codes and Descriptors

HCPCS Code	Short Description	Official Long Description
98975	Rem ther mntr 1st setup&edu	Remote therapeutic monitoring (e.g. therapy adherence, thereapy response); initial set-up and patient education on use of equipment
98976	Rem ther mntr dev sply resp	Remote therapeutic monitoring (e.g. therapy adherence, thereapy response); device(s) supply with scheduled (e.g. daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days
98977	Rem ther mntr dv sply mseskl	Remote therapeutic monitoring (e.g. therapy adherence, thereapy response); device(s) supply with scheduled (e.g. daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days
98980	Rem ther mntr 1st 20 min	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981	Rem ther mntr ca addl 20 min	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (list separately in addition to code for primary procedure)

 

2-Community Health Integration (CHI) and Principal Illness Navigation (PIN)

Broadly, CHI and PIN services are intended to reflect the “additional time and resources helping patients with serious illness navigate the healthcare system or removing health-related social barriers that are interfering with the practitioner’s ability to execute a medically necessary plan of care.” CMS acknowledges that providers may utilize other members of their staff to provide these increasingly important care and social services, including Community Health Workers, Peer Specialists, etc. but that there is not a structure available within Medicare to reimburse these individuals.

Community Health Integration

• In an initiating E/M visit a practitioner may identify the presence of Social Determinant of Health (SDOH) need(s) (defined as: “Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity”).
• If these SDOH needs limit the practitioner’s ability to diagnose/treat the issue(s) that the patient presents with, they can initiate Community Health Integration services and develop a treatment plan.
• CHI services, following the initiating visit, would be provided by a Community Health Worker or other similarly certified/trained auxiliary members of the care team under general supervision of the billing provider.
  • Services provided may include patient-centered assessments, coordinating care between providers, community-based services, and other caregivers, health education, building self-advocacy skills, and other tailored supports.
  • CMS is seeking comment as to whether they should determine the specific types and hours of training required for these personnel in states that do not have licensure or laws/regulations already, or if providing broad competencies is sufficient.
  • These personnel may be contracted with the provider, for example, a community-based organization, so long as there is sufficient clinical integration between the third-party and the provider.
• 60 minutes per calendar month; an initiating visit is only required in the first month. Only one practitioner per month can bill for CHI services for an individual patient.

Principal Illness Navigation

• Eligible patients include those with serious, high-risk disease such as cancer, congestive heart failure, severe mental illness, substance use disorder, and others, expected to last at least 3 months, that significantly increases a patient’s risk of hospitalization, functional decline, or death.
• The purpose of PIN services is to provide individualized help by a peer specialist, or other similar auxiliary staff, to the patient in navigating the complex health care and social support system.
• Similar to CHI services, the provider would identify the need for such services in an initiating E/M visit. Then, individuals operating under general supervision including cancer navigators, diabetes navigators, social worker navigators, etc. would assist the patient in understanding their care plan, obtaining necessary social supports, etc. while taking into account the personal circumstances of each patient.
• 60 minutes per calendar month; an initiating visit is only required in the first month. Only one practitioner per month can bill for PIN services for an individual patient.

3-NARHC Reaction

For several years, NARHC has been advocating for CMS to extend RPM and RTM billing privileges to safety net providers, and NARHC commends CMS for retaining a mechanism for RHCs to provide and bill for these services that would not fit our traditional definition of a reimbursable encounter. However, if the proposed rule is finalized as written, beginning in 2024, the G0511 code will be the special payment code that represents 22 care managements services, and this aggregation presents a myriad of problems.

Unless CMS changes their policy to allow multiple G0511 services per patient per month, safety-net providers and our patients are disadvantaged by this special payment rule.

To be clear, our fee-for-service peers can bill services such as RPM, CCM, CHI, and PIN all for the same patient, in the same month, so long as time and services are not duplicative. However RHCs are only eligible to be reimbursed for one general care management service per patient, per month. Therefore, if an RHC patient is already enrolled in your clinic’s CCM program, regardless of whether they may benefit from additional services like RPM, CHI, etc., the RHC will only be eligible for one G0511 reimbursement for that patient each month.

This increasingly complex bundled approach will limit the services that RHCs can provide to their patients in comparison to fee-for-service providers. NARHC will be engaging with CMS on other potential approaches to care management billing and reimbursement in the RHC setting.

4-Revision of Methodology

Currently, G0511 reimburses at the average of the PFS rates for all services captured (and equally weighted) in the consolidated code. Beginning in 2024, CMS is proposing to use a weighted average of the services billable under G0511. However, because RHCs bill using a consolidated code, there is no utilization data on the various CCM services provided in RHCs. Therefore, in their proposed weighted average, CMS uses utilization data from non-RHC physician offices.

Under this proposed methodology, the 2024 G0511 reimbursement amount would be $72.98. This is still a decrease from the 2023 reimbursement rate, however not as significant as the decrease would have been simply using the true average methodology.

NARHC agrees with a weighted average methodology revision but will continue to prioritize CMS considering other care management reimbursement structures all together to ensure that RHCs are not limited to providing their patients with, and billing, just 1 of 22 services in a given month.

5-Clarification Regarding Obtaining Beneficiary Consent

Finally, CMS used this rulemaking opportunity to clarify the CCM and Virtual Communication Services requirements around obtaining beneficiary consent. Pre-COVID-19 policy required that beneficiary consent for these services was obtained either by or under the direct supervision of a primary care practitioner. CMS granted flexibilities during the COVID-19 Public Health Emergency (PHE) allowing consent to be obtained via general supervision. Moving forward, CMS is clarifying the following:

• Informed consent must be obtained prior to the start of CCM and Virtual Care Communications services but can occur at the time that the service is initiated by staff who furnish such services.
  • Consent can be obtained either at the CCM initiating visit or separately obtained.
    • If separately obtained, it can be verbal and done under general supervision, so long as it includes the required information and is documented in the medical record.
  • The individual obtaining consent may be under contract with the RHC.
• Informed consent must include the availability of CCM services, that only one provider can bill for these services each month, and that the patient may stop the services at any time.

Please contact Sarah Hohman, NARHC Director of Government Affairs at Sarah.Hohman@narhc.org with any questions or other feedback, and don’t forget to register for NARHC’s August 30th webinar on these CMS proposed rules here.