RHC Policies Addressed in the CY 2023 Physician Fee Schedule Final Rule
CMS issued the CY2023 Medicare Physician Fee Schedule Final Rule which included several provisions that impacted RHCs. A list of provisions effective January 1, 2023 is outlined below. Information regarding each of these policies is available in the CY 2023 Medicare Physician Fee Schedule Final Rule Fact Sheet.
New Care Management Codes for Chronic Pain Management (CPM) and General Behavioral Health Integration (GBHI)
Conforming Technical Changes to 42 CFR 405.2463 and 42 CFR 405.246
Specified Provider-Based RHC Payment-Limit Per-Visit
The following HCPCS codes have been revised to reflect the updates in the Consolidated Appropriations Act (CAA), 2023:
CY 2023 Payment Rate
COVID-19 Public Health Emergency (PHE) - Updates for RHCs
To provide as much support as possible to RHCs and their patients during the COVID-19 (PHE), we have made several changes to RHC requirements and payments. These changes are for the duration of the COVID-19 PHE, and we will continue to review our policies as the situation evolves. For additional information and other flexibilities, please see the link: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf (PDF)
COVID-19 Vaccines in RHCs
COVID-19 vaccines and their administration will be paid the same way influenza and pneumococcal vaccines and their administration are paid in RHCs. Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through the cost report. The beneficiary coinsurance and deductible are waived. For Medicare Advantage patients, RHCs and FQHCs should submit COVID-19 vaccine administration claims to the Medicare Advantage Plan for dates of service on or after January 1, 2022. Original Medicare won’t pay for these claims beginning in January 2022. For dates of service in 2021, RHCs and FQHCs should use the cost report to bill for administering COVID-19 vaccines. For additional information, please see https://www.cms.gov/covidvax.
Payment for Telehealth Services for RHCs During the COVID-19 PHE
On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) was signed into law. Section 3704 of the CARES Act authorizes RHCs to furnish distant site telehealth services to Medicare beneficiaries during the COVID-19 PHE. Medicare telehealth services generally require an interactive audio and video telecommunications system that permits real-time communication between the practitioner and the patient. RHCs with this capability can provide and be paid for telehealth services to patients covered by Medicare for the duration of the COVID-19 PHE.
Section 4113 of the CAA, 2023 extends the telehealth policies enacted in the CAA, 2022 through December 31, 2024 if the PHE ends prior to that date.
Distant site telehealth services can be furnished by any health care practitioner working for the RHC within their scope of practice. Practitioners can furnish distant site telehealth services from any location, including their home, during the time that they are working for the RHC, and can furnish any telehealth service that is approved as a distant site telehealth service under the Physician Fee Schedule (PFS). A list of these services can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
Payment for Mental Health Visits Furnished by RHCs via Telecommunications
Beginning January 1, 2022, RHC mental health visits will include visits furnished using interactive, real-time telecommunications technology. This change will allow RHCs to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the beneficiary is not capable of, or does not consent to, the use of video technology. Therefore, we are finalizing that there must be an in-person mental health service furnished within 6 months prior to the furnishing of the telecommunications service and that in general, there must be an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders. However, exceptions to the in-person visit requirement may be made based on beneficiary circumstances (with the reason documented in the patient’s medical record) and more frequent visits are also allowed under our policy, as driven by clinical needs on a case-by-case basis.
Section 4113 of the CAA, 2023 delayed the in-person requirements under Medicare for mental health services furnished through telehealth under the PFS and for mental health visits furnished by RHCs via telecommunications technology. For RHCs, in-person visits will not be required until January 1, 2025 if the PHE ends prior to that date.
In order to bill for mental health visits furnished via telecommunications for dates of service on or after January 1, 2022, RHCs should bill Revenue code 0900, along with the appropriate HCPCS code for the mental health visit along with modifier CG. Use modifier 95 for services furnished via audio and video telecommunications and use modifier FQ for services that were furnished audio-only.
For additional information on payment, billing, and claims processing, see https://www.cms.gov/files/document/se20016.pdf (PDF)
Expansion of Virtual Communication Services for RHCs During the COVID-19 PHE
During the COVID-19 PHE, payment for virtual communication services include digital assessment services. Digital assessment services are non-face-to-face, patient-initiated, digital communications using a secure online patient portal. The digital assessment codes that are billable during the COVID-19 PHE are CPT code 99421 (5-10 minutes over a 7-day period), CPT code 99422 (11-20 minutes over a 7-day period), and CPT code 99423 (21 minutes or more over a 7-day period).
To receive payment for the new digital assessment service or virtual communication services (HCPCS codes G2012 and G2010), RHCs must submit an RHC claim with HCPCS code G0071 (Virtual Communication Services) either alone or with other payable services. For claims submitted with HCPCS code G0071 on or after March 1, 2020, and for the duration of the COVID-19 PHE, payment for HCPCS code G0071 is set at the average of the national non-facility PFS payment rates for these 5 codes. See Virtual Communication Services Frequently Asked Questions (PDF)
Care Management Services
Effective January 1, 2023, care management services furnished in RHCs include transitional care management (TCM), chronic care management (CCM), principal care management (PCM), chronic pain management (CPM), and general behavioral health integration (BHI) services. CCM services are paid at the average of the national non-facility PFS payment rates, either alone or with other payable services, using general care management HCPCS code G0511 which is updated annually. At least 20 minutes of qualifying CCM services must be furnished in a calendar month to bill for this service.
Effective January 1, 2022, RHCs and FQHCs can bill TCM services and general care management services provided for the same patient during the same service period if the RHC and FQHC meet the requirements for billing each code.
Psychiatric CoCM services furnished on or after January 1, 2019, are paid at the average of the national non-facility PFS payment rate, either alone or with other payable services, using HCPCS code G0512. This rate is updated annually. At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months, of psychiatric CoCM services must be furnished in order to bill for this service.
Revision of RHC Home Health Agency Shortage Requirement for Visiting Nursing Services During the COVID-19 PHE
RHCs can bill for visiting nursing services furnished by an RN or LPN to homebound individuals under a written plan of treatment in areas with a shortage of home health agencies (HHAs). Effective March 1, 2020 and for the duration of the COVID-19 PHE, the area typically served by the RHC is determined to have a shortage of home health agencies, and no request for this determination is required. RHCs must check the HIPAA Eligibility Transaction System (HETS) before providing visiting nurse services to ensure that the patient is not already under a home health plan of care.
Questions on RHC Issues?
Billing / Payment
- CY 2023 Payment Rate Increases for RHCs
- CY 2022 Payment Rate Increases for RHCs
- CY 2021 Payment Rate Increases for RHCs
- CY 2020 Payment Rate Increase for RHCs
- Chronic Care Management Services (PDF) booklet
- SE22001 (PDF) - Mental Health Visits via Telecommunications for Rural Health Clinics & Federally Qualified Health Centers (PDF)
- Communication Technology Based Services and Payment for Rural Health Clinic (RHCs) and Federally Qualified Health Centers (FQHCs) [January 2019]: MM10843 (PDF)
- CY 2019 Payment Rate Increase for RHCs. See MM10989 (PDF) .
- Medicare Claims Processing Manual: Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers (PDF)
- Medicare Benefit Policy Internet Only Manual: Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services - See MM11019 (PDF)
- RHC Preventive Services Chart (PDF) – Information on preventive services in RHCs including HCPCS coding, same day billing, and waivers of co-insurance and deductibles (Updated on 08/10/2016).
- SE1606 (PDF) - Guidance on the Physician Quality Reporting System (PQRS) 2014 Reporting Year and 2016 Payment Adjustment for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals (CAHs)
- Chapter 29-(T14) -- Independent Rural Health Clinic and Freestanding Federally Qualified Health Center cost Report Form CMS 222-92 (Instructions) (ZIP)
Conditions for Coverage/Participation
- Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 - See Section III. Other Provisions of the Final Rule - C. Payment for Care Management Services and Communication Technology-Based Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 - See Section III. Other Provisions of the Proposed Rule - A. New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)
- Previous RHC Regulations (PDF)
Rural Research Centers
- RHC Fact Sheet
- Effective April 1, 2016, RHCs are required to report a HCPCS code for each service furnished along with an appropriate revenue code. For claims with dates of service on or after April 1, 2016, RHCs should follow the reporting requirements for modifier CG found in MLN Matters Article SE1611 (PDF) . For additional information, see RHC Reporting Requirements FAQs (PDF).
- MM10175 (PDF) - Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)
- MLN General Information
- MLN Matters Articles
- MLN Multimedia
- MLN Publications
External Links for Rural Health
- National Organization of State Offices of Rural Health - Opens in a new window
- National Rural Health Association - Opens in a new window
- Health Resources and Services Administration (HHS) - Opens in a new window
- National Association of Rural Health Clinics - Opens in a new window
- Rural Health Information Hub (RHI Hub) - Opens in a new window
- National Center for Frontier Communities - Opens in a new window
- National Rural Health Resource Center - Opens in a new window
- The National Rural Recruitment and Retention Network - Opens in a new window
- National Association for Rural Mental Health (NARMH) - Opens in a new window
- Kaiser Family Foundation - Opens in a new window
- The National Advisory Committee on Rural Health and Human Services - Opens in a new window
- Rural Health Research Gateway
Frequently Asked Questions
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