Article Detail - JE Part A

Care Management Services

The Care Management Services are now classified as "Care Coordination Services"

• New service(s) added to General Care Management services
  • Advanced Primary Care Management (APCM)
    • Integrates elements of Chronic Care Management (CCM), Transitional Care Management (TCM), and Principal Care Management (PCM)
    • Bill once per patient per month, without time-based requirements
    • APCM HCPCS codes: G0556 (one chronic condition), G0557 (two or more chronic conditions), and G0558 (Qualified Medicare Beneficiary (QMB) status with two or more chronic conditions)
• Starting January 1, 2025, RHCs and FQHCs must bill the individual CPT codes and add-on codes (as necessary) for each care coordination service instead of using the general care management HCPCS code G0511
  • Providers can bill G0511 until July 1, 2025
  • Update billing systems to capture these coding changes
• For more information, refer to Section 230

Multiple visits on Same Day

This section now include:

• An Intensive Outpatient Program (IOP) service and medical visit on the same day
• A dental visit and medical visit on the same day
• Report appropriate modifiers:
  • Modifier 25 (RHC) and modifier 59 (subsequent FQHC medical visit)
  • If a mental health visit and IOP service occur on the same day, only the IOP service will be paid, with the mental health visit included in the IOP rate (packaged)
  • For more information, refer to Section 40.3
• Dental services closely (inextricably) linked to specific medical services and meeting clinic policies are considered qualifying visits and paid at the RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS) payment rate
  • For more information, refer to Section 110.1
• Expansion of Intensive Outpatient Program (IOP) services
  • Starting January 1, 2025, payment for IOP services will be adjusted to cover four or more services, based on the outpatient hospital rate
  • For more information, refer to Section 250.1

Preventive Services

Coverage Changes on Preventive Services

• Hepatitis B (G0010) vaccine and its administration are separately billable with a qualifying visit
  • Practitioner's order is no longer necessary
  • Starting January 1, 2025, include hepatitis B vaccine costs in the cost report
  • Starting July 1, 2025, providers may submit institutional claims for pneumococcal, influenza, hepatitis B, and COVID-19 vaccinations, with or without a qualifying visit at the time of service.
    • This policy does not apply to vaccinations administered during home health visits
    • Paid at 95 percent of their Average Wholesale Price (AWP)
• Drugs Covered as Additional Preventive Services (DCAPS) and their associated supply and administration fees are billed separately and paid at 100 percent of the Medicare amount
  • Pre-exposure prophylaxis (PrEP) for HIV HCPCS code G0012
  • No coinsurance and deductible
  • Refer to CMS PrEP for HIV and Related Preventive Services
• For more information, refer to Sections 220

Telehealth Services

Telehealth Flexibilities through December 31, 2025

• RHCs and FQHCs can continue to bill for non-behavioral health telehealth services, including audio-only technology, using HCPCS code G2025
  • Modifier 95 (optional reporting) using video and audio technology
  • Modifier 93 using audio-only communications technology
• For more information, refer to Section 200

References

• Change Request (CR)13923
• Medicare Learning Network (MLN) MM13946
• CMS Internet Only Manual (IOM), Publication 100-02 Medicare Benefit Policy Manual, Chapter 13

Please inform your billing staff about these changes.