RHC Care Management Services

Care management services are structured services in addition to any routine care coordination services already furnished as a Rural Health Clinic (RHC) visit. RHCs can only bill one care management service for an individual per month.

Care Management Services include:

  • Transitional care management (TCM)
  • Chronic care management (CCM)
  • General behavioral health integration (BHI)
  • Psychiatric Collaborative Care Model (CoCM)

The patient must meet the criteria and benefit from care management services as determined by the primary care physician, nurse practitioner (NP), physician assistant (PA) or certified nurse midwife (CNM). 

These services require general supervision, the RHC practitioner does not have to be in the same building or immediately available; however, it does require the services to be furnished under the RHC practitioner's overall supervision and control.

Billing and Reimbursement

Coinsurance (20% of billed charges) and deductible apply to care management services in the RHC. HCPCS G0511 and G0512 will be reimbursed from the national non-facility Physician Fee Schedule (PFS) rate.

  • Type of Bill (TOB) - 71X
  • Date of service - Use the date after the minimum requirements for the CPT have been met; any date after that or before the last day of month
    • CMS expects the practitioner to continue furnishing services during a given month
    • Encounter/visit not required for payment
  • Diagnosis code - Practitioner should use most appropriate diagnosis code for patient
  • Revenue code - 052x
  • Modifier - CG not applicable for payment

 

Care Management Service Effective Date CPT Code(s) Narrative Reimbursement
TCM 1/1/13 99495 14-day discharge, moderate complexity Payable either alone the All-Inclusive Rate (AIR) or with another payable service
99496 7-day discharge, high complexity
CCM 1/1/16- 12/31/17 99490 20 minutes or more Physician Fee Schedule (PFS) national average non-facility rate
1/1/18 G0511 20 minutes or more, within a calendar month Separately payable
2018 - $62.28
Annual average of national non-facility PFS rate for 99490 (20 minutes or more of CCM services),
99487 (60 minutes or more of complex CCM services), and 99484 (20 minutes or more of general behavioral health integration services)
General BHI 1/1/18 G0511 20 minutes or more within a calendar month Separately payable
2018 - $62.28
Annual average of national non-facility PFS rate for 99490, 99487 and 99484
Psychiatric CoCM 1/1/18 G0512 70 minutes (initial)
60 minutes (subsequent) or more within a calendar month
Separately payable
2018 - $145.08
Annual average of national non-facility PFS rate for 99492 (70 minutes or more of initial psychiatric CoCM services) and 99493 (60 minutes or more of subsequent psychiatric CoCM services)

 

Tips

Avoid duplicative payment for care management services when provided by another facility or practitioner during the same service period. For example, home health care supervision, hospice care supervision or certain ESRD services.

The evaluation and management (E/M), Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE) initial service or visit with the patient is separately paid and the time cannot be counted towards the required time for billing HCPCS G0511 or G0512.

Resources

 

Last Updated Tue, 21 Jan 2020 11:40:11 +0000