By Juli Eschenbach, Custom Solutions Manager and Clinical SME

This year brings the introduction of a long-requested change for federally qualified healthcare centers (FQHCs) and regional health centers (RHCs): the sunset of the flat-rate, multiple-instance code G0511. The result is a conversion to regular fee-for-service, Physician Fee Schedule (PFS) billing codes for FQHCs and RHCs.

All FQHC/RHCs must convert to the PFS billing codes within the first six months of 2025.

Why did CMS do this for FQHC/RHCs?

The Centers for Medicare and Medicaid Services expanded G0511 so much that the agency said the flat rate for this code was longer appropriate. Other insights:

• The payment calculations CMS did in the past for all-encompassing G0511 don’t fit the model anymore.
• FQHC/RHCs provided feedback to CMS for years that it’s difficult to audit if you’re billing the same code for every single service. That leads to complexities surrounding measurement of which service was provided, proving what the scope of work was, and how to demonstrate value of service. PFS code billing going forward will lead to transparency in the billing and also allows for proper payment of each service rendered.

Expansion of billing opportunities

CMS expressly stated for the first time that FQHC and RHCs will be allowed add-on codes.   Previously, an FQHC/RHC was eligible for one RPM, one CCM, so on and so forth. But now they are broadening the use of all of the care management codes (for more on codes including chronic care management and behavioral health integration, click here).

Although some FQHCs and RHCs might see a drop in reimbursement if they were only billing one flat-fee code per care management program previously, the expansion means that each patient can be eligible for the add-on time codes. This means that additional time codes for reimbursement are now available.

In addition, CMS has already stated that they will wrap the new APCM codes to be available to FQHCs, which is untraditional. CMS usually makes FQHCs wait a while before they are eligible to apply the for-fee service codes to FQHCs. It’s encouraging that the agency did so out of the gate this year.

ChronicCareIQ: Your prepared partner

ChronicCareIQ already positioned its software a year in advance to be able to support these noteworthy changes. Our team saw the writing on the wall regarding G0511 and made underlying changes to code structures to be able to “flip the switch.” The result is a partner who is ready to support providers in capturing the entirety of 2025 as PFS codes. We’re also here with expert guidance around CMS rules stating that both G0511 and PFS care management codes can’t be submitted for the same month.