It’s the most wonderful time of the year! CMS Guidance for 2018

The Holidays are coming - good food, conversation, gifts, developing New Year’s budgets and strategies...Wait – budgets and strategies?

Yes, you read right! Health centers can maximize their budgets (and thus their Mission) by reviewing Federal policy updates and reimbursement changes to FQHCs.

Let’s look at the CMS reimbursement changes published on November 2nd to see if we can expect goodies or lumps of coal for 2018. There are two significant areas of financial changes for health centers in 2018:

Care Management Services: Chronic Care Management and Behavioral Health Integration

Chronic Care Management (CCM) services have received little fanfare from health centers since the program's 2015 implementation, due to low reimbursement rates and the burdensome paperwork and time tracking to justify the code requirements.

However, a little discussed item is that behavioral health conditions can be part of chronic care management services that entities offer. CMS continues the move toward integrated care emphasizing behavioral health components and, effective January 1, 2018, FQHCs can receive payment for Chronic Care Management (CCM) or general Behavioral Health Integration (BHI) services when 20 minutes or more of CCM or general BHI services are furnished under code G0511, General Care Management. G0511 will be an FQHC and RHC specific code and will replace CPT code 99490 starting January 1st, 2018.

The positive here is that the new code reimbursement is an average of previously used codes. If this rule was in place for 2017, the reimbursement for G0511 would be approximately $61.00 per beneficiary per month versus the present $42.00.

Here are some additional incentives for health centers to review their Care Management offerings:

  • CMS has significantly eased enrollment and oversight requirements in 2017 and State Medicaid providers are recognizing these service codes.

  • Some PCA’s and many EMR platforms are maintaining care management modules and assistance that make time tracking, documentation, and implementation an easier lift in 2018.

CCM Website

CMS Care Coordination Teaching Guide:


Behavioral Health: Psychiatric Collaborative Care Model 

CMS is instituting a Collaborative Care Model (CoCM) with a unique CPT code for 2018.

CMS defines psychiatric CoCM as a "defined model of care that integrates primary health care services with care management support for patients receiving behavioral health treatment, and includes regular psychiatric inter-specialty consultation with the primary care team, particularly regarding patients whose conditions are not improving."

Starting January 1st, FQHCs can receive payment for psychiatric Collaborative Care Model (CoCM) services when 70 minutes or more of initial psychiatric CoCM services or 60 minutes or more of subsequent psychiatric CoCM services are furnished and G0512 is billed either alone or with other payable services on an FQHC claim. The new code can be billed alone or in addition to other services furnished during the RHC or FQHC visit. 

As with the general Chronic Care Management code above, the 2018 reimbursement is an average of present codes and would be approximately $134.58 had this rule been in place for 2017.

The requirements are similar to CCM services where this code can only be billed once per month per beneficiary, and cannot be billed with other care management services such as Transitional Care Management.

A financial and services review of the new codes may be appropriate for entities to assess the best options for your center.

While not part of your 2018 finances, this change will lessen administrative burdens moving forward. 

ACO Assignment

As part of the 21st Century Cures Act passed in December of 2016, ACO Assignment eliminates the multi-step process of assigning ACO patients who see only non-physician providers in a FQHC setting. The guidance allows for ACO assignments starting with the 2019 reporting year.

21st Century Cures Act Overview:  

We started this journey with the goal of determining if CMS was delivering health centers lumps of coal or goodies for 2018. The addition of BHI/CCM and CoCM specific codes with increased reimbursement rates seems to fall under the "goodie" category for many entities. The opportunities for health centers that have not implemented Care Management Services in the past appear significant, with centers presently offering these services seeing additional benefits in the coming year. 

Take a closer look at the CMS goodie bag this Holiday Season– there could be unexpected goodies there for your health center in 2018!


Chuck Hutchings is the Director Healthcare Operations & Strategy at RDI.

To connect with Chuck on LinkedIn, click here.


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