by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 26th, 2022

There is an ongoing battle to identify and manage chronic conditions that place a patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These types of chronic conditions are costly, and according to the CMS 2018 Chronic Conditions Chart, the average Medicare beneficiary suffers from a minimum of two chronic conditions, with an average per capita rate over $2,000. In an effort to provide physicians and other qualified healthcare practitioners (QHPs) with the tools necessary to identify beneficiaries struggling with chronic conditions, changes to the rules on reporting care management services were made in the 2021 Medicare Final Rule. In the final rule, CMS announced that both Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) will be allowed to bill for Chronic Care Management (CCM) Services reported with HCPCS codes G0511 and G0512, concurrently with Transitional Care Management (TCM) Services reported with CPT codes 99495 and 99496, billed for the same beneficiary during the same service period (calendar month). 

CCM and TCM services are rich sources of information, with documentation that identifies chronic conditions and complex or potentially complex chronic conditions, for beneficiaries. The documentation for both services can be used to assign Hierarchical Condition Category (HCC) codes for risk adjustment purposes. It also provides a great opportunity for both FQHC and RHC providers to help the underserved populations receive continuity of care for their chronic conditions, and feel like they have some consistency in their overall care. 

Additionally, due to the underserved populations who seek evaluation and treatment from these entities, the likelihood of data containing the increasingly important social determinants of health (SDoH) is likely to be contained in these evaluations, and as we have recently read, chronic conditions affected by SDoH are important to identify and report. With health equity at the top of the list of goals for the Centers for Medicare and Medicaid Innovation (CMMI), consistent SDoH reporting will play an important role in CMS considering these codes for future HCC assignment. 

As a reminder, the following codes identify encounters where care management services were either established through a formal care plan or care management activities were carried out for the patient: 

G0506 (RVU 1.810/National Unadjusted Rate $62.64)

Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service) 

G0511 (RVU 2.290/National Unadjusted Rate $79.25)

Rural Health Clinic or Federally Qualified Health Center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (Physician, NP, PA, or CNM), per calendar month

References:

• CMS Research Statistics Data & Reports
• CY 2022 Medicare Physician Fee Schedule Final Rule

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.