The Centers for Medicare & Medicaid Services (CMS) recently issued its calendar year (CY) 2025 final rules for the Medicare Physician Fee Schedule (MPFS).
As we noted in the proposed rule newsletter and discussed at the DZA conference, there are lots of changes on the horizon for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC), including:
- Preventive Vaccines Billing
- Productivity Standards
- Primarily Primary Care
- G0511 Consolidate Code
- RHC Lab Services
- Dental Services
- Telehealth
- Intensive Outpatient Program (IOP)
Preventive Vaccines Billing
The RHC statute mandates that preventative vaccines (pneumococcal, influenza, COVID-19, and soon Hepatitis B), along with their administration for Medicare patients, be reimbursed at 100% of reasonable costs, rather than the 80% limit applied to other services. Currently, these vaccines are not billed to Medicare and payments are reimbursed through the cost report.
Beginning on or after July 1, 2025, RHCs and FQHCs can bill preventive vaccines and the administrative costs at the time of service.
These claims will initially be reimbursed similarly to other Part B vaccine claims, at 95% of the Average Wholesale Price for the vaccine product itself. Vaccine administration will be paid based on the Part B Vaccine Administration National Fee Schedule, adjusted for locality.
HOWEVER, because these preventative vaccines will continue to be reimbursed at 100% costs, payments for these services received at the time of service will need to be annually reconciled on the cost report to receive full vaccine and administrative costs. (Sorry, not sorry: cost report preparers will be asking for the same vaccine data, and now for Hepatitis B, too!)
Did you catch that Hepatitis B vaccines are now considered preventive vaccines? Historically, the Hepatitis B vaccine was reimbursed as part of the RHC all-inclusive rate (AIR) or FQHC prospective payment system (PPS) rate, similar to other vaccines. Effective January 1, 2025, Hepatitis B will be paid at the reasonable cost in RHCs and FQHCs and no longer be included in the RHC AIR or FQHC PPS rate.
One last vaccine treat – CMS clarified that RHC and FQHC providers are also eligible to bill HCPCS code M0201 for an additional in-home payment for the above preventive vaccine administration, provided the home visit meets all required criteria.
What changes are to be made for billing?
- Effective January 1, 2025 – Hepatitis B vaccines will be considered a preventative vaccine; therefore, do NOT bill like other vaccines: instead, treat these vaccines like pneumococcal, influenza, and COVID-19
- Effective July 1, 2025 – preventative vaccines should be billed at the time of services
P.S. – CMS intends to release further guidance on implementing these policies before the effective date of July 1, 2025. For example, CMS has not addressed whether vaccines not billed at the time of service will be allowed as part of the yearend cost report reconciliation.
Productivity Standards
Currently, RHC productivity standards are set at 4,200 visits per full-time equivalent (FTE) physician and 2,100 visits per FTE nurse practitioner, physician assistant, or certified nurse midwife. The cost report settles on the larger of actual visits or minimum productivity standards.
Since all RHCs are now subject to an upper payment limit—either the clinic-specific cap for grandfathered RHCs or the national statutory cap for new and independent RHCs—the productivity standards are considered antiquated, redundant, and the cause of negative implications; therefore, CMS finalized removing the productivity standards for RHCs, effective for cost reporting periods ending after December 31, 2024.
What does this mean for cost reports that are not calendar yearend?
CMS did not address this issue in the final rule. Best guess? Either the productivity standard will be prorated or cost report data will be reported into two sections: one for the period before January 1, 2025, where the old productivity standards apply, and another for the period after January 1, where the new policy without productivity standards will be used.
What if our RHC wants to qualify for productivity exemption, since it’s going away?
CMS clearly stated, “We do not agree with instructing MACs to apply a waiver during final settlement that would eliminate any application of the guidelines as we are striving to have all RHC fiscal year ends for this change be handled consistently.” This would apply to older cost reports that have not been finalized yet (that is, without a Notice of Program Reimbursement) and cost reports beginning in 2024 that do not have a calendar yearend.
Primarily Primary Care
Federal rules state that RHCs and FQHCs are to be primarily engaged in “providing outpatient health services.” However, State survey guidance states, “RHCs may not be primarily engaged in specialized services,” and stipulates that “primarily engaged” is determined if more than 50% of total RHC hours is providing primary care services.
This causes quite the conundrum for RHCs wanting to provide more specialized services (which are technically “outpatient” services).
So, CMS finalized two things:
- Added the following to the 491.9(2) regulation:
- (i) The clinic or center must provide primary care services.
- (ii) The clinic is not a rehabilitation agency or a facility primarily for the care and treatment of mental diseases.
- And, beginning January 1, 2025, RHCs will no longer be surveyed to a requirement that they provide more than 50% of operating hours as primary care services.
CMS also withdrew FQHCs from the proposal. FQHCs will continue to provide health and behavioral health services, but were removed for any unintended consequences this provision may impose on FQHCs.
G0511 Consolidate Code
Since 2016, RHC and FQHCs have been able to bill for Chronic Care Management (CCM) services using a consolidated care management code, G0511. This payment was separate from the RHC AIR and FQHC PPS rate, and their associated costs are to be reported as non-RHC/FQHC services on the cost report.
Not all CCM services are the same, though – with some services being more complex and costly than the flat rate, CMS proposed for RHCs and FQHCs to bill the individual codes that make up the code G0511.
What changes are to be made for billing?
- Beginning January 1, 2025, RHCs should bill, on the UB-04 claim form, the CPT codes used for CCM services. Note: since some of the fee schedule reimbursements may be lower than the consolidated rate, RHCs will be eligible to bill for add-on time-based codes.
- After July 1, 2025, G0511 will no longer be reimbursable.
RHC Lab Services
CMS removed hemoglobin and hematocrit (H&H) from the list of lab services that RHCs (not FQHCs) must have the equipment and supplies to provide directly within the RHC.
Historically, RHCs reported the H&H test infrequently, if at all. By removing this requirement, CMS aims to reduce the burden associated with purchasing and maintaining the laboratory equipment needed for these tests. RHCs can still provide this test but it is no longer a requirement.
In addition, CMS listened to commentors and removed the current requirement that RHCs directly provide “examination of stool specimens for occult blood.”
Dental Services
Medicare is precluded from paying for most dental services, including routine cleanings and treatment. However, dentists are physicians; services furnished by physicians, if face-to-face and medically necessary, are billable visits in RHCs and FQHCs. Therefore, CMS finalized that dental services that are inextricably linked to a specific medical service are billable visits and can be paid under the RHC AIR or FQHC PPS rate.
The KX modifier is to be used on a RHC or FQHC claim to indicate that the service is medically necessary and that the provider has included appropriate documentation in the medical record to justify the medical necessity of the service or item. The KX modifier, for dental claims, indicates that the claim is inextricably linked to covered services.
Additionally, CMS finalized that when a medical encounter and covered dental visit are provided to the same patient on the same day in an RHC or FQHC, they qualify for an exception to the same day visit limitations and will be reimbursed as two separate billable encounters.
This also means that for cost report purposes there will be allowable and non-allowable dental visits to be reported separately. Allowable visits and their costs will be reported as physician visits and costs whereas the associated costs for non-allowable visits will be reported as non-RHC/FQHC costs and visits will be excluded from total visits.
Telehealth
Telehealth services were set to expire on December 31, 2024. CMS finalized that RHCs and FQHCs can continue to bill for services furnished using telecommunication technology until December 31, 2025. Currently, telehealth services are paid a flat rate and their associated costs are to be reported as non-RHC/FQHC services on the cost report.
Due to the success and popularity of providing telehealth services, ideally these services should be paid under the RHC AIR or FQHC PPS rate. In other words, reach out to your Member of Congress and let your voice be heard.
And, oh yeah, CMS further delayed the occasional in-person visit requirement prior to, and for the duration of those services, until January 1, 2026.
Intensive Outpatient Program
Beginning in 2024, RHCs and FQHCs can furnish Intensive Outpatient Program (IOP) services for patients with mental health needs. These services intended to serve patients who need a higher level of care than traditional outpatient services, but whose needs aren’t severe enough for 24-hour services. A physician must certify that a patient requires behavioral health services for a minimum of 9 hours and a maximum of 19 hours per week.
At the time, CMS established a 3-service per day limit although other providers were eligible to bill more for IOP services. After reviewing and deliberating over public comments, CMS finalized to establish a payment for four or more services per day in an RHC/FQHC setting.
Closing
If you have any questions regarding the CY 2025 MPFS Final Rules, contact us or reach out to a DZA reimbursement consultant today.
Tristi Cohelan
Principal
