CMS Pub. 100-02, ch. 13, § 230.3

CCM services furnished between January 1, 2016, and December 31, 2017, are paid

based on the PFS national average non-facility payment rate when CPT code 99490 is

billed alone or with other payable services on an RHC or FQHC claim.

CCM or general BHI services furnished between January 1, 2018, and December 31,

2018, are paid at the average of the national non-facility PFS payment rate for CPT codes

99490 (30 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), when general care management HCPCS code G0511 is on an RHC or FQHC

claim, either alone or with other payable services.

CCM or general BHI services furnished on or after January 1, 2019, are paid at the

average of the national non-facility PFS payment rate for CPT codes 99490, 99487,

99484, and 99491(30 minutes or more of CCM furnished by a physician or other

qualified health care professional), when general care management HCPCS code G0511

is on an RHC or FQHC claim, either alone or with other payable services.

CCM, PCM or general BHI services furnished on or after January 1, 2021 are paid at the

average of the national non-facility PFS payment rate for CPT codes 99490, 99487,

99484, and 99491, and CPT codes 99424 (30 minutes or more of PCM services furnished

by physicians or non-physician practitioners (NPPs)) and 99426 (30 minutes or more of

PCM services furnished by clinical staff under the direct supervision of a physician or

NPP), when general care management HCPCS code G0511 is on an RHC or FQHC

claim, either alone or with other payable services.

CCM, PCM, CPM or general BHI services furnished on or after January 1, 2023 are paid

at the average of the national non-facility PFS payment rate for CPT codes 99490, 99487,

99484, 99491, 99424, 99426, and G3002 (30 minutes or more of CPM services) when

general care management HCPCS code G0511 is on an RHC or FQHC claim, either

alone or with other payable services. The payment rate for HCPCS code G0511 is

updated annually based on the PFS amounts for these codes.

CCM, PCM, CPM, general BHI, RPM, RTM, CHI or PIN services furnished on or after

January 1, 2024, are paid at the weighted average of the national non-facility PFS

payment rate by taking the utilization of the base code for the service furnished and any

applicable add-on codes used in the same month, as well as any base code reported

alone in a month, when general care management HCPCS code G0511 is on an RHC or

FQHC claim, either alone or with other payable services. The actual utilization of the

services that comprise G0511 will be obtained by using the most recently available data

for the services paid under the PFS. The payment rate for HCPCS code G0511 is

updated annually based on the PFS amounts for these codes.

RHCs and FQHCs may bill HCPCS code G0511 multiple times in a calendar month for

the codes listed in the table below as long as all requirements are met and there is not

double counting. For example, RHCs and FQHCs can bill HCPCS code G0511 twice

for 20 minutes of qualifying CCM services and 30 minutes of qualifying PCM services,

as long as, the clinical staff minutes do not overlap.

Effective January 1, 2025, RHCs and FQHCs are required to bill the individual

CPT/HCPCS base codes and add-on codes for each of the care coordination services

to receive payment separate from the RHC AIR or FQHC PPS. Billing the individual

codes replaced the reporting of HCPCS code G0511. Care coordination services are

paid at the national non-facility PFS payment rates.

Note: CMS permitted billing of HCPCS code G0511 to continue through September

30, 2025.

Advanced Primary Care Management Services (APCM) furnished on or after

January 1, 2025, are paid at the national non-facility PFS payment rates.

A list of all care coordination services for RHCs and FQHCs are available on the

RHC and FQHC websites at https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center and https://www.cms.gov/medicare/payment/prospective-payment-systems/federally-qualified-health-centers-fqhc-center, respectively.

Coinsurance

For FQHCs, coinsurance for care coordination services is 20 percent of the lesser of

submitted charges or the national non-facility PFS payment rate for each individual

HCPCS code.

For RHCs, coinsurance for care coordination services is 20 percent of the lesser of the

submitted charges or the national non-facility PFS payment rate for each individual

HCPCS code.

Care coordination costs are reported in the non- reimbursable section of the cost report

and are not used in determining the RHC AIR or the FQHC PPS rate.