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CMS Finalizes Rules Impacting RHCs Effective January 2024

CMS has issued final rules that may result in significant operational, revenue cycle, and regulatory reimbursement impacts for RHCs beginning in January 2024.
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In November 2023, CMS issued final rules for the 2024 Medicare Physician Fee Schedule (MPFS) and the 2024 Medicare Outpatient Prospective Payment System (OPPS). Both of these rules contained finalized policy proposals that will impact rural health clinics (RHCs) beginning in January 2024:

  • Telehealth Flexibilities
  • Medicare Coverage of Marriage and Family Therapists and Mental Health Counselor Services
  • Intensive Outpatient Program (IOP) Services Billable in RHC Under Special Payment Rule
  • Expansion of RHC Care Management Services
  • Definition Change to Nurse Practitioner

Telehealth Flexibilities

CMS has officially extended some telehealth flexibilities that were allowed during the public health emergency (PHE) to continue through December 31, 2024. Specifically, CMS finalized the following:

  • RHCs may be reimbursed for telehealth services utilizing CPT code G2025
  • Removed the originating and geographic site requirements, which allows patients to be located in any location during the telehealth visit. This would include the patient’s home. It should be noted that telehealth services are to be provided during the RHC’s operating hours
  • Delayed the in-person requirement for mental health visits performed via telehealth
  • Extended audio-only coverage allowance for telehealth services
  • Expanded the list of telehealth distant site providers to include Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs)

New Billable RHC Provider Types

MFTs and MHCs have now been officially added as qualified RHC provider types. An MHC is an individual who:

  • “(A) possesses a master’s or doctor’s degree which qualifies for licensure or certification as a mental health counselor, clinical professional counselor, or professional counselor under the State law of the State in which such individual furnishes the services described in paragraph (3);
  • (B) is licensed or certified as a mental health counselor, clinical professional counselor, or professional counselor by the State in which the services are furnished;
  • (C) after obtaining such a degree has performed at least two years of clinical supervised experience in mental health counseling; and
  • (D) meets such other requirements as specified by the Secretary.”

Effective January 1, 2024, MFTs and MHCs will be able to generate Medicare encounters and be reimbursed for those services at the RHC’s all-inclusive rate (AIR). MFTs and MHCs also have the ability to meet the requirement that a provider must be available to provide care to patients at all times the clinic is open.

Intensive Outpatient Program (IOP) Services

IOP services are outpatient mental health services that are designed for patients who require more complex mental health care than would be able to be accomplished during a typical office visit, but not so severe that an inpatient mental service would be required. These services are intended for patients with acute mental illnesses such as depression and substance abuse disorders who require a higher level of care. In its proposal, CMS specified the services eligible to be provided and reimbursed under an IOP may include:

  • Individual and group therapy with physicians, psychologists, and other mental health professionals as available under state law
  • Occupational therapy
  • Furnishing of drugs and biologicals for therapeutic purposes that are not self-administered
  • Family counseling (as part of treatment of the patient’s condition)
  • Patient training and education
  • Individualized activity therapies
  • Diagnostic services
  • Other related services for diagnosis and active treatment intended to improve or maintain the patient’s condition and function

To quality a patient for IOP services, a physician is required to certify that a patient needs behavioral health services for at least nine, but no more than 19 hours per week. That certification must be completed by a physician at least once every other month for the patient to continue to qualify for services and the plan of care must demonstrate that the patient:

  • Requires at least nine hours of therapeutic services per week
  • Is likely to benefit from coordinated services rather than individual sessions of outpatient treatment
  • Does not need 24-hour care
  • Has a support system outside of the IOP
  • Has received a mental health diagnosis
  • Is not a danger to themselves or others
  • Has the cognitive and emotional ability to tolerate the IOP

IOP services will not be reimbursed at the RHC’s AIR, but rather under a special rule that would allow for a flat payment of approximately $280 per day. RHCs will be allowed to perform up to three services per day and to qualify for the special payment, at least one of the three services must be from Table 44 Proposed Partial Hospitalization and Intensive Outpatient Primary Services found on page 367 of the HOPPS Proposed Rule.

Because IOPs are a new service for RHCs, there is an expectation of future rulemaking outlining how services may be provided and reimbursed.

Expansion of RHC Care Management Services

Historically, RHCs have only been allowed to bill and be reimbursed for Care Management Services, including Remote Patient Monitoring, Remote Therapeutic Monitoring, or using CPT code G0511 or G0512 once per month per beneficiary. Under the new final rule, RHCs may now bill G0511 multiple times per month as long as the services rendered are “medically reasonable and necessary, meet all requirements, and not be duplicative of services paid to RHCs and FQHCs under the general care management code for an episode of care in a given calendar month.” In addition, CMS has finalized the establishment of new care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN), which also will be billed to Medicare using the G0511 code and those services will be reimbursed as long as a qualified provider performs the service.

Definition Change to Nurse Practitioner

CMS has changed the definition of a nurse practitioner to state that an individual must “be certified as a primary care nurse practitioner at the time of provision of services by a recognized national certifying body that has established standards for nurse practitioners and possesses a master’s degree in nursing or a Doctor of Nursing Practice (DNP) doctoral degree.” This change allows individuals certified by additional certifying boards, including the American Academy of Nurse Practitioners Certification Board, American Nurses Credentialing Center Certification Program, Pediatric Nursing Certification Board, and the National Certification Corporation, to now meet the definition of a nurse practitioner as long as the other requirements are met.

These changes may result in significant operational, revenue cycle, and regulatory reimbursement impacts for RHCs beginning in January 2024. If you have any questions about the new requirements or would like assistance in evaluating the organization’s readiness and potential impact, please reach out to a professional at FORVIS.

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