FQHCs: The Expanding Landscape of Medicare Billing Outside of PPS for Care Management Services

Summary:

• Medicare has steadily expanded the services that Federally Qualified Health Centers can bill outside the Prospective Payment System, creating new reimbursement opportunities beyond traditional patient encounters.
• As Medicare continues to carve out exceptions to the Prospective Payment System methodology, FQHCs should reassess their billing, coding, and compliance strategies to capture available reimbursement for non-face-to-face services and care management programs.

Federally Qualified Health Centers (FQHCs) are primarily reimbursed by Medicare through the Prospective Payment System (PPS), which pays a per-visit rate to cover a typical bundle of medically necessary services provided during a patient encounter. Increasingly, however, FQHCs have opportunities to bill certain care management services to Medicare outside the PPS bundle. The steady expansion of these services over the last decade is one of the most significant changes to Medicare FQHC reimbursement since the Affordable Care Act (ACA).

The ACA reformed Medicare FQHC reimbursement by shifting from an individualized cost-based methodology to a national, encounter-based rate.

Before the ACA, Medicare paid for FQHC services using a cost-based system under which an FQHC’s all-inclusive rate (AIR) was calculated based on its own historical costs, subject to productivity standards and an upper payment limit.[1] In 2010, the ACA directed the Centers for Medicare & Medicaid Services (CMS) to develop the PPS methodology for FQHC services beginning October 1, 2014.[2] This represented a fundamental transformation of Medicare FQHC reimbursement.

Under the Medicare PPS methodology, an FQHC is paid based on the lesser of its actual charges or a national encounter-based rate, adjusted for the FQHC’s geography, but not based on its individual costs.[3] The national rate is set based on aggregate FQHC cost data, updated annually by an inflation factor. [4] Initially, there were only rare exceptions to reimbursement through the single PPS rate, such as separate rates for new patients and patients receiving yearly preventive services.

CMS has gradually authorized separate Medicare FQHC reimbursement for a range of care management services billed outside of the PPS.

The core Medicare PPS reimbursement covers face-to-face encounters between an FQHC patient and practitioner.[5] However, in the years following the development of the PPS methodology, CMS has gradually introduced billing codes for non-face-to-face care management services. Separate payment for these services is generally justified by the theory that while they are critical for patient care, they are not cleanly captured through the PPS rate. The brief timeline below details the history of these changes.

2016. The first non-face-to-face service added outside the PPS was chronic care management (CCM). Beginning January 1, 2016, FQHCs could receive separate payment for providing at least 20 minutes of qualifying care management services to Medicare beneficiaries with two or more chronic conditions that met certain criteria, such as placing the patient at significant risk of death or decline.[6]

2018. For 2018, CMS authorized separate Medicare FQHC payment for two additional non-face-to-face services: general behavioral health integration (BHI) and psychiatric collaborative care model (CoCM).[7]

• BHI is a team-based, collaborative approach to care that focuses on integrative treatment of patients with primary care or behavioral health conditions.[8] BHI services are appropriate for patients presenting with new or pre-existing behavioral health or psychiatric conditions.
• Psychiatric CoCM is a model of collaborative care provided by a care team that includes both a primary care provider and a health care manager who collaborates with a psychiatric consultant.[9]

In 2018, CMS also introduced HCPCS code G0511, which was used to standardize FQHC billing for a range of general care management services until CMS made further changes in the 2025 Physician Fee Schedule Final Rule.[10]

2019.  For 2019, CMS authorized FQHCs to be paid separately from PPS for virtualcommunication services, including communication technology-based services and remote evaluation services.[11] These services include brief communications (e.g., five minutes) with an FQHC practitioner to determine whether a visit is necessary.[12] Separate payment is unavailable when the service originates from a related billable visit or leads to a billable visit within the next 24 hours.[13]

2021.  For 2021, CMS authorized FQHCs to submit and receive Medicare payment under the separate codes for Principal Care Management (PCM) services, which are available for patients who have one high-risk chronic condition.[14] Patients who qualify for PCM services have a serious chronic condition expected to last between three months and one year, or until the death of the patient, and which may have led to a recent hospitalization or placed the patient at significant risk of death or functional decline.[15]

2023.  For 2023, CMS authorized FQHCs to receive separate Medicare payment for chronic pain management (CPM) services when, during a calendar month, at least 30 minutes of qualifying services are furnished for a beneficiary.[16] To qualify for CPM services, a beneficiary must have a diagnosis of pain that has lasted more than three months.[17]

2024.  CMS significantly expanded the monitoring and care coordination services for which FQHCs could receive separate Medicare payment in 2024, adding half a dozen new categories. At the time, payment for most of these services was made through the HCPCS G0511 general care management code.[18]

CMS authorized separate Medicare FQHC payment for Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) under the general care management code.[19] These services involve the collection and transmission of data and the analysis and interpretation of data that occurs outside of a standard office visit. RPM is focused on digitally collected physiologic data, whereas RTM services focus on monitoring of respiratory system status, musculoskeletal system status, therapy adherence, and therapy response.

CMS also authorized separate Medicare FQHC payment through the general care management code for Community Health Integration (CHI) and Principal Illness Navigation (PIN) services to help patients with serious illnesses navigate the health care system.[20] CHI services, including coordination of care, facilitation of access to services, and communication between settings, are typically performed by auxiliary personnel, such as a community health worker, and help address a patient’s social determinants of health.[21] PIN services involve non-face-to-face services, including the creation of a treatment plan, for a serious, high-risk disease expected to last at least three months that places the patient at significant risk of hospitalization or nursing home placement, acute exacerbation or decompensation, functional decline, or death.[22] CMS confirmed that FQHCs could also receive payment for related PIN-Peer Support (PIN-PS) services.

FQHCs became eligible for separate Medicare payment for intensive outpatient program (IOP) services for individuals with acute mental illness.[23] These services are intended to improve or maintain the patient’s condition and prevent relapse or hospitalization. FQHCs may be paid for IOP services at the hospital IOP rate.[24]

2025.  CMS increased the complexity of Medicare care management coding and billing for FQHCs in 2025 by sunsetting the use of G0511, which had been a general-purpose care management code. It began requiring FQHCs to bill for a wide variety of care management services through the more nuanced code set used by other physician practices.[25]

CMS also introduced coding and payment policies for Advanced Primary Care Management (APCM) services, which combine elements of several existing care management and communication technology-based services into a per-calendar-month bundle.[26]

2026. The CY 2026 Medicare Physician Fee Schedule Final Rule gives FQHCs additional opportunities to bill and receive payment for care coordination and communication technology-based services that historically were paid through FQHC-specific bundled codes.

Starting January 1, 2026, FQHCs may use three HCPCS codes — G0568, G0569, and G0570 — as APCM add-on codes for BHI or CoCM.[27] FQHCs must bill the specific CPT/HCPCS codes for CoCM services rather than use an all-in-one code. For communication technology-based and remote evaluation services, CMS discontinued G0071.[28] Instead, FQHCs must bill the specific code for the service furnished:

• HCPCS G2010 — remote evaluation of patient images or video.
• HCPCS G2250 — remote assessment of recorded patient information.
• CPT 98016 — a “virtual check-in” code for a brief communication technology-based service.

CMS also finalized a policy under which care management services established and paid under the Medicare Physician Fee Schedule will typically also be reimbursable to FQHCs separately from the PPS, subject to CMS guidance.[29]

Takeaways

The ACA promoted a streamlined vision for Medicare FQHC reimbursement: a uniform per-visit rate set based on national data with minimal adjustments. Over the last decade, CMS has deviated from that vision in ways that complicate Medicare FQHC billing and reimbursement, particularly for non-face-to-face care management and care coordination services. FQHCs now must understand the range of Medicare billing options available outside the PPS rate.

Foley is here to help you navigate the complexities of FQHC reimbursement. Please reach out to the authors, your Foley relationship partner, or our Health Care Practice Group with any questions.

[1] Ctrs. for Medicare & Medicaid Servs., Final Policy and Payment Changes for the New Medicare Prospective Payment System (PPS) for Federally Qualified Health Centers Beginning October 1, 2014, available at https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-changes-new-medicare-prospective-payment-system-pps-federally-qualified-health.

[2] Medicare Claims Processing Manual, Ch. 9, § 30.1.

[3] Id.

[4] 89 Fed. Reg. 61,596, 61,780 (proposed July 31, 2024).

[5] 42 C.F.R. § 405.2463(b)(1).

[6] 80 Fed. Reg. 70,886, 70,918, 71,080-81 (Nov. 16, 2015).

[7] 82 Fed. Reg. 52,976, 53,169–80 (Nov. 15, 2017).

[8] Id.

[9] Id. at 53,171-72.

[10] See 89 Fed. Reg. 97710, 97998-99 (Dec. 9, 2024).

[11] 83 Fed. Reg. 59,452, 59,685 (Nov. 23, 2018). 

[12]Id.

[13] Medicare Benefit Policy Manual, Ch. 13, § 240; 90 Fed. Reg. 49,266, 49,555–56 (Nov. 5, 2025).

[14] 84 Fed. Reg. 62,568, 62,692 (Nov. 15, 2019).

[15] Id.

[16] 87 Fed. Reg. 69,404, 69,737 (Nov. 18, 2022).

[17] Id. at 69,737.

[18] 89 Fed. Reg. 97999 (Dec. 9, 2024).

[19] 88 Fed. Reg. 78,818, 79,073 (Nov. 16, 2023).

[20] 88 Fed. Reg. 78,818, 79,073 (Nov. 16, 2023).

[21] Medicare Benefit Policy Manual, Ch. 13, § 230.2.7.

[22] 88 Fed. Reg. 78,818, 79,073-74.

[23] 88 Fed. Reg. 81,540, 81,838 (Nov. 22, 2023).

[24] Medicare Benefit Policy Manual, Ch. 13, § 250; 42 C.F.R. §§ 405.2462(j), 405.2468(g)(2).

[25] 89 Fed. Reg. 98000-98010 (Dec. 9, 2024).

[26] 89 Fed. Reg. 98012 (Dec. 9, 2024).

[27] Ctrs. for Medicare & Medicaid Servs., FQHC/RHC News & Announcements, CMS.GOV, available at https://www.cms.gov/fqhc-rhc-news-announcements#PFS.

[28] 90 Fed. Reg. 49,266, 49,554 (Nov. 5, 2025).

[29] See id. at 49,558.