Principal Care Management, G2064, G2065, in the FQHC.


My physician mentioned there is a new care management code that FQHCs can report for patients with one chronic condition.  Is that correct?  If so, what is the new code?


Your physician is most likely referring to codes G2064 and G2065, Principal Care Management (PCM).  The codes were new in 2020 but were designed for providers billing under the Physician Fee Schedule – not in the FQHC setting.  This changed with the CMS Final Rule and as of January 1, 2021, FQHCs/RHCs may now report and receive payment but must report the service using code G0511. 

PCM is for comprehensive care management of a single high-risk illness or complex condition that is expected to last at least 3 months. The severity of the condition places the patient at risk for hospitalization, exacerbation, decompensation, or functional decline. The condition may have resulted in a recent hospitalization.  The patient’s comorbidities may increase the complexity. The condition requires development/revision of a disease-specific care plan. The patient’s medication regimen is expected to require frequent adjustments. To paraphrase CMS, all medically necessary elements must be furnished during the month, but not all components will be needed every month. Code G2064 is for management by the physician or other qualified health care professional (QHP) when it consumes at least 30 minutes of time per calendar month.  Code G2065 is for clinical staff time under the direction of the physician/QHP with the same definition and requirements. 

Again, for FQHC Medicare, you will bill the service with the general care management code G0511. This can be reported on the claim alone or with other payable services. Watch carefully for other bundled services, which were a hot-ticket item for other Chronic Care Management services in recent years during OIG reviews. Ensure verbal consent to receive services is documented.

Be sure to review and study the definitions of each code to ensure appropriate reporting.  Review and discuss with your physician(s) so everyone understands the service, requirements and documentation expectations.