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February 14, 2022

Chronic Care Management (CCM) for Providers in Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)

The Chronic Care Management (CCM) services program provides comprehensive care management for the patient with multiple chronic medical conditions. These services extends beyond the routine office visit care. CCM services allow the health care provider and the patient/ caregivers to work together in the management of the patient’s chronic medical conditions.

Eligibility requirements for beneficiaries
To enroll, the patient must have two or more chronic medical conditions that:

  • Are expected to last at least 12 months or until death of the patient
  • Place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline

Chronic Care Management Services are part of the beneficiary’s Medicare Part B benefits. The beneficiary may need to pay a monthly fee for CCM services. The beneficiary’s Medicare Part B deductible and coinsurance apply. If the beneficiary has supplemental insurance, it may help cover this monthly cost.

Eligibility criteria for providers
Chronic care Management allows the health care provider to be paid separately while providing care to the beneficiary. To qualify to bill for Chronic Care Management services, the health provider must be classified as one of the following:

  • Physician
  • Physician Assistant
  • Certified Nurse Midwife
  • Certified Nurse Specialist
  • Nurse Practitioner

The billing health care provider should provide at least 20 minutes of CCM services per calendar month. This care can be personally provided by the health care provider or provided by clinical staff under the direction of the billing health care provider.

Start of Care requirements
Beneficiary consent needs to be obtained either during or after the initiating visit and prior to starting or billing Chronic Care Management services. Consent needs to be either completed by or under the direct supervision of the FQHC or RHC primary care provider.

  • The beneficiary consent can be verbal or written.
  • It must be documented in the medical record and include information on the availability of the Chronic Care Management services, any cost sharing involved, notification that only one health care provider can provide and bill for Chronic Care Management services per calendar month, and information about the right to stop Chronic Care Management services at any time (to be effective at the end of the calendar month). Beneficiary consent should also include information informing the patient about permission to consult with relevant specialists.

The health care provider can start the patient on CCM services if it has been determined that the patient qualifies.

  • If the patient has not been seen by the health care provider within one year prior to starting Chronic Care Management services or is a new patient, the FQHC or RHC health care provider is required to perform a face-to face visit to start Chronic Care Management services.
  • This face-to face visit can be an Annual Wellness Visit, Initial Preventative Physical Exam, Transitional Care Management, or any other qualifying face-to-face visit with the billing health care provider.
  • It is separately billed as a FQHC or RHC visit.

Billing for Chronic Care Management services in Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC)
The HCPCS code G0511 is used when billing when billing for CCM services in FQHCs/RHCs.

  • HCPCS code G5011 is defined as Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) only, general care management, 20 minutes or more of clinical staff time for Chronic Care Management services or behavioral health integration services directed by an RHC or FQHC practitioner at (physician, NPO, PA, or CNM) per calendar month.
  • Requirements for CCM services in FQHC/RHC include:
    • At least 20 minutes of care coordination (CCM) services per calendar month.
    • Provided under the direction of the billing FQHC/RHC health care provider.
    • Delivered by the FQHC/RHC healthcare provider or by the FQHC/RHC clinical staff under the general supervision of the billing FQHC/RHC health care provider.
  • The health care provider should ensure that the documentation in the patient's medical record supports that the patient is at significant risk of death, acute exacerbation/decompensation, or functional decline due to chronic medical conditions.
  • The CCM services may bill HCPCS code G0511 once every 30 days if all requirements for CCM services are met.
  • Please note- FQHCs/RHCs cannot bill HCPCS code G0506- Comprehensive assessment of and care planning for patients requiring chronic care management services

Starting with the calendar year 2022 and going forward, health care providers at RHCs and FQHCs may provide and bill for CCM, TCM, and other care management services for the same beneficiary during the same service period as long as all requirements for billing each code are met.

For more detailed information regarding eligibility requirements, benefits of Chronic Care Management, and CCM documentation requirements, please refer to CGS Chronic Care Management for ProvidersPDF.

Resources
For further information, please refer to the following:

References

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