Medicare Chronic Care Management Fees for FQHCs and RHCs

by Adele Allison, 

Question:  With the Meaningful Use incentives tapering off and the lack of penalties for Medicaid eligible professionals, what motivation does a CHC or RHC have to continue with EHR adoption and use?



Indeed, FQHCs and RHCs have never been subject to many CMS program penalties including Meaningful Use (MU), and the latest an eligible provider can launch the Medicaid EHR Incentive Program and receive full incentives ($63,750 paid out over 5 years) is 2016.  The MU payment adjustments are limited to Medicare providers paid under a fee schedule; and Medicaid is state governed, which prevents the federal government from imposing Medicaid payment penalties. 


However, CMS recently made a move to tie economic drivers to the adoption of “CCM certified technology” by safety net providers in the form of enhanced payments – around $40 per qualifying Medicare patient per month.  CCM stands for chronic care management and the minimum EHR capabilities a vendor would need overlaps with MU-certified systems and includes the support of interoperability, care plans, limited social determinants of health documentation and care coordination for patients to manage chronic conditions. 


As of Jan. 2015, the total number of Medicare beneficiaries was just shy of 55 million patients, a number that will continue to grow by around 4.2 million per year through 2030.  Currently, 58 percent of Medicare payments to providers are made using traditional fee-for-service reimbursement.  In Jan. 2015, the Secretary of HHS announced aggressive goals to move Medicare payments to alternative payment models (APMs) such as accountable care organizations (ACOs), bundled payments, and capitation or tie fee-for-service reimbursement to measures of quality.  These payment reforms seek to directly impact the traditional Medicare provider faction, but policymaking has not forgotten those providers who care for the underserved and has recently circled back to create a financial opportunity in addition to and beyond Meaningful Use.


Each year, CMS releases rules (regulations) that outline changes to programs linked to provider reimbursement, many of which relate to the Medicare physician fee schedule (PFS).  In 2014, the Medicare final rule created a CPT code to compensate PFS providers for chronic care management (CCM) services addressing Medicare patients with multiple co-morbidities who were at risk for death, acute exacerbation and/or functional decline – 99490.   This code is intended to reimburse for non-face-to-face work required when delivering comprehensive, coordinated care management.  In 2015, CMS included an efficiency measure – the use of a certified electronic health record technology (CEHRT) – in the billing requirements for CCM under its fee schedule rule.  FQHCs and RHCs, who do not bill under a PFS, were not included in this provision.


On Jul. 15, 2015, CMS published a proposed rule in the Federal Register that includes an additional payment to FQHCs and RHCs for CCM services not captured under the RHC AIR or FQHC PPS payments.  If finalized, this payment could represent around $40 for each ailing Medicare patient treated at a FQHC/RHC effective Jan. 1, 2016.


Here’s how it works.  Only 1 clinician (physician, nurse practitioner, physician assistant, or certified midwife) can bill the 99490 code each month and there must be a minimum of 20 minutes of CCM-related service work performed.  There are restrictions in billing this code in overlap with other CMS care management services rendered at the same time.  Reimbursement will be based upon the national average of non-facility PFS payment rate (in 2015, this rate is $42.91) and the code can be billed with other services including E&M.  Standard rates of FQHC/RHC coinsurance and/or deductibles apply.


Medicare patients eligible for the CCM service must have 2 or more chronic conditions that are expect to last at least 12 months or until the patient’s death and be at risk.  There are no face-to-face requirements to bill for these services, however, the patient must be informed about the availability of these services and provide written consent to have them performed.  Additionally, billing CCM services requires inclusion of:


  • Continuity of care scheduling
  • Chronic disease management such as assessment, tracking of preventive care adherence, medication reconciliation, and oversight of medication self-management
  • The generation of a patient-centered care plan from the EHR that incorporates the patients choices, including a problem list, expected outcome/prognosis, measurable treatment goals, symptom management, planned interventions, medication management, any ordered community/social services, responsible party to each intervention, requirements for periodic review, and revisions as needed
  • The electronic availability of the care plan for the patient
  • Management of care transitions, including referrals
  • Coordination of any home or community-based clinical services to support the patient’s psychosocial needs
  • Secured, electronic messaging with the patient and caregiver (faxing is specifically omitted)
  • Use of current Office of National Coordinator (ONC) edition CEHRT, a MU requirement – referred to within the rule as “CCM Certified Technology”


Look for the final rule to be released around November and make sure you understand any changes or clarifications that come about.  CMS is seeking public comments on this and other key provisions related to provider reimbursement. Comments for this proposed rule can be submitted electronically at by 5:00 PM ET on September 8, 2015.