FQHC - CCM Guidelines and Requirements for 2016



The 2016 PFS Final Rule provides a mechanism for FQHCs to be reimbursed for chronic care management (“CCM”) services in Medicare.  CCM services include physician or non-physician practitioner care related to management of chronic diseases, such as post-discharge care management services and care coordination services.

CMS began to reimburse Part B suppliers for CCM services in 2014.  When this change was made, CMS explained that FQHCs could not be reimbursed for CCM services under their prospective payment system (“PPS”) payment methodology.  This was because FQHCs can only bill for face-to-face encounters between a patient and a Medicare FQHC provider, and much of the care provided under CCM does not involve face-to-face contacts or services provided by FQHC billable clinicians.  In its 2015 PFS rulemaking, CMS sought public comment on how it could change policy to reimburse FQHCs for CCM.

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CMS announced its solution in the 2016 PFS Final Rule.  Effective January 1, 2016, FQHCs will be able to bill Medicare for CCM according to the national average non-facility payment rate for the CCM CPT code (for the first quarter of 2015 this amounted to $42.91 per beneficiary per calendar month).  To receive the payment, the FQHC must provide at least 20 minutes of qualifying CCM services during a calendar month to a patient with multiple chronic conditions that are expected to last at least 12 months and which place the patient at significant risk.  Medicare will only make one CCM payment per beneficiary, per month, and the 20 minute requirement.

The FQHC will bill Medicare for CCM under its Part A provider number.  The amount of the CCM payment will be added to an FQHC’s Medicare PPS payments, and will not be made as a separate PFS payment.  In order to qualify for payment, an FQHC must also meet various scope of service and documentation requirements, including obtaining patient consent, as well as following specified electronic health record standards.

OCULUS HEALTH CCM Customized for FQHC's:

  • Attain compliance with the chronic care management (CCM) reimbursement program without adding significant workload on your providers.
  • Proactively engage patients in their care and reduce hospitalizations and ER visits.
  • Achieve fast ROI with a net new revenue stream.
  • Avoid risk with monthly compliance reports.


Effective January 1, 2016, FQHCs and RHCs will be able to bill for chronic care management services. Oculus Health's platform helps providers remotely monitor and manage the elderly dual-eligible patients they serve while offering an opportunity to significantly increase revenue. With Oculus Health CCM, FQHCs can easily determine which patients are trending poorly and intervene prior to a trip to the ED or hospitalization.


References: CMS FQHC Guidelines

                       CMS CCM Frequently Asked Questions


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