(Medicare Benefit Policy Manual)

230.2.3  Chronic Pain  Management (CPM) Services                           (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) Effective January 1, 2023, RHCs and FQHCs are paid for CPM services when a minimum of 30 minutes of qualifying non- face- to-face CPM services are furnished during a calendar month.  CPM services may be furnished to patients with multiple chronic conditions that involve chronic pain, and may include a person -centered plan of care, care coordination, medication management, and other aspects of pain care.  230.2. 4 General Behavioral Health Integration (BHI) Services            (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  BHI is a team -based, collaborative approach to care that focuses on integrative treatment  of patients with primary care and mental or behavioral health conditions. Effective  January 1, 2018, RHCs and FQHCs are paid for general BHI services when a minimum  of 20 minutes of qualifying general BHI services during a calendar month is furni shed to patients with one or more new or pre -existing behavioral health or psychiatric conditions  being treated by the RHC or FQHC primary care practitioner, including substance use  disorders, that, in the clinical judgment of the RHC or FQHC primary care practitioner,  warrants  BHI  services.  General BHI  service requirements  include:   An initial assessment and ongoing monitoring using validated clinical rating  scales;   Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status  changes;   Facilitating  and coordinating  treatment such as psychotherapy,  pharmacotherapy,  counseling  and/or  psychiatric  consultation; and  Continuity  of care with a designated member  of the care  team.  230.2. 5 Payment for General Care Management Services                    (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) CCM services furnished between January 1, 2016, and December 31, 2017, are paid based on the PFS national average non- facility payment rate when CPT code 99490 is  billed  alone  or with other payable  services on  an RHC  or FQHC claim.  CCM or general BHI services furnished between January 1, 2018, and December 31, 2018, are paid at the average of the national  non- facility  PFS payment  rate for CPT codes  99490 (30 minutes or more of CCM services), 99487 (60 minutes or more of complex  CCM services), and 99484 (20 minutes or more of general behavioral health integration services), when general care man agement HCPCS code G0511 is on an RHC or FQHC  claim,  either  alone  or with  other  payable  services.  CCM or general BHI services furnished on or after January 1, 2019, are paid at the  average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, and 99491(30 minutes or more of CCM furnished by a physician or other  qualified  health  care professional), when general  care management  HCPCS  code  G0511 is on an RHC or  FQHC  claim, either  alone  or with  other  payable  services.   CCM, PCM or general BHI services furnished on or after January 1, 2021 are paid at  the average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, and 99491, and CPT  codes  99424 (30 minutes or more of PCM services  furnished by physicians o r non- physician practitioners (NPPs)) and 99426 (30 minutes  or more of PCM services furnished by clinical staff under the direct supervision of a  physician or NPP), when general care management HCPCS code G0511 is on an RHC  or FQHC claim, either alone or with other payable services.    CCM, PCM, CPM or general BHI services furnished on or after January 1, 2023 are paid at the average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, 99491, 99424 and 99426 when general care management HCPCS code G0511 is on an RHC or FQHC claim, either alone or with other payable services. The payment rate for  HCPCS  code  G0511 is updated annually  based  on the  PFS amounts for  these codes.  Coinsurance for care management services is 20 percent of  lesser of submitted charges or  the payment rate for G0511. Care management costs are reported in the non- reimbursable section of the cost report and are not used in determining the RHC AIR or  the FQHC  PPS rate.  G0511 can be billed once  per month per  beneficiary  when  at least 20  minutes of CCM services, at least 30 minutes of PCM services, or at least 20 minutes of  general  BHI  services  have  been  furnished and  all other  requirements  have  been  met.  Only services furnished by an RHC or FQHC practitioner or auxiliary personnel that are within the scope of service elements can be counted toward the minimum 20 minutes that  is required to bill for CCM and general BHI  services and the minimum 30 minutes that is  required to bill for PCM services, and does not include administrative activities such as  transcription  or translation services.      230.3  Psychiatric Collaborative Care Model (CoCM) Services  (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)  Psychiatric CoCM is a specific model of car e provided by a primary care team consisting of a primary care provider and a health care manager who work in collaboration with a psychiatric consultant to integrate primary health care services with care management support for patients receiving behavior al health treatment.  It includes regular psychiatric inter-specialty consultation with the primary care team, particularly regarding patients whose conditions are not improving.  The primary care team regularly reviews the beneficiarys treatment plan and  status with the psychiatric consultant and maintains or adjusts treatment, including referral to behavioral health specialty care, as needed.  Patients with mental health, behavioral health, or psychiatric conditions, including substance use disorders, who are being treated by an RHC or FQHC practitioner may be eligible for psychiatric CoCM services, as determined by the RHC or FQHC primary care practitioner.  A separately billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP, PA, or CNM) is required before psychiatric CoCM services can be furnished.  This visit can be an E/M, AWV, or IPPE visit, and must occur no more than one -year prior to commencing care management services.   Psychiatric CoCM services do not need to have  been discussed during the initiating visit, and the same initiating visit can be used for psychiatric CoCM as for CCM and BHI services, as long as it occurs with an RHC or FQHC primary care practitioner within one year of commencement of psychiatric CoCM services.  Beneficiary consent to receive care management services must be obtained either by or under the direct supervision of the RHC or FQHC primary care practitioner, may be written or verbal and must be documented in the patients medical record before psychiatric CoCM services are furnished.  The medical record should document that the beneficiary has been informed about the availability of care management services, has given permission to consult with relevant specialists as needed, and has been inf ormed of all of the following:   There may be cost -sharing (e.g. deductible and coinsurance in RHCs, and coinsurance in FQHCs) for both in-person and non- face- to-face services that are provided;  Only one practitioner/facility can furnish and be paid for these services during a calendar month; and   They can stop care management services at any time, effective at the end of the calendar month.   Beneficiary consent remains in effect unless the benef iciary opts out of receiving care management services.  If the beneficiary chooses to resume care management services after opting out, beneficiary consent is required before care management services can resume.  If the beneficiary has not opted out of car e management services but there has been a period where no care management services were furnished, a new beneficiary consent is not required.  RHC or FQHC Practitioner Requirements   The RHC or FQHC practitioner is a primary care physician, NP, PA, or CNM who:  Directs the behavioral health care manager and any other clinical staff;   Oversees the beneficiarys care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed; and   Remains i nvolved through ongoing oversight, management, collaboration and reassessment.   Behavioral Health Care Manager Requirements  The behavioral health care manager is a designated individual with formal education or specialized training in behavioral health, in cluding social work, nursing, or psychology, and has a minimum of a bachelors degree in a behavioral health field (such as in clinical social work or psychology), or is a clinician with behavioral health training, including RNs and LPNs.  The behavioral health care manager furnishes both face- to-face and non-face- to-face services under the general supervision of the RHC or FQHC practitioner and may be employed by or working under contract to the RHC or FQHC.  The behavioral health care manager:   Provides assessment and care management services, including the administration of validated rating scales;   Provides behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whos e status changes;   Provides brief psychosocial interventions;   Maintains ongoing collaboration with the RHC or FQHC practitioner;   Maintains a registry that tracks patient follow -up and progress;   Acts in consultation with the psychiatric consultant;  Is available to provide services face -to-face with the beneficiary; and   Has a continuous relationship with the patient and a collaborative, integrated relationship with the rest of the care team.   Psychiatric Consultant Requirements   The psychiatric consultant is a medical professional trained in psychiatry and qualified to prescribe the full range of medications.  The psychiatric consultant is not required to be on site or to have direct contact with the patient and does not prescribe medications or furni sh treatment to the beneficiary directly.  The psychiatric consultant:    Participates in regular reviews of the clinical status of patients receiving psychiatric CoCM services;   Advises the RHC or FQHC practitioner regarding diagnosis and options for resolvi ng issues with beneficiary adherence and tolerance of behavioral health treatment; making adjustments to behavioral health treatment for beneficiaries who are not progressing; managing any negative interactions between beneficiaries behavioral health and medical treatments; and   Facilitates referral for direct provision of psychiatric care when clinically indicated.  Payment for Psychiatric CoCM   Psychiatric CoCM services furnished on or after January 1, 2019, are paid at the average of the national non- facility PFS payment rate for CPT codes 99492 (70 minutes or more of initial psychiatric CoCM services) and CPT code 99493 (60 minutes or more of subsequent psychiatric CoCM services) when psychiatric CoCM HCPCS code, G0512, is on an RHC or FQHC claim, either alone or with other payable services.  This rate is updated annually based on the PFS amounts for these codes.  At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months, of psychiatric CoCM services must have b een furnished in order to bill for this service.  Coinsurance for psychiatric CoCM services is 20 percent of the lesser of submitted charges or the payment rate for G0512.  Psychiatric CoCM costs are reported in the non-reimbursable section of the cost report and are not used in determining the RHC AIR or the FQHC PPS rate.  G0512 can be billed once per month per beneficiary when all requirements have been met.   Only services furnished by an RHC or FQHC practitioner or auxiliary personnel that are within the scope of service elements can be counted toward the minimum 60 minutes that is required to bill for psychiatric CoCM services and does not include administrative activities such as transc ription or translation services.    240  Virtual Communication Services  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implementation: 01- 02 -19)