(Medicare Benefit Policy Manual)

Care management services are RHC and FQHC services  and include transitional care  management (TCM), chronic care management (CC M), principal care management  (PCM),  chronic pain management (CPM), general behavioral health integration (BHI), and psychiatric collaborative care  model (CoCM) services.  The RHC and FQHC face -to-face requirements are waived for  these care management servi ces. Effective January 1, 2017, care management services  furnished by auxiliary personnel may be furnished under general supervision. (Note:  General supervision does not require the RHC or FQHC practitioner to be in the same  building or immediately availab le, but it does require the services to be furnished under  the overall supervision and control of the RHC or FQHC practitioner.)  Except for TCM  services, care management services are paid separately from the RHC AIR or FQHC PPS  payment methodology. RHCs an d FQHCs may not bill for care management services for  a beneficiary if another practitioner or facility has already billed for care management  services for the same beneficiary during the same time period.   However effective January 1, 2022, RHCs and FQHCs may  bill for care management and TCM services and other  care management services  (outside  of the RHC AIR  or FQHC  PPS payment), for the same beneficiary during the same time period.  Coinsurance and  deductibles are applied as applicable to RHC claims, and coinsurance is applied as  applicable to FQHC claims.   230.1 - Transitional Care Management Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Effective January 1, 2013, RHCs and FQHCs are paid for TCM services furni shed by an RHC or FQHC practitioner when all TCM requirements are met.  TCM services must be  furnished within  30 days of the date  of the patients  discharge  from  a hospital  (including outpatient observation or partial hospitalization), SNF, or community mental health  center.   Communication (direct contact, telephone, or electronic) with the patient or caregiver  must commence within 2 business days of discharge, and a face -to-face visit must occur  within 14 days of discharge for moderate complexity decisio n making (CPT code 99495), or within 7  days of  discharge  for high complexity  decision making  (CPT  code  99496).  The TCM visit is billed on the day that the TCM visit takes place, and only one TCM  visit may be paid per beneficiary for services furnished duri ng that 30 day post -discharge period.   TCM services are billed by adding CPT code 99495 or CPT code 99496 to an RHC or FQHC claim, either alone or with other payable services. If it is the only medical service provided on that day with an RHC or FQHC pract itioner it is paid as a stand -alone  billable  visit.  If it is furnished on the  same day  as another  visit, only  one visit is paid.  230.2  General  Care  Management Services                                                    (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) General Care Management Services include: Chronic Care Management  (CCM ), Principal Care Management ( PCM ), Chronic Pain Management (CPM) and general Behavioral Health Integration ( BHI) services. A separately  billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP,  PA, or CNM) is required before care management 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. Care management services do not need to have  been discussed during the initiating visit, and the same initiating visit can be used for  CCM , PCM, CPM  and general  BHI services as long as it occurs with an RHC or FQHC prim ary care practitioner within one year of commencement of care management 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 CCM , PCM, CPM  or general  BHI services  are furnished. The medical  record  should document  that the beneficiary has  been informed about the availability of care management services, ha s given permission  to consult with relevant specialists as needed, and has been informed 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 beneficiary 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 care management services but there has  been a period where no care management services were furnished, a new beneficiary  consent  is not required.     230.2.1  Chronic Care  Management (CCM) Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Effective January 1, 2016, RHCs and FQHCs are paid for CCM services when a  minimum of 20 minutes of qualifying CCM services during a calendar month is  furnished. CCM services may be furnished to patients with  multiple chronic conditions  that are expected to last at least 12 months or until the death of the patient, and that place  the patient at significant risk of death, acute exacerbation/decompensation, or functional  decline.  CCM  service requirements  include :  Structured recording of patient health information using Certified EHR  Technology including demographics, problems, medications, and medication  allergies  that inform  the care plan, care  coordination, and ongoing  clinical care;   24/7 access to physicians or other qualified health care professionals or clinical  staff including providing patients/caregivers with a means to make contact with  health care professionals in the practice to address urgent needs regardless of the  time of day or day of week, and continuity of care with a designated member of  the care team with whom the patient is able to schedule successive routine  appointments;   Comprehensive care management including systematic assessment of the patients  medical, functional, and psychosocial needs;  system -based approaches to ensure  timely receipt of all recommended preventive care services; medication  reconciliation with review of adherence and potential interactions; and oversight  of patient self -management of  medications;  Comprehensive  care plan including the creation,  revision, and/or  monitoring  of an  electronic care plan based on a physical, mental, cognitive, psychosocial,  functional, and environmental (re)assessment and an inventory of resources and  supports; a comprehensive care plan for all health issues with particular focus on  the chronic  conditions being  managed;   Care plan information made available electronically (including fax) in a timely  manner within and outside the RHC or FQHC as appropriate and a copy of the  plan of care  given to the  patient and/or  caregiver;   Management of care transitions between and among health care providers and  settings, including referrals to other clinicians; follow -up after an emergency  department  visit; and follow -up after discharges  from  hospitals, skilled  nursing  facilities, or other health care facilities; timely creation and exchange/transmit  continuity  of care document(s)  with  other  practitioners and  providers;   Coordination with home - and community -based clinical service providers, and documentation of co mmunication to and from home - and community -based  providers regarding the patients psychosocial needs and functional deficits in the  patients  medical record;  and  Enhanced opportunities for the patient and any caregiver to communicate with the  practitione r regarding the patients care through not only telephone access, but  also through the use of secure messaging, Internet, or other asynchronous non-  face- to-face consultation methods.  230.2.2  Principal Care  Management (PCM)  Services                             (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) Effective January 1, 2021, RHCs and FQHCs are paid for PCM services when a  minimum of 30 minutes of qualifying PCM services are furnished during a calendar  month. PCM  services  may  be furnished to patients  with  a single  high-risk or complex  condition that is expected to last at least 3 months and may have led to a recent  hospitalization,  and/or placed the  patient at significant risk  of death.  PCM  service requirements  include:   A single complex chronic condition lasting at least 3 months, which is the focus of  the care  plan;   The condition is  of sufficient  severity  to place patient  at risk of hospitalization  or have  been the  cause of a recent hospitalization;   The condition requires  development  or revision of  disease- specific care plan;   The condition requires  frequent  adjustments  in the medication  regiment; and  The condition is  unusually  complex  due to comorbidities.   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)