Federally Qualified Health Center (FQHC)

Policy Update 2018: FQHC Chronic Care Management:

The 2018 CMS PFS Final Rule significantly increased payment rates for CCM performed in FQHC’s.

2018 Medicare Part B Physician Fee Schedule Final Rule


Beginning in January, 2016, Federally Qualified Health Centers (FQHCs) can receive reimbursement for Chronic Care Management.  We work with FQHCs, Electronic Health Records, and other organizations to provide complete, compliant CCM solutions for FQHCs – driving improved patient outcomes alongside new revenue opportunities.

Beginning on January 1, 2016, RHCs and FQHCs may receive an additional payment for the costs of CCM services that are not already captured in the RHC AIR or the FQHC PPS for CCM services to Medicare beneficiaries having multiple (two or more) chronic conditions that are expected to last at least 12 months (or until the death of the patient), and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

RHCs and FQHCs can bill for CCM services when a RHC or FQHC practitioner furnishes a comprehensive evaluation and management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM service, and initiates the CCM service as part of this visit.

CCM payment will be based on the Medicare PFS national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim. The rate will be updated annually and has no geographic adjustment. The RHC and FQHC face-to-face requirements are waived when CCM services are furnished to a RHC or FQHC patient.

Coinsurance would be applied as applicable to FQHC claims, and coinsurance and deductibles would apply as applicable to RHC claims. RHCs and FQHCs would continue to be required to meet the RHC and FQHC Conditions of Participation and any additional RHC or FQHC payment requirements.

RHCs and FQHCs cannot bill for CCM services for a beneficiary during the same service period as billing for transitional care management or any other program that provides additional payment for care management services (outside of the RHC AIR or FQHC PPS payment) for the same beneficiary.