(Last Updated On: December 2, 2016)

In January of 2015, the Centers for Medicare & Medicaid Services (CMS) introduced Chronic Care Management (CCM) under CPT code 99490 as part of Medicare Physician Fee Schedule (PFS). However, when Chronic Care Management was introduced, CPT 99490 was not made fully available for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). Beginning on January 1, 2016, CPT 99490 was made fully available to both FQHCs and RHCs with requirements that were very similar to, but not exactly the same as, the CCM requirements under the Physician Fee Schedule. In one area, overall outsourcing of CCM, the requirements between physician practices (under the PFS) and FQHCs/RHCs do differ. In February 2016, CMS released a FAQ regarding CPT 99490 in FQHCs/RHCs with seemingly contradicting statements that are in fact accurate. In the FAQ, CMS states that CCM services can be contracted out:

“Q31. Can CCM services be contracted out to a company that provides case management services?

Yes. There is no prohibition or restrictions on contracting out CCM services once the RHC/FQHC practitioner has initiated CCM services.”

Even though CCM can be contracted out, there are stipulations around “direct supervision” suggesting that the clinical staff providing the CCM services have to be in the same facility as the practitioner (suggesting that outsourcing of CCM is not possible):

“Q27. What are the requirements for direct supervision?

Direct supervision requires that a RHC/FQHC practitioner be present in the RHC/FQHC and immediately available to furnish assistance and direction. The RHC/FQHC practitioner does not need to be present in the room when the service is furnished. There is no exception to the direct supervision requirement at this time for CCM services furnished by auxiliary staff in RHCs/FQHCs.”

What does this all mean? The difference between CPT 99490 for physician practices versus FQHCs/RHCs lays in the supervision requirement. Under PFS (for physician practices), clinical staff can provide care coordination services under “general supervision” of the physician whereas FQHCs/RHCs require “direct supervision” of staff. Under “general supervision”, the service is furnished under the billing physician/practitioner’s overall direction and control, but that physician/practitioner could be on call and not necessarily onsite. Under “direct supervision”, the physician/practitioner has to be present in the office/facility where the service is being provided and must be immediately available to furnish assistance and direction, but he/she need not necessarily be present in the same room where the service is furnished.

Perhaps the best interpretation of this CMS CCM FAQ is that CCM services can be “contracted” but cannot be provided offsite. FQHCs / RHCs can contract a care management company to physically send an employee onsite to provide CCM services under the “direct supervision” of the FQHC/RHC practitioner, enabling them to bill CPT 99490.  However, FQHCs/RHCs cannot truly outsource CCM and contract with a company that furnishes the services remotely (offsite).  There may be other methods through which FQHCs/RHCs can make arrangements with nearby physicians and specialists to truly contract CCM out to an offsite care management company, but these CCM arrangements must be evaluated on a case by case basis as no explicit direction has been given from CMS.

These requirements can limit the ability of FQHCs/RHCs to deploy CCM as FQHCs/RHCs now will have to invest time and capital to hire/train staff, build processes/protocols, purchase technology, and perform ongoing management for CCM, on a tight budget – all of which is avoidable if FQHCs/RHCs were able to partner with a true offsite care management company. The hope is that CCM will continue to evolve and requirements will shift to maximize the impact of CCM on the Medicare population as this is in the best interest of patients, even if this requires relaxing FQHC/RHC 99490 requirements to maximize CCM adoption.

See the full February CMS Chronic Care Management FAQ for FQHCs/RHCs here.