(Last Updated On: December 2, 2016)

Our previous post, Decoding CPT 99490: Partnering for Chronic Care Management (CCM) in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) outlined limitations in 2016 around FQHCs/RHCs contracting CCM services to a third-party care coordination company; specifically the requirement of “direct supervision” of auxiliary staff, meaning that all CCM care coordinators had to be onsite at the FQHC/RHC. However, the Centers for Medicare and Medicaid Services (CMS) received feedback on CCM implementation in both FQHCs and RHCs that has resulted in CMS revisiting these particular CCM requirements.

As described in Decoding CPT 99490: Partnering for Chronic Care Management (CCM) in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), the stringent “direct supervision” requirement for CCM limits ability of FQHCs/RHCs to deploy CCM. If unable to partner with a care coordination company, FQHCs/RHCs have to invest time and capital to hire/train staff, build processes/protocols, purchase technology, and perform ongoing management for CCM – all on a limited budget. The feedback received by CMS alluded to in the proposed updates to the rule echoed that staffing and budget constraints were two key factors preventing uptake of CCM by FQHCs/RHCs:

Since payment for CCM in RHCs and FQHCs began on January 1, 2016, some RHCs and FQHCs have informed us that, in their view, the direct supervision requirement for auxiliary staff has limited their ability to furnish CCM services. Specifically, these RHCs and FQHCs have stated that the direct supervision requirement has prevented them from entering into contracts with third party companies to provide CCM services, especially during hours that they are not open, and that they are unable to meet the CCM requirements within their current staffing and budget constraints.

The CMS proposed updates to the 2017 rule would allow “general supervision” for both Chronic Care Management (CCM) and Transitional Care Management (TCM) in FQHCs/RHCs. “General supervision” means services are furnished under the billing physician/practitioner’s overall direction and control, but the physician/practitioner can be on call and not necessarily onsite. This would allow FQHCs/RHCs to partner with an offsite third-party care coordination company to bill CPT 99490 (CCM) and CPT 99495/ 99496 (TCM). Specifically the proposed update states:

Although many RHCs and FQHCs prefer to furnish CCM and TCM services utilizing existing staff, some RHCs and FQHCs would like to contract with a third party to furnish aspects of their CCM and TCM services, but cannot do so because of the direct supervision requirement. Without the ability to contract with a third party, these RHCs and FQHCs have stated that they find it difficult to meet the CCM requirements for 24 hours a day, 7 days a week access to services. To enable RHCs and FQHCs to effectively contract with third parties to furnish aspects of CCM and TCM services, we propose to revise §405.2413(a)(5) and §405.2415(a)(5) to state that services and supplies furnished incident to TCM and CCM services can be furnished under general supervision of a RHC or FQHC practitioner. The proposed exception to the direct supervision requirement would apply only to auxiliary personnel furnishing TCM or CCM incident to services, and would not apply to any other RHC or FQHC services. The proposed revisions for CCM and TCM services and supplies furnished by RHCs and FQHCs are consistent with §410.26(b)(5), which allows CCM and TCM services and supplies to be furnished by clinical staff under general supervision when billed under the PFS.

These changes to CCM/TCM are only proposed for 2017 and not yet finalized. CMS will continue to accept public comment on the 2017 proposed rule until September 6, 2016 with the final rule being published in November. If passed, the proposed CCM/TCM related changes could help remove a large roadblock for implementation of these programs for FQHCs / RHCs in 2017.