1. Chronic Care Management and Virtual Communication Services Billing
Carolina Medical Home Network

2. Chronic Care Management
What patients are eligible?
Who Can Perform CCM?
What Services are eligible for CCM?
Pre-Requisites for CCM
Billing CCM
Chronic Care Management

3. Medicare Patients with two or more chronic conditions that are expected to last 12 months or until the death of the patient. The chronic condition places the patient at risk for death, acute exacerbations, decompensation or functional decline.
CCM Eligibility

4. Who can perform CCM? MD NP PA CNS CNM
Clinical Staff of the Eligible Providers
The Eligible Providers provide oversight to their clinical staff. There is supervision, but it is not required that the clinical staff and Eligible Provider are in the same physical location.
Who can perform CCM?

5. What Services are Eligible for CCM?
Continuity of Care
Care Management and Care Planning
Transitional Care Management (TCM)
Coordination with Home and Community based clinical service providers
24/7 Access to urgent needs
Enhanced communication (i.e. )
EMR documentation of demographics, problems, medications, and allergies in a Certified EMR
What Services are Eligible for CCM?

6. An Initiating Visit must occur for new patients or patients not seen within a year of initiating CCM services (i.e. AWV, IPPE, TCM or E/M)
CCM consent does not have to be discussed or obtained during the initiating visit.
A certified EMR must be used to document standardized information for core clinical information (demographics, problem lists, medications lists, and allergies)
Documentation for CCM elements (i.e. Care Plan) or TCM not required to occur in a certified EMR
Verbal consent must be obtained and documented in the EMR prior to commencing CCM services
Only required once
Must Discuss:
Availability of services and cost sharing
Notification that only one provider can provide CCM services per month
Notification that the patient can stop services at any time
Approval for the provider to consult with specialty providers
Pre-Requisites

7. Billing FQHCs and RHCs must use the HCPCS code G0511
An appropriate ICD code must accompany the claim
Code can be billed alone or with other FQHC payable services
Both services will be paid
Rate for G0511 is $67.03 per month per patient for 20+ minutes of qualifying services
The date for billing can be the date the requirements are met or a later date prior to the end of the month
Complex CCM is not payable to FQHCs or RHCs
Visit is cost shared with the patient and co-insurance and deductibles are applied
Cost sharing cannot be waived for the patient
Financial Assistance can be offered
Cannot be billed during the 30-day TCM service period
Billing

8. Virtual Communication Services
What are Virtual Communication Services?
What communication qualifies?
Who can provide the services?
Pre-Requisites
Billing
Virtual Communication Services

9. Virtual Communication Services
Eligible Providers provide remote evaluation of patients using technology based communication.
Considered a brief discussion to determine if a visit is necessary
Must be 5+ Minutes
The medical discussion cannot be related to a FQHC service provided in the previous 7-days
The medical discussion cannot lead to a visit within the next 24- hours or next available appointment
Must be initiated by the patient
Providers following up with patients about their condition are not eligible services
Virtual Communication Services

10. What type of Communication Qualifies?
Telehealth services are not the same as VCS. Telehealth services are considered a substitute for in in-person visit and are considered a FQHC visit
Telephone Calls, integrated audio/video systems, store and forward method such as sending a picture or video to the eligible provider initiated by the patient are eligible
The eligible provider may respond using the telephone, audio/video, secure text messaging, , or the patient portal
What type of Communication Qualifies?

11. Who can provide VCS? MD NP PA CNW Clinical Psychologists
Clinical Social Workers
Support Staff do not qualify
Who can provide VCS?

12. Patient must have had a FQHC or RHC billable visit within the previous year
Consent should be obtained and documented in the medical record
Pre-Requisites

13. Billing FQHCs and RHCs must use the HCPCS code G0071 for billing
Rate for G0071 is $13.69 and can be billed as frequently as needed for the patient (There are no frequency limitations at this time)
Visit is cost shared with the patient and co-insurance and deductibles are applied
Cost sharing cannot be waived for the patient
Financial Assistance can be offered
VCS cannot be billed for related services for a visit within 7-days and cannot results in a visit within 24-hours
VCS can be billed alone or in conjunction with CCM or on the same claim as a billable visit (*Note Restrictions Above)
Billing

14. https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics- Center.html
Health-Centers-FQHC-Center.html
Payment/PhysicianFeeSched/PFS-Federal-Regulation- Notices.html
Resources