2026 Reimbursement Tips eBook Medicare Reimbursement, Coding & Documentation Guidance for FQHCs
NACHC’s Reimbursement Tips help health centers navigate Medicare reimbursement, coding, and documentation in line with CMS guidelines. These resources are available to Health Center Program staff who complete the VTF Assessment.
eBook access is available upon completion of the VTF Assessment Complete the assessment at reglantern.com/vtf.
Why Medicare?
FQHCs can strategically leverage Medicare reimbursement and care models to:
Æ Increase the size of their patient population served, and retain their current aging population Æ Strengthen their mission by serving vulnerable older adults and individuals with disabilities Æ Improve financial stability Æ Enhance population health outcomes through team-based care and reimbursement led by care team members other than the provider
FOUNDATION RESOURCES FQHC Payment Guide LEARNER LEVEL: 100 View PDF
This FQHC Payment Guide is designed to help Federally Qualified Health Centers (FQHCs) understand and navigate the primary payment mechanisms available across Medicare, Medicaid, and commercial payers—including the billing codes, reimbursement structures, and compliance considerations needed to optimize revenue and ensure regulatory adherence.
Looking Beyond Medicaid: Medicare as a Strategic Payer for FQHCs LEARNER LEVEL: 100 View PDF
As more Medicare beneficiaries turn to FQHCs for care, new opportunities are emerging to expand impact and strengthen sustainability. By understanding Medicare’s structure and leveraging its reimbursement and care models, FQHCs can grow their patient base, support vulnerable populations, improve financial stability, and drive better health outcomes through team-based care.
Program of All-Inclusive Care for the Elderly (PACE) LEARNER LEVEL: 200 View PDF
PACE supports frail older adults with complex care needs by providing comprehensive, person-centered services that allow them to remain safely in their homes. By prioritizing independence, dignity, and connection, PACE enhances quality of life while reducing the need for institutional care.
Medicare Billing Terms Made Simple LEARNER LEVEL: 100 View PDF
As Medicare reimbursement and care delivery models continue to evolve, understanding key Medicare and FQHC billing terminology is essential for compliant operations and effective program implementation. This resource is designed to help health centers navigate common CMS terms related to care management, telehealth, supervision, visits, providers, and payment methodologies. By strengthening foundational knowledge of Medicare requirements, FQHCs can better support coordinated, team-based care while improving operational and reimbursement readiness.
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Wellness, Prevention & Education
Medicare services reimbursed at the Prospective Payment System (PPS) rate focused on patient wellness, disease prevention, and education.
LEARNER LEVEL: 200 View PDF
Initial Preventive Physical Exams (IPPE) & Annual Wellness Visits (AWV) These Medicare Wellness Visits offer opportunities to improve patient outcomes through prevention by detecting health risks early and engaging patients in discussion and planning of healthy activities and behaviors. Reimbursed through Medicare PPS, wellness visits can increase health center revenue by increasing visit volumes, supporting incentive payments within value-based care models, and registering qualified patients for chronic care management.
Advance Care Planning (ACP) LEARNER LEVEL: 200 View PDF
LEARNER LEVEL: 200 View PDF
ACP services allow providers and patients the opportunity to discuss, document, and plan their preferences for future medical care and end-of-life decisions, ensuring their values and wishes are respected when they can no longer make decisions for themselves.
Diabetes Self-Management Training (DSMT) & Medical Nutrition Therapy (MNT) DSMT and MNT are Diabetes Self-Management Education and Support Services (DSMES) provided to patients with diabetes to establish the foundation of care, skills, and behaviors needed to self-manage their diabetes so that they can improve their health and quality of life.
Tobacco Cessation Counseling LEARNER LEVEL: 200 View PDF
Tobacco cessation counseling services are behavioral change interventions provided to patients who struggle with nicotine dependence and the toxic effects of tobacco and nicotine.
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Telehealth & Virtual Communication
Medicare telehealth services have expanded access to care, allowing FQHC patients to connect with providers remotely for behavioral health, medical and preventive services, and more.
Extended FQHC Telehealth Services LEARNER LEVEL: 200 View PDF
Eligible Medicare Part B telehealth visits are reimbursable when they involve the use of interactive audio-visual or audio-only telecommunications technology permitting two-way, real-time communication between the qualified provider and patient. Any of these services may also be furnished in-person.
Mental Health Telehealth LEARNER LEVEL: 200 View PDF
An FQHC mental health visit involves an encounter between an FQHC practitioner and the patient, which can take place either in person or through interactive, realtime audio and video communication technology. In certain cases, audio-only technology is also permissible.
Virtual Communication Services (VCS) LEARNER LEVEL: 200 View PDF
VCS refer to healthcare services provided remotely, typically via digital platforms including smartphones, tablets, email, secure messaging, and patient portals. These services benefit patients by offering greater accessibility to healthcare, reducing the need for in-person visits, and enabling timely consultations which can improve convenience and continuity of care, especially for those in rural or underserved areas.
Telehealth is breaking down barriers—connecting FQHC patients to essential care anytime, anywhere.
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Care Management — Overview Resources Care management programs support patients with chronic conditions, non-clinical drivers of health, and complex care needs through structured, ongoing services. These programs aim to improve patient outcomes, enhance coordination across providers, and optimize care transitions.
LEARNER LEVEL: 200 View PDF
FQHC Medicare Care Management: Operational and Billing Essentials This guide provides an overview of key considerations that apply broadly across all Medicare care management programs. Ideal resource for health centers considering, or beginning, to offer care management services.
Summary of Medicare Care Management Services LEARNER LEVEL: 200 View PDF
At-a-glance comparison of Medicare care management programs covering service description and elements, patient eligibility, service providers, and billing codes. Developed to assist health centers in deciding which services are a good fit for their patient populations and staffing model.
Care management provides coordinated, continuous care that leads to better outcomes.
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Care Management — Reimbursement Tips NACHC’s library of Reimbursement Tips documents provide a clear, practical overview of how these programs work, including patient eligibility, service requirements, documentation expectations, and billing considerations.
Chronic Care Management (CCM, CCCM & PCM) LEARNER LEVEL: 200 View PDF
This resource provides a clear overview of Medicare care management services, including Chronic Care Management (CCM), Complex Chronic Care Management (CCCM), and Principal Care Management (PCM). It outlines patient eligibility, service requirements, documentation, and billing considerations to help health centers effectively deliver and integrate ongoing coordinated care for patients with chronic or complex conditions.
CCM Return on Investment (ROI) Calculator Reimbursement Tips LEARNER LEVEL: 200 View PDF
This tool helps Federally Qualified Health Centers (FQHCs) estimate the financial impact of providing Chronic Care Management (CCM) services. By entering key inputs like patient volume, staffing, and reimbursement rates, you can quickly calculate potential revenue, costs, and overall return on investment.
Transitional Care Management (TCM) LEARNER LEVEL: 200 View PDF
TCM services are designed to aid patients during the transition from an inpatient hospital or facility setting back to the community setting. These services include timely outreach, care coordination, medication reconciliation, and follow-up to ensure continuity of care.
Chronic Pain Management (CPM) LEARNER LEVEL: 200 View PDF
CPM services support patients with chronic pain through ongoing, coordinated care that addresses both clinical and functional needs. These services include an individualized treatment plan with assessment, care planning, medication and treatment management, and coordination with other providers.
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Care Management — Reimbursement Tips Care management services largely involve non-face-to-face care coordination activities performed by auxiliary personnel under the general supervision of an authorized billing provider. For definitions of terms used throughout this document, see NACHC resource, Medicare Billing Terms Made Simple. Behavioral Health Integration (BHI) LEARNER LEVEL: 200 View PDF
BHI services support patients with behavioral health conditions through ongoing care coordination and collaboration between the primary care team and behavioral health resources. These services include assessment, care planning, monitoring, and facilitation of treatment to ensure patients receive appropriate, timely support.
Psychiatric Collaborative Care Model (CoCM) LEARNER LEVEL: 200 View PDF
CoCM services support patients with behavioral health conditions through a structured, team-based model that includes the treating provider, a behavioral health care manager, and a psychiatric consultant. These services include systematic assessment, care planning, ongoing monitoring using validated tools, and regular psychiatric consultation to guide treatment.
Community Health Integration (CHI) LEARNER LEVEL: 200 View PDF
CHI services support patients with unmet upstream drivers that impact health outcomes. These services include assessment, care planning, resource navigation, and coordination with community-based organizations to help patients access needed supports.
Principal Illness Navigation (PIN) LEARNER LEVEL: 200 View PDF
PIN services support patients with serious or high-risk conditions by helping them navigate the healthcare system and access necessary care. These services include assessment, care planning, coordination, and connection to clinical and supportive resources, often addressing barriers to treatment adherence.
Simple, actionable guidance for navigating reimbursement.
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Care Management — Reimbursement Tips Advanced Primary Care Management (APCM) stands apart from other care management services as it must be driven by the patient’s primary provider, categorizes patients by need level, and uses quality measures to assess program effectiveness. Advanced Primary Care Management (APCM) LEARNER LEVEL: 200 View PDF
LEARNER LEVEL: 200 View PDF
APCM services support patients through comprehensive, longitudinal care delivered by the primary care team and billed as a bundled monthly service, with the ability to incorporate behavioral health through newly established add-on codes.
Remote Physiologic Monitoring (RPM) & Remote Therapeutic Monitoring (RTM) RPM and RTM services support patients by collecting and monitoring health data outside of traditional clinical settings. RPM focuses on physiologic data (e.g., blood pressure, glucose), while RTM captures therapy-related data (e.g., medication adherence, musculoskeletal or respiratory status) to guide treatment.
Supplemental Care Management Resource Sliding Coinsurance for Medicare Care Management LEARNER LEVEL: 200 View PDF
For Medicare Care Management Services, patients pay 20% coinsurance based upon the lesser of the submitted charges or the local payment rate for the service codes. Coinsurance may be covered in part or in full by secondary coverage, and may be ‘slid’ commensurate with the sliding fee discount program policy of the health center.
Patient coinsurance may apply to Medicare Care Management Services.
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Co-Occurring Care Management Services
For an example of how Medicare care management services can work together to support a patient, view these two short videos:
Meet Maria!
Layering the Cake
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Questions? Email us at:
QualityCenter@nachc.org
Resources within this eBook are updated in accordance with the latest Centers for Medicare & Medicaid Services (CMS) guidelines, while the links remain the same.
This eBook is designed for Federally Qualified Health Centers (FQHCs) and FQHC partners who are interested in learning about, and leveraging, opportunities for Medicare reimbursement.