MiPCT/PDCM
Billing Road Show
July 2013
Agenda
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2
MiPCT/PDCM Procedure Codes
Why should I bill G/CPT Codes?
Case Studies
Quiz
Patient List
Blue Care Network
What is a typical day for a Care Manager?
Resources
Questions
Break Out Time
MiPCT/PDCM Procedure Codes
Effective 4/1/2012
G9001 - Initiation of Care Management (Comprehensive Assessment)
G9002 - Individual Face-to-Face Visit
98961 - Education and training for patient self-management for 2–4
patients; 30 minutes
98961 - Education and training for patient self-management for 5–8
patients; 30 minutes
98966 – 5-10 minutes of medical discussion
98967 – 11-20 minutes of medical discussion
98968 – 21-30 minutes of medical discussion
Effective 4/1/2013
99487 - First hour of clinical staff time directed by a physician or other
qualified health care professional with no face-to-face visit, per calendar
month.
99489 - Each additional 30 minutes of clinical staff time directed by a physician or
other qualified health care professional, per calendar month. (An add-on code that
should be reported in conjunction with 99487)
G9007 - Coordinated care fee, scheduled team conference
G9008 - Physician Coordinated Care Oversight Services (Enrollment Fee)
3
Why should we bill G/CPT Codes?
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Instrumental to the success of MiPCT/PDCM and the CMS demo overall
(Michigan has the largest number of members participating in the demo
nationally)
We need to be able to show customers that PDCM has high engagement
rates
We need a large enough “n” to have a successful evaluation
Long-term viability of PDCM
– If we are successful in MiPCT, more customers will join the program
– If we can’t demonstrate impact and value to customers, PDCM program will
end
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G/CPT codes are the BCBSM mechanism for paying for PDCM (makewhole payments were intended to be for start-up, and will not be paid to
POs whose practices are not engaging BCBSM members and billing
G/CPT codes)
Comparative report that shows year-to-date G/CPT code BCBSM billing
volume at a summary level for all Physician Organizations in MiPCT is
now available.
SPECIAL NOTE
• PGIP philosophy is that PCMH infrastructure and care
processes should be implemented for all patients
– But payable services can only be provided to patients who
have the benefit
– PDCM is a payable service and should NOT be provided to
patients who do not have the benefit
– Delivering PDCM to patients who do not have the benefit will
contaminate the control group and distort the evaluation results
• If the evaluation doesn’t find a difference between patients with the
PDCM benefit and those without, the PDCM program will not
continue
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MiPCT Care Management - Case Presentations
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Case 1
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Case 1: Care Manager Post Hospital
Follow-up
8
•
59 year old male s/p digit amputation, discharged from hospital
– Other Diagnoses: Diabetes, HTN, Hyperlipidemia, Neuropathy
•
Pre-assessment
– Right foot dressing, not weight bearing
– I/D consult in the hospital
– Appears that no changes in medications were made in the hospital
– MRSA on inpatient culture (pending results at DC)
– A1C 6.2; LDL 98 BP: 132/78
•
Care giver support
– At time of discharge lives with wife, who has macular degeneration and DM
– Unemployed, not working due to foot ulcer
Care Manager - First Office Visit with Patient
CM completes office visit with patient and wife
Medication reconciliation:
Patient brought in all pills to visit. He reports taking
Bactrim for wound infection.
Medication reconciliation identified patient on Bactrim
without known reason- not clear on discharge plan
Care Coordination:
– I/D specialty appointment in mid April
– Questions on his follow-up visits
Self Management Support:
– Patient questions on control ranges
– Patient self-regulating Lantus doses based on
his HS blood sugars
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• Patient agrees to
participate in care
management
• This office visit
contributes to
G9001
Care Manager Office Visit (cont.)
Risk Assessment
– Patient and wife report inability
to “see” the wound and are
uncomfortable with wound
changes.
– Fear of wound not healing and
their skill in managing the
wound care
Depression Assessment
– PHQ2 negative
10
• Patient agrees to
participate in care
management (20 min)
• This office visit
contributes to G9001
Day 1 Care Coordination –
Closing the Gap
CCM reviews inpatient hospital stay information and
discharge plan directly in record
Determines that Bactrim doses will be out on
Saturday, and pt. lab report show MRSA—unknown
to I/D, Hospitalist and PCP as culture report was not
available at time of discharge
Contacts I/D specialist to obtain an earlier
appointment—patient not set to go until 3 weeks later
Speaks with I/D directly and receives refill on
Bactrim and appointment for upcoming Monday
Sets up homecare to monitor wound at home (not in
place at DC). Wife not able to do dressing changes
due to macular degeneration
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Speaks directly with Home Health Agency
RN, reviewed history, meds and treatment
plan
Care Coordination
time with medical
neighborhood:
60 min - Bill 99487
(at end of the month)
Week 1 - Care Manager Phone Visit
Self Management Support
• Addressed patient and spouse concern
regarding wound care
•Education and teach back of ranges of blood
sugar
•Educated on contacting office for medication
adjustment for blood sugar out of range
•Follow-up phone scheduled for the following
week
•Assessment completed, self management
goal agreed upon
• Check Blood sugar daily, record results
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Completion of
Comprehensive
Assessment (30 min) Bill G9001
Week 1: Care Manager follow-up call
CCM conducts first weekly phone
visit with patient
– Patient states he is doing better, still
not ambulating.
– Worried about getting his
medications as he is not able to
drive and he is due for refills.
– Homecare nurse has been out and
visits are every 2 days—wound
healing nicely.
– Contacted I/D specialist to review
treatment plan, ongoing ABX.
Reinforced this plan with the patient.
– Still has questions about his meal
planning and the best foods for he
and his wife.
– Mentions he has some swelling in
his legs.
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Phone visit with patient 20 min - Bill
98967
Care Coordination with medical
neighborhood – 20 min (need to
track total Care Coordination
minutes (60 min + 20 min) – 99489
Week 2: Care Manager Phone Visit, Care Coordination
Ongoing Care Coordination
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More in--depth history on swelling.
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Contacted Homecare to coordinate plan of care
– arrange for collaborative call at the time of the home
visit to review findings and discuss necessary
treatment changes.
•
Contacted pharmacy
– Arranged for home delivery of refills.
•
Contacted dietician
– Arranged for phone education to support
healthier food choices.
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Care Coordination:
Day 1 = 60 min
Week 1 = 20 min
Week 2= 30 min
Total cumulative time
Care Coordination = 110
minutes. Now able to
quantity bill 99489.
Week 2: Care Manager Phone Visit (cont.)
Follow up phone visit
– medication reconciliation
• Reviewed with patient current
diuretic meds and dosing.
– assess swelling
– assess wound healing
– progress of self
management goal
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Phone visit 10 min
Bill 98966
Case 2
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Case 2: Transition of Care - Post Hospital Discharge
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65 year old woman history of breast cancer 25 years ago
Admitted to hospital after a syncopal episode at church
Suffered skull and finger fracture
During hospital course patient was found to have severe Mitral
Regurgitation and under went heart catheterization
Transition of Care – 24 hr. Post Hospital Care
Manager Phone visit
Care manager reviews hospital
discharge summary
– Post discharge phone call made
within 24 hours post discharge
• Patient’s concern identified
– pressure dressing in place with
no patient instructions
– patient is confused about how to
take her medications
• Assessment
• Provide education
– after hours access to PCP
practice
– wound care – HHA Care
Manager will assist
– Red flags – shortness of breath,
weight gain, dizziness, fever,
redness/swelling around wound
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Phone visit is 20 min =
Bill 98967
Transition of Care
• Care Manager actions (cont.)
– Completed medication reconciliation
• Patient has a new prescription for Toprol but did not start to take this
medication
– Contact daughter who is able to pick up from pharmacy and bring to patient
– Verified that patient received oxygen and understood use and care of
oxygen
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Transition of Care
•
Care Manager actions 24 post
hospital visit:
– Coordination of care
• Referral for home care visit that
day
• Spoke directly with Home Health
Agency Care Manager
– shared phone visit assessment
findings, patient’s concern
– Follow up call with HHA RN
• Discussed HHA RN visit plan (i.e.
wound, med rec, patient
education, and patient to take
daily weights)
• HHA RN visit is scheduled weekly
– Verified that patient had follow up
appointments with PCP,
cardiothoracic surgeon
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Care Coordination = 20 minutes
(need to track cumulative care
coordination minutes) Do not bill
for Care coordination at this time.
NOTE: when total Care
Coordination adds up to 31
minutes you may bill 99487 (at
end of the month).
Transition of Care: Day 2 Follow up
Phone visit
• Care Manager actions:
– Follow up phone visit two days
post discharge
– Medication reconciliation
– Assess weight, HF symptoms,
wound healing
• Patient’s weight is stable, no
swelling, no shortness of breath
– Then weekly times 4 phone visits
– Verified PCP appointment day 3
post hospitalization, will see Care
Manager face to face same day
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Phone visit 10 min =
Bill 98966
Case 3
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Case 3: Moderate Care Management
Ms. H
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53 yr. old female
History:
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diagnosed at age 11 yrs. with “chronic bronchitis”
persistent asthma
asthma exacerbation
Ms. H – First Care
Manager phone visit
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Care Manager phone visit
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Ms. H was not convinced
that she “needed” asthma
education
Approach: Respect Ms. H’s
current knowledge about
her asthma
Patient agrees to participate
in care management
Patient agrees to participate in
Care Management.
Phone visit 10 minutes – this will
be added toward the G 9001
Ms. H – Care manager
face to face visit
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Face to Face CM visit
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Patient’s peak flow 250
Discuss
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triggers – mold, cold weather
current use of medications patient uses inhaled corticosteroid PRN and also
uses albuterol PRN
Patient completes Asthma Control test – result 6/25
Asthma Control Test
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Ms. H: Care Manager face to face visit
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Assessment completed
Education: purpose of controller
inhaler and importance of daily use
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Visual Tools
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Poster of controller and rescue
inhalers
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Asthma Booklet - Normal
airway, inflamed airway, airway
under attack
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Reference tool
•
Patient’s peak flow was 250
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looked up predicted peak
flow based on ht and age =
430
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Self management goal: Patient
will compete the peak flow and
record result 3 to 4 days in the
next week
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Face to Face Care
Management visit 20
minutes (20 minute face
to face and the 10
minute phone visit = 30
minutes: Bill G9001
Ms. H – Follow up Phone Visits
CM phone visit week 1
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Tools, self management goals, home
work for Patient:
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Asthma Action Plan
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Revisit Self management goal:
Patient will compete the peak flow
and record result 3 to 4 days in the
next week
CM phone visit week 2
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Discuss Peak Flows (range, look at
several days)
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After 2 weeks patient’s peak flow = 420
(improved!)
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Discuss use of medications
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Patient reports marked improvement!!
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Follow up phone visit in 2 weeks agreed
upon
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Week 1 Phone
visit 20 minutes Bill 98967.
Week 2 Phone
visit: 14 minutes Bill 98967
Case 4
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Case 4: Moderate Care Management:
Mr. J
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30
50 yr. old male, married, 3 children, occupation – cement
truck driver
Ht. 5’9”, wt. 337 lbs.
Diagnoses: Diabetes, HTN, Hyperlipidemia, Morbid
obesity
Medications: metformin, glipizide, lisinopril-HCTZ,
simvastatin and actos
Labs: HgA1c 9.9, T Cholesterol 152, Trig. 81, HDL 37,
LDL 99
BP 125/70
J’s First Care Manager visit –
Face to Face
Care Manager heard patient’s concern
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Patient’s goal: Lose weight
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J has a large ventral hernia
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surgeon advised patient to lose weight
currently not a candidate for surgery due to weight
Patient agrees to participate in care management
J’s First Care Manager visit –
Face to Face
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Assessment, individualized
plan of care, patient’s selfmanagement goal
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Identified preferred method of
visits and frequency of follow
up
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exercise at least one hour
everyday after work
Plan: monthly phone call visit
by Care Manager (monthly
phone visits x 3 completed) –
address self management
goal, barriers, solutions
Face to face visit with
Care manager 40
minutes, Bill G9001
J’s PCP visit
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28 lb. weight loss over 3 mos. period
BP 124/70, hgA1c 6.5 (3 mos. prior hgA1c 9.9 )
Assessment
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significant lifestyle modifications leading to wt. loss
vast improvement in DM and HTN
discontinue Actos
J’s Barriers and
Plan of Care
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Barrier
Actions
Weight loss plateau
Dietary modifications, Care manager
placed referral to dietician
Getting through social events, Holidays
etc.
Drink water before going to the
parties, smaller portions of sweets
Knee pain
Started Physical Therapy (PT), Care
Manager discussed with PCP and
placed referral for PT
Decreased motivation—not working
much—after work habit changed, loss
of exercise buddy
Develop a new routine, Find a buddy.
Care Manager discussed with J –
“what would work for him?”
Care Manager
interventions
• Care Manager phone visit 1 with
patient
– Discuss with patient to explore
patient’s ability and willingness
to follow up with PT, Dietician
– Follow up on self management
goal, modify self management
goal
Care Management Phone
visit – 15 minutes, Bill
98967
Care Coordination- 35
minutes, Bill 99487
• Coordination of care
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Referral to PT, Dietician
Discuss case with PCP.
Team Conference – Bill
G9007
Once a Month Care
Management Phone visits:
J’s - Accomplishments
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50 pound weight loss over 12
months
HgA1C down to 6 from 9.9
• Two medications discontinued:
Actos, HCTZ
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Care Manager phone
visits, once per
month, each visit
ranges 8 to 10
minutes: Bill 98966
J’s Current Status
• Gained “back” some weight
• Still struggling but remains motivated
• Care Manager phone visits “help more than you know”
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Quiz
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Answers to Quiz
1.
I can render care management services to any BCBSM, BCN, or Medicare
Advantage member. False
2. Medical Assistants can serve as Care Managers. False
3. I should contact Michigan Data Collaborative (MDC) if I have questions about
the Patient List. True
4. The patient list is the only place I need to check eligibility, for members of a High
Deductible Health Plans with Health Savings Account. False
5. My Physician indicates a patient needs care management; however, the patient
is not on the patient list. It is still appropriate to render the service. False
6. There is no cost to patients for care management. False
7. Procedure codes G9001 (Initiation of Care Management) and 99487 (First hour
of clinical staff time…) may be billed more than once. False
8. Once I receive the patient list, there is nothing further I need to do. False
9. I can bill a telephone assessment (98966-98968) before a G9001 (Initiation of
Care Management) or G9002 (Face to Face Care Management). True
10. I can bill G9001 (Initiation of Care Management) without a face to face visit and
the completion of the assessment. False
11. I should bill all active diagnoses on every claim. True
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All Payer Patient List
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All-Payer Patient Lists
• Available on the MDC MiPCT Dashboards
– On the Download PO Reports tab
• Distribution: Monthly
– Target release date is the 3rd week of each month (dependent upon
data availability)
– Notifications:
• Email announcement to dashboard users
• Notice on the MDC Website (What’s New section)
• Notice in the MiPCT FLASH newsletter
• BCBSM Medicare Advantage Patient List available in a
separate file
– Uses same file layout as the All-Payer Patient List
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All-Payer Patient
Lists
•See All-Payer Patient List Information document on the MDC Website
Support page
•https://www.michigandatacollaborative.org/MDC/#/support
•Provides details of the content in each month’s files:
•Also Includes attribution assignment schedules and a list of available data fields
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BCN MiPCT PDCM Billing
James H. Haskins IV, MPH
Administrative Manager Clinical Affairs
Blue Care Network
Blue Care Network is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
BCN Eligible Members
• While BCN offers multiple products, only the commercial
underwritten population is eligible for PDCM service
– Self-funded customers must agree to participate
– Currently, one customer has agreed to participate and another customer
will be joining this month
• BCN members belonging to an other product are not eligible
– These members are not appearing on the patient list
– The claims will deny and BCN data shows over 1000 claims for these
products have been billed since April 1, 2012
• BCN Medicare Advantage HMO-POS
• Blue Cross Complete (Medicaid)
• BCN 65 (Medicare Supplemental)
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BCN Clinical Edits
• BCN has diverged slightly from BCBSM for billing guidelines on
these codes
• Any procedure code that includes a global post-surgery follow up, the
PDCM service will deny
• For the phone calls, 98966-98968, the codes contain language about
the service being within 7 days
– So if the date of service on this code is less than 7 days from the
previously billed code, the claim will deny
– 98966 billed with date of service 7/1 pays, 98967 billed with date of
service 7/7 will deny
– 98966 billed with date of service 7/1 pays, 98967 billed with date of
service 7/9 will pay
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BCN System Challenges: Right Now
• BCN has recently run a denied claims report and we have
discovered some claims that probably should have paid
• The claims system was denying for services rendered in the
outpatient hospital setting (location 22)
• As an HMO, everything is structured around the member’s assigned
PCP
– PDCM services are denying when billed by a PCP who is not the
member’s PCP
– BCN is evaluating how to fix this issue
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Care Manager Typical Day
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MDC: Sample Report Member List
• Physician Level attribution list, by Practice
• Includes information on Risk Scores, Visits, and Conditions
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Visit
Counts
Chronic
Conditions
# Inp. Visits
# Readmits
# PC visits
# Care Coord. Encounters
# Maint. Rx Scripts
Asthma
COPD
CHF
CAD
Diabetes
HTN
ADHD
CKD
Obesity
Member
Information
Attribution
Information
Risk
Score
Name
DOB
Age
Age Group
Gender
Payer
Physician
Practice
PO
Risk Score
Risk Group
Care Management - Building a
Patient Case load
• Care manager and PCP review
MiPCT list sorted by risk and
payer
– Target moderate and complex
patients that are in need of
care (based on medical
record review and CM/PCP
clinical judgment)
– Recent hospital/ED
discharges (and other high
risk transitions)
– Just-in-time office visits
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MiPCT Patient Lists – Key Steps
– New potential patients
• Review reports and identify patients with high ER utilization,
inpatient stays, complexity, …
• Meet with PCP to determine if identified patients are
moderate or complex and would benefit from Care
Management
– Current patient’s already enrolled in Care manager’s caseload
• Review pharmacy, ER visit, hospitalizations (will have this
data starting 4/13)
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Care Management Patient Screening - MiPCT Patient List
PO distributes MiPCT patient list to
Care Managers
REFERRAL/
SCREENING
ENROLLMENT/
ENGAGEMENT
Outreach with
patient (visit,
phone)
PCP, team referral
Admit/discharge
notifications for
transition of care
calls
Review patients
scheduled the next
day for PCP visit
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Compare to
MiPCT member
list; assess
appropriateness
Discuss with PCP :
Is patient
recommended for
care management?
Yes = identify
patient is eligible
for G9001
MANAGEMENT/
INTERVENTION
Assess, develop
care plan,
implement
interventions,
monitor and
update care plan
Submit G CPT code
billing if appropriate
CLOSURE (as
appropriate)
CCM / HCM/MCM
Role - Building a
Patient Caseload
Incoming patient
referrals
If yes, enroll patient;
CCM/ HCM/MCM
develop care plan,
communicate
/coordinate with team
Review MiPCT patient
eligible list
Screen to Identify
Patients appropriate
for CM
Conduct patient
assessment, patient
agrees to participate :
Y/N
Communicate with
Physician, confirm
patient is a candidate
for care management *
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* Note: patient selection is
made in partnership with
the physician
MiPCT Dashboards
Population
Membership
•
Attributed members by Payer
Risk Information
•
# of members by Risk Level
Population Information
•
# patients by Chronic Condition (Asthma,
CKD, CHF, etc)
Quality Measures
Screening and Test Rates
•
Diabetes tests, Cancer Screens, etc
Prevention
•
Immunization Rates, Wellness Visits, etc.
Comparison to Benchmarks
Utilization Measures (avail in Jan. ‘13)
Rates
•
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ED Use, Admissions, Re-admissions, etc
Comparison to Benchmarks
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PLEASE REMEMBER
– Payable services can only be provided to patients
who have the benefit
– PDCM is a payable service and should NOT be
provided to patients who do not have the benefit
– Delivering PDCM to patients who do not have the
benefit will contaminate the control group and distort
the evaluation results
• If the evaluation doesn’t find a difference between patients
with the PDCM benefit and those without, the PDCM program
will not continue
54
Where do I send questions?
Patient List –
michigandatacollaborative@med.umich.edu
Claims and Billing – log an issue through PGIP
Collaboration Site or
mipctdemo@michigan.gov
Clinical – mipctdemo@michigan.gov
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Resource Packet
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MiPCT/PDCM Billing Road Show
Slide Deck
MiPCT/PDCM Quiz
PDCM Payment Policy & Billing
Guidelines for Medicare
Advantage
MDC – All Payer Patient List
Information
MDC – All Payer Patient List FAQ
Transitional Care Management
Procedure Codes FAQ
PGIP SharePoint Collaboration
Site Quick Reference Guide
•
•
•
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Qualified non-physician
practitioners on the PDCM Team
–MA Article
What is an HSA (HDHP)?
Provider Delivered Care
Management: FAQ
MiPCT/PDCM-BCBSM/BCN/MA
Resource Page
BCBSM MiPCT/PDCM
Reimbursement Policy and Billing
Guidelines
MiPCT/PDCM Codes: April 2013
– All
MiPCT/PDCM Codes: April 2013Physician Only
Questions
57
Break Out Time
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Claims
Billing
Clinical
Patient List