Provider Delivered Care Management
Billing Guidelines Webinar
March 6, 2012
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Agenda
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PDCM Reimbursement Policy Design
General Conditions of Payment
Patient Eligibility
Provider Requirements
Billing Guidelines
PDCM Payment Policy Design
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Fee-for-service methodology – 7 payable codes for services performed by qualified non-physician
practitioners
– Face-to-face (individual and group)
– Telephone-based
Payable to approved providers only
– Non-approved providers billing for these services are subject to recovery
BCBSM will pay the lesser of provider charges or BCBSM’s maximum fee
– Subject to PCMH enhanced compensation provisions
– Determined by rendering provider identified on the claim
• PCMH-designation status uplifts of 10% or 20%
• CNPs or PAs paid at 85%
No cost share imposed on members EXCEPT members with Qualified High Deductible Health Plans
with a Health Savings Account
CODE
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SERVICE
FEE*
G9001
Initial assessment
$112.67
G9002
Individual face-to-face visit (per encounter)
$56.34
98961
Group visit (2-4 patients) 30 minutes
$14.08
98962
Group visit (5-8 patients) 30 minutes
$10.47
98966
Telephone discussion 5-10 minutes
$14.45
98967
Telephone discussion 11-20 minutes
$27.81
98968
Telephone discussion 21+ minutes
$41.17
*Net of Incentive amount
General Conditions of Payment
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For billed services to be payable, the following conditions apply:
– The patient must be eligible for PDCM coverage.
– The services must be delivered and billed under the auspices of a practice or
practice-affiliated PO approved by BCBSM for PDCM reimbursement.
• Based on patient need
• Ordered by a physician, PA or CNP within the approved practice
• Performed by the appropriate qualified, non-physician health care professional
employed or contracted with the approved practice or PO
• Billed in accordance with BCBSM billing guidelines
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Non-approved providers billing for PDCM services will be subject to audit and
recoveries.
Patient Eligibility
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The patient must have active BCBSM coverage that includes the BlueHealthConnection® Program.
This includes:
– BCBSM underwritten business
– ASC (self-funded) groups that elect to participate
– Medicare Advantage patients (further detail forthcoming)
Checking eligibility:
– Eligible members with PDCM coverage will be flagged on the monthly patient list
– Providers should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to
confirm BCBSM overall coverage eligibility
The patient must be an active patient under the care of a physician, PA or CNP in a PDCMapproved practice and referred by that clinician for PDCM services
– No diagnosis restrictions are applied
– Referral should be based on patient need
The patient must be an active participant in the care plan
Services billed for non-eligible members will be rejected with provider liability.
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Provider Requirements: Care Management Team
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Individuals performing PDCM services must be qualified non-physician practitioners employed by
practices or practice-affiliated POs approved for PDCM payments
The team must consist of:
– A lead care manager who:
• Is an RN, licensed MSW, CNP or PA
• Has completed an MiPCT-accepted training program
– Other qualified allied health professionals:
• Any of the above, plus…
• Licensed practical nurse, certified diabetes educator, registered dietician, masters of
science trained nutritionist, clinical pharmacist, respiratory therapist, cerified asthma
educator, certified health educator specialist (bachelor’s degree or higher), licensed
professional counselor, licensed mental health counselor
Each qualified care team member must:
– Function within their defined scope of practice
– Work closely and collaboratively with the patient’s clinical care team
– Work in concert with BCBSM care management nurses as appropriate
Note: Only lead care managers may perform the initial assessment services (G9001)
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Provider Requirements: Billing and Rendering Provider
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PDCM services are only payable to practices or POs approved for PDCM reimbursement.
–For 2012, MiPCT-participating providers only
Two potential models
–Practice-based care management team
–Physician-organization-based care management team
Practice-based
Physician
Organizationbased
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Rendering
Provider
Billing
Provider
Physician, CNP
or PA within the
PDCM-approved
practice
Physician
practice
PO-based billing
entity
The rendering provider identified on the claim determines the fee.
Rendering and billing providers must be appropriately enrolled with BCBSM.
–For PO-based arrangement, the PO must obtain an NPI and enroll with BCBSM
–Affiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in connection
with the PO entity
BCBSM’s Provider Consulting area is prepared to assist with the enrollment process.
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Billing and Documentation: General Guidelines
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The following general billing guidelines apply to PDCM services:
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Approved practices/POs only
Professional claim
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No diagnostic restrictions
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7 procedure codes
PDCM may be billed with other medical services on the same claim
PDCM may be billed on the same day as other physician services
All relevant diagnoses should be identified on the claim
No quantity limits (except G9001)
No location restrictions
Documentation demonstrating services were necessary and delivered as reported
Code-Specific Requirements: G9001
Initiation of Care Management (Comprehensive Assessment)
G9001
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Coordinated Care Fee, Initial Rate (per case)
Payable only when performed by an RN, MSW, CNP or PA with approved level of care
management training (i.e., lead care manager)
One assessment per patient per year
Contacts must add up to at least 30 minutes of discussion
Assessment should include:
– Identification of all active diagnoses
– Assessment of treatment regimens, medications, risk factors, unmet needs, etc.
– Care plan creation (issues, outcome goals, and planned interventions)
Billed claims must include:
– Date of service (date patient is “enrolled” in care management)
– All active diagnoses identified in the assessment process
Record documentation must additionally include:
– Dates, duration, name/credentials of care manager performing the service
– Formal indication of patient engagement/enrollment
– Physician coordination and agreement
NOTE: More detailed requirements/expectations applicable to Medicare Advantage
patients are under development.
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Code-Specific Requirements: G9002
Individual, Face-to-Face Care Management Visit
G9002
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Coordinated Care Fee, Maintenance rate (per encounter)
Payable when performed by any qualified care management team member
No quantity limits
Encounters must:
– Be conducted in person
– Be a substantive, focused discussion pertinent to patient’s care plan
Claims reporting requirements:
– Each encounter should be billed on its own claim line
– All diagnoses relevant to the encounter should be reported
Record documentation must additionally include:
– Date, duration, name/credentials of team member performing the service
– Nature of discussion and pertinent details relevant to care plan (progress, changes, etc.)
Code-Specific Requirements: 98961, 98962
Group Education & Training Visit
98961
98962
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Education and training for patient self-management for 2-4 patients, 30 minutes
Education and training for patient self-management for 5-8 patients, 30 minutes
Payable when performed by any qualified care management team member
No quantity limits
Each session must:
– Be conducted in person
– Have at least two, but no more than eight patients present
– Include some level of individualized interaction
Claims reporting requirements:
– Services should be separately billed for each individual patient
– Code selection depends upon total number of patient participants in the session
– Quantity depends upon length of session (reported in thirty minute increments)
– All diagnoses relevant to the encounter should be reported
Additional documentation requirements:
– Dates, duration, name/credentials of care manager performing the service
– Nature of content/objectives, number of patients present
– Any updated status on patient’s condition, needs, progress
Code-Specific Requirements: 98966, 98967, 98968
Telephone-based Services
98966
98967
98968
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Telephone assessment and management, 5-10 minutes
Telephone assessment and management, 11-20 minutes
Telephone assessment and management, 21+ minutes
Payable when performed by any qualified care management team member
No more than one per date of service (if multiple calls are made on the same day, the times spent
on each call should be combined and reported as a single call)
Each encounter must:
– Be conducted by phone
– Be at least 5 minutes in duration
– Include a substantive, focused discussion pertinent to patient’s care plan
Claims reporting requirements
– Code selection depends upon duration of phone call
– All diagnoses relevant to the encounter should be reported
Additional documentation requirements:
– Dates, duration, name/credentials of care manager performing the call
– Nature of the discussion and pertinent details regarding updates on patient’s condition, needs,
progress
QUESTIONS?
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