Medicare Advantage
Provider Delivered Care Management
Billing Guidelines
Webinar 6/27/12 and 6/2812
Presented by Maureen Brown
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Topics
• Overview of Provider Delivered Care (PDCM)
• Medicare Advantage (MA) Differences
• MiPCT Specifics
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Care Management
Training Guidelines
– Services provided by Moderate care managers are
billable once care managers complete MiPCT
approved self-management training.
– Services provided by Complex care managers are
billable once care managers have completed
• MiPCT approved self management training
• MiPCT Complex Care Management training or
registered on line for the course
– PDCM-codes should not be billed by untrained care
managers
3
4
Patient Eligibility
•
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 PDCM-approved 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.
5
Care Management Team
•
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 care manager who:
• Is an RN, licensed MSW, CNP or PA
• Has completed a MiPCT-accepted training program
• Accepts responsibility for ensuring that PDCM services being delivered by any care
management team member are appropriate and aligned with the patient’s overall plan of
care
– 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, certified 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
Billing and Documentation –
General Guidelines
•
6
The following general billing guidelines apply to PDCM services:
– Approved practices/POs only
– Professional claim
• 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
– No diagnostic restrictions
• All relevant diagnoses should be identified on the claim
– No quantity limits - except G9001 – restricted to 1/patient/year
– No location restrictions
– Documentation demonstrating services were necessary and delivered
as reported to BCBSM
• providers must maintain a reasonable level of documentation
• details for documentation are identified for each procedure code
7
Initiation of Care Management
(Comprehensive Assessment)
G9001
G9001
•
•
•
•
•
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
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
G9001 - Documentation
•
•
•
•
Initiation of care management
Limit of one G9001 per patient per year
Contacts must add up to 30 min. of discussion
Identification of the care manager responsible for the overall care
plan - name, title
• Identification of the patient’s PCP, coordination & agreement
• Enumeration of each encounter to include:
– Date, duration and modality of contact
•
at least one visit is face to face
– If contact is made with a person other than the patient, the name
of the individual and their relationship with the patient must be
documented
G9001 - Documentation cont.
• Overall findings from the assessment of patient’s medical condition
and personal circumstances including, but not limited to:
– All active diagnoses
– Current physical and mental/emotional status
• Capabilities
• Limitations
– Current medical treatment regimens
– Current medications
– Risk factors
• Lifestyle issues
• Health behaviors
• Self-management activities, etc.
G9001 - Documentation cont.
• Assessment findings
– Available resources and unmet needs
– Level of he patient’s understanding of his/her condition(s) and readiness for
change
– Perceived barriers to treatment plan adherence
• Care Plan
– Individualized short and long term desired outcomes and target goal
dates
– Anticipated interventions to help the patient achieve their goals and
timeframes for follow-up
• Patient’s agreement and consent to engage/participate in care
management
G9001 - Documentation cont.
• For patient’s enrolled in ongoing care management
–
–
–
–
Monitor
Evaluate
Revise/update care plan
Full re-evaluation every 12 months
Individual, Face-to-Face
Care Management Visit G9002
12
G9002 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
Individual, Face-to-Face
Care Management Visit –
G9002
•
Record documentation must include:
– Date, duration of contact, name/credentials of team member performing
the service
– All diagnoses relevant to the encounter
– Other individuals in attendance (if any) and their relationship with the
patient
– Nature of discussion and pertinent details relevant to care plan
(progress, changes, etc.)
– Updated status on patient’s medical conditions, care needs, and
progress to goal
– Any revisions to care plan goals, interventions and target dates
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Telephone-based Services –
98966, 98967, 98968
98966
98967
98968
•
•
•
•
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
15
Group Education & Training Visit –
98961, 98962
98961 Education and training for patient self-management for 2-4 patients, 30
minutes
98962 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 (for example, if call lasted more than 30 minutes you would bill
additional codes for each 30 minute increment)
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
Group Education & Training Visit –
98961, 98962
98961 Education and training for patient self-management for 2-4 patients, 30
minutes
98962 Education and training for patient self-management for 5-8 patients, 30
minutes
– Quantity depends upon length of session (reported in thirty minute
increments)
•
Documentation requirements:
– All diagnoses relevant to the encounter should be reported
– Dates, duration of class, name/credentials of care manager performing
the service
– Nature of content/objectives of the training
– Total number of patients in attendance
– Any updated status on patient’s medical condition, care needs, and
progress to goal
MA Differences
•
•
•
•
Fee Schedule
Patient Eligibility
Comprehensive Assessment (G9001)
Documentation for Comprehensive
Assessment (G9001)
• Claim Submission
MA Fee Schedule
Code
TOS
Quantity
Reported
Medicare Advantage
Fee Amount
98961
9
x
$16.17
98962
9
x
$12.02
98966
9
$16.59
98967
9
$31.93
98968
9
$47.28
G9001
1
$129.37
G9002
1
$64.69
Patient Eligibility
• Medicare Advantage patients must have active Medicare
Advantage coverage and PDCM benefits
– Some Employer Groups are Excluded
– If an insurer other than BCBSM commercial or BCBSM
Medicare Advantage is the primary insurer, the
Medicare Advantage member is not eligible for PDCM
services
Wellness Visit vs.
Comprehensive Assessment
• Billing Guidelines Request that All MA patients Have Comprehensive
Assessment Annually
• Is the Comprehensive Assessment (G9001) Intended to Replace the
Annual Wellness Visit (G0438)?
– Clarification - CMS expects all Medicare Advantage members to have a
Wellness visit with their physicians annually for planning and preventive
purposes. During this Wellness visit all the chronic conditions, and any
new diagnoses the member has, should also be listed. In the event that
the member has had the Wellness visit (G0438) there will be no
requirement for them to have the Provider Delivered Care Management
(PDCM) Comprehensive Assessment (G9001). If the physician and care
manager feel that the member could benefit from also having a G9001
comprehensive care management assessment, however, the care
manager may conduct the assessment and the service will be payable.
Wellness Visit vs.
Comprehensive Assessment –
Continued
• Wellness Visit
– Performed by Physician
– Purpose is for Planning and Preventive Care
– Some Patients Never Take Advantage of Annual Wellness Visit
• Comprehensive Assessment (G9001)
– Performed by Non-physician Care Manager
– Purpose is to Assess Appropriateness of Care Management
Services
• MA’s Intention is to Have All Diagnoses Identified for purposes of:
– Patients Receiving Appropriate Treatment/Care
– Documenting Chronic and Acute (Temporary) Conditions
Comprehensive Assessment
(G9001)
• Must Include a Face-to-Face Component
• When delivered by Registered Nurse (RN) or Master of Social Work
(MSW)
– Must be delivered under direct supervision of the physician (i.e.,
physician and care manager provide patient care in the same office suite)
– The patient’s physician must review and sign the comprehensive
assessment note
– The physician’s NPI must be reported in the Rendering Provider field on
the claim
– CMS Requirements
Claim Submission –
COB
• Medicare Advantage members are not eligible for PDCM services
if an insurer other than BCBSM is the primary insurer
• Coordination of benefits
– Bill BCBSM Medicare Advantage Directly if Medicare Advantage is
Primary
– Bill BCBSM Commercial Directly if BCBSM Commercial is Primary
Claim Submission –
G9001 & Rendering NPI
• Care Manager Registered Nurse (RN) or Master of Social Work
(MSW)
– Rendering NPI is the Physician
– To meet CMS Requirements
• Care Manager by Certified Nurse Practitioner (CNP) or Physician
Assistant (PA)
– Rendering NPI is the CNP or PA
Claim Submission –
G9001 & DOS
• Patients Entering into Care Management
– DOS is Date Patient Enrolls in Care Management
• Patients Not Entering into Care Management
– DOS is Date of Face-To-Face Component of Assessment
Claim Submission –
Paper Claims or
Diagnosis Limitations
• G9001 Code Only - in addition to the claim, use Medicare Plus Blue
PPO 2012-Physician Assessment Healthy Advantage Rewards form
• Instructions for submission are in included at the bottom of the form.
• Forms may be obtained by:
– In the MA Billing Guidelines Document clicking on the link named:
2012-Physician-Assessment
– From the MA Billing Guidelines Document, pasting the following address
into your web browser:
bcbsm.com/pdf/medicare/2012/MedicarePLUS-PPO-2012Physician-Assessment.pdf
– Sending an email to the following address to receive an email with a link
to the form: marevenuemgtops@bcbsm.com
Questions?