Provider Delivered Care Management Billing Guidelines Webinar March 6, 2012

Agenda PDCM Reimbursement Policy Design General Conditions of Payment Patient Eligibility Provider Requirements Billing Guidelines

PDCM Payment Policy Design 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 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 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 Non-approved providers billing for PDCM services will be subject to audit and recoveries.

Patient Eligibility 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 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.

Provider Requirements: 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 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)

Provider Requirements: Billing and Rendering Provider 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 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 Rendering Provider Billing Practice-based Physician, CNP or PA within the PDCM-approved practice Physician practice Physician Organization-based PO-based billing entity BCBSM’s Provider Consulting area is prepared to assist with the enrollment process.

Billing and Documentation: General Guidelines 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) No location restrictions Documentation demonstrating services were necessary and delivered as reported

Code-Specific Requirements: G9001 Initiation of Care Management (Comprehensive Assessment) 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 (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.

Code-Specific Requirements: G9002 Individual, Face-to-Face Care Management Visit 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 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 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 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 Telephone assessment and management, 5-10 minutes 98967 Telephone assessment and management, 11-20 minutes 98968 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

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