Provider Delivered Care Management Billing Guidelines Webinar February 2013

2 Agenda Reimbursement Policy Design Overview Billing Guidelines for New PDCM Codes –99487, 99489, G9007, G9008 Summary Chart of Billable PDCM Codes by Provider Type Clarification for Transitional Care Management Codes Questions

3 PDCM Payment Policy Design Overview Fee-for-service methodology 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 BCBSMs maximum fee No cost share imposed on members EXCEPT members with Qualified High Deductible Health Plans with a Health Savings Account CODESERVICEFEE* Codes for Care Management Team Services G9001Initial assessment$ G9002Individual face-to-face visit (per encounter)$ Group visit (2-4 patients) 30 minutes$ Group visit (5-8 patients) 30 minutes$ Telephone discussion 5-10 minutes$ Telephone discussion minutes$ Telephone discussion 21+ minutes$ Complex chronic care coordination, first hour$ Complex chronic care coordination, additional 30 minutes$43.05 Codes for Physician Services G9007Coordinated care fee, scheduled team conference$28.59 G9008Physician coordinated care oversight services$47.65 *Net of Incentive amount

4 Code-Specific Requirements: 99487, Complex chronic care coordination services 99487First hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Intended as reimbursement for significant time spent coordinating with other providers and/or agencies Payable when performed by any qualified care management team member The cumulative duration of communication time must be at least 31 minutes in a calendar month to be billable Contacts may be by phone or face-to-face Time spent communicating with the patients primary care physician or caregiver is not included Quantity limitations: –99487 may only be billed once per calendar month, per patient –99489 may be quantity billed Documentation must include: –Date of contact –Duration of contact –Name and credentials of the allied professional on the care team making the contact –Identification of the provider or community agency with whom the discussion is taking place –Nature of the discussion and pertinent details

Time Guidelines for Billing Complex Care Coordination should be billed for the first 31 to 75 minutes of care coordination for a patient in a month is billed in addition to for each additional 30 minutes of interactions A code may be billed when at least 51% of the time designated in the descriptor is met Total timeCode(s)Quantity (in minutes)to bill 1-30Cannot be billed

6 Code-Specific Requirements: G9007 Coordinated Care Fee, Scheduled Team Conference G9007Coordinated care fee, scheduled team conference This code is to be billed by the physician and is payable to the physician for formally scheduled discussion –Must include primary care physician and care manager –May include other team members –Patient should not be present The scheduled discussion per patient must be at least 10 minutes in duration Discussion must be based on need, e.g. –Patient is not progressing –There is a change in the patients status Discussion must be substantive and focused on a patients individualized care plan and goal achievement Outcomes and next steps for each patient must be agreed upon Claims reporting requirements: –Separately billed for each individual patient discussed during the team conference –Can be billed once per patient per day Documentation must include: –Enumeration of each encounter including: Date of team meeting Duration of discussion for individual patient Name and credentials of allied professionals present for team conference –Nature of discussion and pertinent details –Any revisions to the care plan goals, interventions, and target dates (if necessary)

7 Code-Specific Requirements: G9008 Engagement Fee G9008Physician coordinated care oversight services This code is to be billed by the physician and is payable to the physician Intended as reimbursement for each patient upon enrollment (i.e. completion of an agreed upon care plan) A written care plan with action steps and goals accepted by the physician, care manager, and patient must be in place –Care plan must be formally shared between all 3 parties –Ideally, this interaction is face-to-face with all 3 parties present –An E&M visit performed by the physician must be simultaneously or previously billed for the patient –A G9001 or G9002 performed by the care manager must be simultaneously or previously billed for the patient Quantity limitations: –May be billed only one time per patient, per physician Documentation must include: –Evidence of a written shared action plan for the patient developed by the care manager that has been reviewed and approved by the billing physician

Billable PDCM Codes by Provider Type Provider Type Service Care ManagerOther Care Team Members Physician Initial AssessmentG9001--G9008 Face-to-face EncounterG9002* Phone98966, 98967, Group98961, 98962* Team Conference--G9007 Complex Care Coordination99487, *These encounters should be billed as E&M visits.

Informational: Clarification for TCM Codes

10 Clarification for Transitional Care Management Codes: 99495, Moderate complexity; patient contact within 2 business days of discharge and a face-to-face within 14 calendar days of discharge 99496High complexity; patient contact within 2 business days of discharge and a face- to-face within 7 calendar days of discharge These are not PDCM-specific codes. Transitional care codes were released 1/1/13. These codes are not exclusive to the PDCM program. These codes should be billed by the physician, CNP, or PA who conducts the post- discharge follow-up visit, like an E&M service. These codes are intended to be billed at the end of 30 days post discharge (from a hospital, LTAC, SNF, partial hospital, etc. to home). They are billable by only one provider in that period. They are intended to cover just one face-to-face visit. If there is a second visit, it would be billed separately (e.g., as a regular E&M). Discharge day management codes (99238/ for hospitals and 99315/99316 for SNF) can be still be billed when the TCM codes are billed. The TCM codes may NOT be used by a physician who also reports a service to the patient with a global period of 10 or 90 days. If TCM codes are billed by the physician, payment is still allowed for any care management team services billed in the time window associated with the TCM codes.

11 QUESTIONS? Please submit additional questions through our Collaboration Site or your BCBSM provider consultant.