Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. Provider Delivered Care Management Billing Guidelines Webinar October 2013

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

3 PDCM Payment Policy Design Fee-for-service methodology – 12 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 CNPs or PAs paid at 85% of our fee schedule No cost share imposed on members EXCEPT members with Qualified High Deductible Health Plans with a Health Savings Account

PDCM Procedure Codes 4 Effective 11/1/2013 G Initiation of Care Management (Comprehensive Assessment) G Individual Face-to-Face Visit 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 Telephone assessment 5-10 minutes of medical discussion Telephone assessment minutes of medical discussion Telephone assessment minutes of medical discussion 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 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) G Coordinated care fee, scheduled team conference G Physician Coordinated Care Oversight Services (Enrollment Fee) Effective 1/1/2014 S Counseling and discussion regarding advance directives or end of life care planning and decisions

5 General Conditions of Payment For billed services to be payable, the following conditions apply: –The patient must be eligible for PDCM coverage. Ordered by a physician, PA or CNP within the approved practice; a note indicating these services were ordered must be in the medical record. –Based on patient need –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 Services billed for non-eligible members will be rejected with provider liability.

6 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 –(Note: BCN is not participating in PDCM-Oncology) Checking eligibility: –Providers should check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm contract and benefit eligibility. A practice should follow its current process for determining patient eligibility –Determining patient eligibility for care management is not the responsibility of the care manager –For information on how to access eligibility information, practices should contact their BCBSM Provider Consultant 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. The patient must be an active participant in the care plan.

7 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, LMSW, CNP or PA Has completed lead care manager training program Has completed a self-management support 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, 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 It is recommended that each qualified care team member also complete a self- management support training program

8 Provider Requirements: Billing and Rendering Provider 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 Provider Practice-basedPhysician, 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.

9 Billing and Documentation: General Guidelines The following general billing guidelines apply to PDCM services: –Approved practices/POs only –Professional claim 12 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 –Quantity limits apply to some codes (i.e. G9001, G9007, G9008) –No location restrictions –Documentation demonstrating services were necessary and delivered as reported –Documentation identifying the CM isn’t required, but documentation must be maintained in medical records identifying the provider for each patient interaction

10 Code-Specific Requirements: G9001 Initiation of Care Management (Comprehensive Assessment) G9001Coordinated 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 care manager, 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) –Current physical and mental/emotional status and treatment –Level of patient’s understanding of his/her condition and readiness for change –Perceived barriers to treatment plan adherence Billed claims must include: –Date of service (date patient is “enrolled” in care management) –Record documentation must additionally include: –Dates, duration, and modality ( face to face or phone), name/credentials of care manager performing the service –Formal indication of patient engagement/enrollment –Physician coordination and agreement Note: Only lead care managers may perform the initial assessment services (G9001)

Code-Specific Requirements: G9001 Initiation of Care Management (Comprehensive Assessment) continued NOTE: BCBSM Medicare Advantage If the service is delivered by a RN or MSW, in order to fulfill CMS requirements, the service must be delivered under direct supervision of the physician (meaning the physician is present in the same office suite). –The patient’s physician must review and sign the medical record. –The physician’s NPI must be reported in the Rendering Provider field on the claim. 11

12 Code-Specific Requirements: G9002 Individual, Face-to-Face Care Management Visit G9002Coordinated 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: G9002 Individual, Face-to-Face Care Management Visit continued –Updated status: medical condition, care needs and progress to goal –Any revisions to the care plan goals, interventions, and target dates (if necessary) –Other individuals in attendance (if any) and their relationship with the patient 13

14 Code-Specific Requirements: 98961, Group Education & Training Visit 98961Education and training for patient self-management for 2-4 patients, 30 minutes 98962Education 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 team member performing the service –Nature of content/objectives, number of patients present –Any updated status on patient’s condition, needs, progress

15 Code-Specific Requirements: 98966, 98967, Telephone-based Services 98966Telephone assessment and management, 5-10 minutes 98967Telephone assessment and management, minutes 98968Telephone assessment and management, 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 team member performing the call –Nature of the discussion and pertinent details regarding updates on patient’s condition, needs, progress with goals and target dates

16 Code-Specific Requirements: G9007 This code is to be billed by the physician and is payable only to the physician. The scheduled discussion should include sufficient time to discuss changes to the patient’s status. Discussions must be substantive and focused on content pertinent to the patient’s individualized care plan, interventions, goal achievement, target dates Outcomes and next steps for each patient must be agreed upon and documented. Documentation can be completed by the physician or the care manager –If another member of the care team is present, include their name(s) and credentials Separately billed for each individual patient discussed during team conference. One per patient per day G9007 Coordinated care fee, scheduled team conference

Code-Specific Requirements: G9008 G9008 Physician Coordinated Care Oversight Services (Enrollment Fee) This code is to be billed by the physician and is payable only to the physician. 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 A written care plan with action steps and goals accepted by the physician, care manager and patient is in place G9008 may be billed only one time per patient, per physician 17

Code-Specific Requirements: and 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 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) This code is payable for contacts made by any of the qualified allied personnel approved for PDCM on the care management team. The cumulative duration of communication time to bill must be at least 31 minutes in duration to be billable (i.e., 51% of an hour) Discussions must be substantive and focused on coordinating services that are pertinent to the patient’s individualized care plan and goal achievement. These codes should be billed at the end of each calendar month utilizing the last encounter date for that month. Appropriate coding and quantities are dependent upon the cumulative amount of time spend on care coordination activities in that month. 18

Code-Specific Requirements: and A code may be billed when at least 51% of the time designated in the descriptor of that code is met. –To bill the first hour, the cumulative amount of time must equal at least 31 minutes –To bill an additional 30 minutes, the cumulative amount of time must equal at least 16 minutes The code should be billed for the first 31 to 75 minutes of care coordination services for a patient in a month The code is billed in addition to for each additional 30 minutes of interactions. –99487 and would be billed if the total time spent was 76+ minutes of care coordination –99489 may be quantity billed if the total coordination time exceeds 105 minutes in a single month may only be billed once per calendar month, per patient may be quantity billed You will need to determine a method for tracking this time each month. 19

Code-Specific Requirements: and Documentation should include: Date and 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 20

Code-Specific Requirements: and

Code-Specific Requirements: S0257 S0257 Counseling and discussion regarding advance directives or end of life care planning and decisions This code should be used to bill for individual face-to-face or telephonic conversations regarding end-of-life care issues and treatment options Billable when performed by any qualified member of the care management team (i.e., lead care manager) No limits on number of services per patient per year List separately in addition to code for appropriate evaluation and management service Documentation associated with S0257 that must be recorded and maintained in the patient’s record should include: –Enumeration of each encounter including: Date of service Duration of contact Name and credentials of the allied professional delivering the service Other individuals in attendance (if any) and their relationship with the patient All active diagnoses 22

Code-Specific Requirements: S continued –Pertinent details of the discussion (and resulting advance care plan decisions), which, at a minimum, must include the following: A person designated to make decisions for the patient if the patient cannot speak for him or herself The types of medical care preferred The comfort level that is preferred –Advanced care planning discussions/decisions may also include: How the patient prefers to be treated by others What the patient wishes others to know –Indication of completion of an advance directive or Physician Orders for Life-Sustaining Treatment (POLST) document 23

Code Summary 24

QUESTIONS? Oncology Practices –Please send questions to the Provider Delivered Care Management Oncology Expansion mailbox- MiPCT Practices –Please send questions to 25