1. Provider Delivered Care Management Billing Guidelines Webinar
March 6, 2012

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 – 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 minutes
$27.81
98968
Telephone discussion 21+ minutes
$41.17
*Net of Incentive amount

4. 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.

5. 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.

6. 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)

7. 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.

8. 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

9. 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.

10. 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.)

11. 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

12. Code-Specific Requirements: 98966, 98967, 98968 Telephone-based Services
98966 Telephone assessment and management, 5-10 minutes
98967 Telephone assessment and management, 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

13. QUESTIONS?