3. BCBSM 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
3
5. General Conditions of Payment
For billed services to be payable, the following
conditions apply:
• The patient must be eligible for PDCM coverage
Non‐approved providers billing for PDCM services
will be subject to audit and recoveries
5
6. General Conditions of Payment
For billed services to be payable, the following
conditions apply:
• 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
6
7. Care Management Training
Guidelines
Services provided by Moderate Care Managers
are billable once Care Managers complete
approved self‐management training
Services provided by Complex Care Managers
are billable once care managers have
completed approved Complex Care
Management training
PDCM‐codes should not be billed by untrained
care managers
7
8. 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
Services billed for non-eligible members will be rejected with provider liability.
8
9. 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
Services billed for non-eligible members will be rejected with provider liability.
9
10. Patient 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 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.
10
11. 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
11
12. Provider Requirements: Care
Management Team
The team must consist of:
• A lead care manager : RN, LMSW, CNP or PA who has
completed an MiPCT‐accepted training program
• Other qualified allied health professionals:
• LPN CDE, certified diabetes educator, RD, Nutritionist
Master’s Level, Pharmacist, respiratory therapist, certified
asthma educator, certified health educator specialist
(bachelor’s degree or higher), licensed professional
counselor, licensed mental health counselor
12
13. Provider Requirements: Care
Management Team
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)
13
14. Provider Requirements:
Billing and Rendering Provider
Rendering Billing
Provider Provider
Practice‐based Physician, CNP Physician
or PA within practice
Physician the PDCM‐ PO‐based
Organization‐ approved billing entity
based practice
BCBSM’s Provider Consulting area is prepared to assist with the enrollment
process. Please contact Laurie Latvis at llatvis@bcbsm.com
14
15. 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
15
16. Billing and Documentation:
General Guidelines
• 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
• Documentation identifying lead CM isn’t
required, but documentation must be maintained
in medical records identifying the provider for
each patient interaction
16
17. G9001:
Initiation of Care Management
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
17
18. G9001:
Initiation of Care Management
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
18
19. G9001:
Initiation of Care Management
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.
19
20. G9002:
Individual, Face‐to‐Face
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
20
21. G9002:
Individual, Face‐to‐Face
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.)
21
22. Code‐Specific Requirements:
98961, 98962
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)
22
23. Code‐Specific Requirements:
98961, 98962
Each session must:
• Be conducted in person
• Have at least two, but no more than eight patients
present
• Include some level of individualized interaction
Each session must:
• Be conducted in person
• Have at least two, but no more than eight patients
present
• Include some level of individualized interaction
23
24. Code‐Specific Requirements:
98961, 98962
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
24
25. Code‐Specific Requirements:
98961, 98962
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
25
26. Code‐Specific Requirements:
98966, 98967, 98968 Telephonic
98966 Assessment and management, 5‐10 minutes
98967 Assessment and management, 11‐20 minutes
98968 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)
26
27. Code‐Specific Requirements:
98966, 98967, 98968 Telephonic
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
27
28. Code‐Specific Requirements:
98966, 98967, 98968 Telephonic
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
28
29. BCN Care Coordination Payment
Effective April 1, 2012 and forward, providers
need to submit claims for care coordination
services rendered
For January 1 to March 31, 2012, BCN will pay a
lump sum equal to three times the average
monthly care coordination payment
• Average monthly care coordination will be calculated
using claims validated and billed for July and August
2012 dates of service
• Payment will be made no later than October 31, 2012
30. BCN 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/“privileged” providers only
• Non‐approved providers billing for these services
are subject to recovery
30
31. BCN PDCM Payment Policy
Design
BCN will pay the lesser of provider charges or
BCN’s maximum fee
• CNPs or PAs paid at 85%
No cost share imposed on members
31
32. BCN PDCM Codes and Fees
CODE SERVICE
G9001 Initial assessment
G9002 Individual face-to-face visit (per encounter)
98961 Group visit (2-4 patients) 30 minutes
98962 Group visit (5-8 patients) 30 minutes
98966 Telephone discussion 5-10 minutes
98967 Telephone discussion 11-20 minutes
98968 Telephone discussion 21+ minutes
• Use applicable regional fee schedule
– Call your BCN provider representative with questions
32
33. BCN 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 BCN for PDCM reimbursement.
• Billed in accordance with BCN billing
guidelines
Non‐approved providers billing for PDCM services
will be subject to audit and recoveries.
33
34. BCN Care Management Training
Guidelines
• BCN same as BCBSM
• Services provided by Moderate Care Managers
are billable once care managers complete
approved self‐management training.
• Services provided by Complex care managers
are billable once care managers have completed
approved Complex Care Management training.
• PDCM‐codes should not be billed by untrained
care managers
34
35. BCN Patient Eligibility
Provider panels are available through Health e‐
Blue web
• Instructions will be forthcoming detailing how to identify the self‐
funded membership not participating in MiPCT
• Providers should also check normal eligibility channels (e.g.,
WebDENIS, CAREN IVR) to confirm BCN 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 o diagnosis restrictions are
applied
• Order for PDCM should be based on patient need
The patient must be an active participant in the
care plan
35
36. Provider Requirements: Care
Management Team (BCBSM)
Individuals performing PDCM services must be
qualified non‐physician practitioners employed by
practices or practice‐affiliated POs approved for
PDCM payments
Refer to BCBSM slide
36
37. Provider Requirements: Billing
and Rendering Provider
Rendering Billing
Provider Provider
Practice‐based Physician, CNP Physician
or PA within practice
Physician the PDCM‐ PO‐based
Organization‐ approved billing entity
based practice
37
38. 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
• PDCM codes and T codes may not be billed for the same member
• No diagnostic restrictions
• All relevant diagnoses should be identified on the claim
• No location restrictions
• Documentation demonstrating services were necessary and delivered as
reported
• Documentation identifying lead CM isn’t required, but documentation
must be maintained in medical records identifying the provider for each
patient interaction
38
39. G9001:
Initiation of Care Management
Same as BCBSM
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
39
40. G9002:
Individual, Face‐to‐Face Care Visit
Same as BCBSM
Payable when performed by any qualified care
management team member
No quantity limits
40
41. 98961, 98962
Group Education & Training Visit
Same as BCBSM
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
41
42. 98966, 98967, 98968
Telephone‐based Services
Same as BCBSM
98966 Telephone assessment and management,
5‐10 minutes
98967 Telephone assessment and management,
11‐20 minutes
98968 Telephone assessment and management,
21+ minutes
42
43. Medicaid Attribution
Medicaid managed care population only
Attributed member:
• Medicaid beneficiary enrolled in a Medicaid Health
Plan AND
• assigned Primary Care Provider is affiliated with
participating practice/PO
44. Enrollee Lists
• Attribution process occurs on the first business day of
the month
• Medicaid enrollee lists submitted to Michigan Data
Collaborative (MDC)
• MDC will post enrollee lists on MDC secure site for
retrieval by PO
– Automated message from MIShare at UMHS
– mlawr@med.umich.edu
– gwenthom@med.umich.edu
• PO responsible for transmitting enrollee lists to
practices
45. Payment Calculation
Medicaid payments calculated as Per Member Per
Month (PMPM) based on monthly attribution
counts:
• $3.00 PMPM Care Coordination paid to PO
• $1.50 PMPM Practice Transformation paid to
Practice
• $3.00 variable payment based on performance paid
to PO
46. Provider Enrollment
Required for Payment
PO’s will be enrolled as an MCO in CHAMPS
system by DCH.
Practices must enroll as either an individual sole
proprietor or as a group in Medicaid CHAMPS
system.
PO Enrollment questions: landfairt@michigan.gov
Provider Enrollment questions: 800‐292‐2550
47. Payment Timing
• Quarterly EFT payments appear as gross adjustment
• Reconcile payment amount with your enrollee list
• Payments released mid month after end of the
quarter
– April (QTR 1)
– July (QTR 2)
– October (QTR 3)
• Regularly check the Payment Update Tab on
MIPCTdemo.org for new/updated information
• Payment questions: landfairt@michigan.gov
48. UMHS CMS Payment Processing
and Distribution to POs
CMS does not have a mechanism to pay POs
directly
• To accommodate this, CMS sends individual line
item remittances to UMHS (as they did for
practice transformation to the practices).
• Though not ideal, CMS will not change their
practice – thus UMHS must receive, reconcile
and then distribute payments
49. UMHS CMS Payment Processing
and Distribution to POs
Work is underway and a front‐end application has
been built to:
‐ Reconcile claims with member lists
‐ Calculate PO payments
‐ Produce PO payment summary
This will result in a payment delay for the first set
of care coordination payments. Goal is to
distribute to POs by early June. Earlier if at all
possible
50. Reporting to MiPCT
MiPCT practices are required to provide an
accounting for the MiPCT Transformation funds
MNO is responsible for gathering information by
April 30
MNO will sign off on all activities regarding care
managers and care manager assistants training
MNO will sign off on patient registry
documentation: WellCentive will be MU by April
30. Practice will use MiPCT funds to cover
enhancement costs ($700)
50
