Presentation on theme: "Provider Delivered Care Management Billing Guidelines Webinar"— Presentation transcript:
1 Provider Delivered Care Management Billing Guidelines Webinar March 6, 2012
2 Agenda PDCM Reimbursement Policy Design General Conditions of Payment Patient EligibilityProvider RequirementsBilling Guidelines
3 PDCM Payment Policy Design Fee-for-service methodology – 7 payable codes for services performed by qualified non-physician practitionersFace-to-face (individual and group)Telephone-basedPayable to approved providers onlyNon-approved providers billing for these services are subject to recoveryBCBSM will pay the lesser of provider charges or BCBSM’s maximum feeSubject to PCMH enhanced compensation provisionsDetermined by rendering provider identified on the claimPCMH-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 AccountCODESERVICEFEE*G9001Initial assessment$112.67G9002Individual face-to-face visit (per encounter)$56.3498961Group visit (2-4 patients) 30 minutes$14.0898962Group visit (5-8 patients) 30 minutes$10.4798966Telephone discussion 5-10 minutes$14.4598967Telephone discussion minutes$27.8198968Telephone 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 needOrdered by a physician, PA or CNP within the approved practicePerformed by the appropriate qualified, non-physician health care professional employed or contracted with the approved practice or POBilled in accordance with BCBSM billing guidelinesNon-approved providers billing for PDCM services will be subject to audit and recoveries.
5 Patient EligibilityThe patient must have active BCBSM coverage that includes the BlueHealthConnection® Program. This includes:BCBSM underwritten businessASC (self-funded) groups that elect to participateMedicare Advantage patients (further detail forthcoming)Checking eligibility:Eligible members with PDCM coverage will be flagged on the monthly patient listProviders should also check normal eligibility channels (e.g., WebDENIS, CAREN IVR) to confirm BCBSM overall coverage eligibilityThe 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 servicesNo diagnosis restrictions are appliedReferral should be based on patient needThe patient must be an active participant in the care planServices 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 paymentsThe team must consist of:A lead care manager who:Is an RN, licensed MSW, CNP or PAHas completed an MiPCT-accepted training programOther 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 counselorEach qualified care team member must:Function within their defined scope of practiceWork closely and collaboratively with the patient’s clinical care teamWork in concert with BCBSM care management nurses as appropriateNote: 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 onlyTwo potential modelsPractice-based care management teamPhysician-organization-based care management teamThe 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 BCBSMAffiliated clinicians identified as the Rendering Provider on PDCM claims must be registered in connection with the PO entityRenderingProviderBillingPractice-basedPhysician, CNP or PA within the PDCM-approved practicePhysician practicePhysician Organization-basedPO-based billing entityBCBSM’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 onlyProfessional claim7 procedure codesPDCM may be billed with other medical services on the same claimPDCM may be billed on the same day as other physician servicesNo diagnostic restrictionsAll relevant diagnoses should be identified on the claimNo quantity limits (except G9001)No location restrictionsDocumentation 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 yearContacts must add up to at least 30 minutes of discussionAssessment should include:Identification of all active diagnosesAssessment 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 processRecord documentation must additionally include:Dates, duration, name/credentials of care manager performing the serviceFormal indication of patient engagement/enrollmentPhysician coordination and agreementNOTE: 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 memberNo quantity limitsEncounters must:Be conducted in personBe a substantive, focused discussion pertinent to patient’s care planClaims reporting requirements:Each encounter should be billed on its own claim lineAll diagnoses relevant to the encounter should be reportedRecord documentation must additionally include:Date, duration, name/credentials of team member performing the serviceNature 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 minutes98962 Education and training for patient self-management for 5-8 patients, 30 minutesPayable when performed by any qualified care management team memberNo quantity limitsEach session must:Be conducted in personHave at least two, but no more than eight patients presentInclude some level of individualized interactionClaims reporting requirements:Services should be separately billed for each individual patientCode selection depends upon total number of patient participants in the sessionQuantity depends upon length of session (reported in thirty minute increments)All diagnoses relevant to the encounter should be reportedAdditional documentation requirements:Dates, duration, name/credentials of care manager performing the serviceNature of content/objectives, number of patients presentAny 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 minutes98967 Telephone assessment and management, minutes98968 Telephone assessment and management, 21+ minutesPayable when performed by any qualified care management team memberNo 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 phoneBe at least 5 minutes in durationInclude a substantive, focused discussion pertinent to patient’s care planClaims reporting requirementsCode selection depends upon duration of phone callAll diagnoses relevant to the encounter should be reportedAdditional documentation requirements:Dates, duration, name/credentials of care manager performing the callNature of the discussion and pertinent details regarding updates on patient’s condition, needs, progress