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Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

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Presentation on theme: "Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association."— Presentation transcript:

1 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 March 6, 2012

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

3 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 BCBSMs 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 CODESERVICEFEE* 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$41.17 *Net of Incentive amount

4 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 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 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 (bachelors 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 patients 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 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 Provider Practice-basedPhysician, CNP or PA within the PDCM-approved practice Physician practice Physician Organization- based PO-based billing entity BCBSMs Provider Consulting area is prepared to assist with the enrollment process.

8 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 9 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 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 10 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 patients 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 11 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 care manager performing the service –Nature of content/objectives, number of patients present –Any updated status on patients condition, needs, progress

12 12 Code-Specific Requirements: 98966, 98967, Telephone-based Services 98966Telephone assessment and management, 5-10 minutes 98967Telephone assessment and management, minutes 98968Telephone 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 patients 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 patients condition, needs, progress

13 13 QUESTIONS?


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