1. Provider Delivered Care Management Billing Guidelines Webinar
Updated OCT 2014 V2

2. PDCM Reimbursement Policy Design General Conditions of Payment
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
We have a job aid that shows you how to confirm if a member is part of a HDHP w/HSA.

4. PDCM Procedure Codes Effective 11/1/2013
G Initiation of Care Management (Comprehensive Assessment)
G Individual Face-to-Face Visit
Group education and training for patient self-management for 2–4 patients; 30 minutes
Group 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.
Medicare Advantage Members: Non-approved providers billing for PDCM services are subject to audit and recoveries.

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, PARS/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.
Need to confirm MA is in or out--KH

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
It’s up to the PO or PU to determine if an RN, LMSW, CNP or PA will be their Lead Care Manager

8. 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
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
Additional documentation requirements:
Dates, duration, name/credentials of care team member performing the service
Nature of content/objectives, number of patients present
Any updated status on patient’s condition, needs, progress

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, LMSW, CNP or PA with approved level of care management training (i.e., lead care manager)
Quantity limit: One assessment per care manager, per practice, per patient, per year
Contacts must add up to at least 30 minutes of discussion
At least one encounter must be face to face
Assessment should include:
Identification of all active diagnoses
Assessment of treatment regimens, medications, risk factors, unmet needs, etc.
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
Care plan creation (issues, outcome goals, and planned interventions)
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)
The initial assessment must include at least one face to face interaction.

10. NOTE: BCBSM Medicare Advantage
Code-Specific Requirements: G9001 Initiation of Care Management (Comprehensive Assessment) continued
NOTE: BCBSM Medicare Advantage
If the service is delivered by a RN or LMSW, 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).
Patient’s verbal agreement and consent to engage/participate in care management. This agreement must be documented in the medical record.
The patient’s physician must review and sign the comprehensive assessment that becomes part of the medical record.
The physician’s NPI must be reported in the Rendering Provider field on the claim.

11. 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
Quantity limit: The appropriate quantity is based on the total cumulative time the patient spends with a care management team member(s) on that day. If more than one care management team member has a separate face-to-face with the same patient on that day, the length of time spent with the patient during each interaction should be added together to determine the correct quantity to bill.
If the total cumulative time with the patient adds up to:
1-45 minutes, report a quantity of 1
46-75 minutes, report a quantity of 2
minutes, report a quantity of 3
minutes, report a quantity of 4

12. Code-Specific Requirements: G9002 Individual, Face-to-Face Care Management Visit continued
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.)
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. Code-Specific Requirements: 98961, 98962 Group Education & Training Visit
98961 Education and training for patient self-management by a qualified, nonphysician health
care professional using a standardized curriculum, face-to-face with the patient (could
include caregiver/family) each 30 minutes; 2-4 patients
98962 Education and training for patient self-management by a qualified, nonphysician health
include caregiver/family) each 30 minutes; 5-8 patients
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

14. 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, minutes
Payable when performed by any qualified care management team member
Quantity limit: 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); time reported is cumulative for all qualified care management team members
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 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

15. Code-Specific Requirements: G9007 Team Conference
This code is to be billed by the physician and is payable only to the physician.
Quantity limit: There is a limit of one G9007 paid per physician, per practice, per patient, per day.
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
Includes the name and credentials allied professionals present for team conference.
Separately billed for each individual patient discussed during team conference.
One per patient per day.
G9007 Coordinated care fee, scheduled team conference
The discussion should not be a conversation in passing in the hallway or an exchange through the EMR.

16. Code-Specific Requirements: G9008 Patient Enrollment
G9008 Physician Coordinated Care Oversight Services (Enrollment Fee)
This code is to be billed by the physician and is payable only to the physician.
Quantity limit: G9008 may be billed only one time per patient, per lifetime, per 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

17. Code-Specific Requirements: 99487 and 99489 Care Coordination
99487 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.
99489 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)
These codes are 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.
This is the time spent reaching out to the medical home.

18. Code-Specific Requirements: 99487 and 99489 continued
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
99487 may only be billed once per calendar month, per patient
99489 may be quantity billed
You will need to determine a method for tracking this time each
month.

19. Code-Specific Requirements: 99487 and 99489 continued
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: 99487 and 99489 continued
The following chart is intended to help determine the appropriate codes and quantities for different periods of time.

21. Code-Specific Requirements: S0257 Advance Care / End of Life Planning
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
Quantity limit: 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: S0257 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 whether or not an advance directive or Physician Orders for Life-Sustaining Treatment (POLST) document has been completed

23. Code Summary

24. Medicare Advantage Differences
Patient Eligibility
Annual Wellness Visit
Comprehensive Assessment (G9001)
Claim Submission

25. BCBSM Medicare Advantage – Patient Eligibility
Medicare Advantage patients must have active Medicare Advantage coverage and PDCM benefits
Some ASC Employer Groups are Excluded
If an insurer other than BCBSM commercial or BCBSM Medicare Advantage is the primary insurer, the Medicare Advantage member is not eligible for PDCM services
In the first year of Part B coverage, MA patients must receive a one-time initial preventative physical exam; in subsequent years, an annual wellness visit is mandatory; this is required regardless if the member is eligible for PDCM services

26. BCBSM Medicare Advantage - Wellness Visit vs. Comprehensive Assessment
Billing Guidelines Request that All Medicare Advantage patients have Comprehensive Assessment Annually
The Comprehensive Assessment (G9001) is not intended to replace the annual wellness visit (G0438)
CMS expects all Medicare Advantage members to have a wellness visit with their physicians annually for planning and preventive purposes. During this wellness visit all the chronic conditions, and any diagnoses the member has, should also be listed. In the event that the member has had the wellness visit (G0438) there will be no requirement for them to have the PDCM Comprehensive Assessment (G9001). If the physician and care manager feel that the member could benefit from also having a G9001 comprehensive care management assessment, however, the care manager may conduct the assessment and the service will be payable.

27. QUESTIONS?
Please send questions to the Provider Delivered Care Management Oncology Expansion mailbox-
MORE INFORMATION