1. BCBSM PDCM/MiPCT Program Discussion Session
November 15, 2012

2. Care Management Automated Tools
MiPCT Care Managers should use care management software or other automated tools (e.g., electronic medical records, patient registries) in their work with patients:
Maintain list of active patients, both follow-up and new
  Document information from care management visits, including diagnoses, self-management goal-setting, and transitions of care information
  Create and maintain patient care plans
  Generate care manager activity reports and align the health information tools with existing care management workflows at your organization

3. Care Management Automated Tools
In some cases, patients who drop off the monthly list may still be eligible for care management services
Under our attribution  methodology, a patient could drop off the list if they are seen by a provider in a different PO.  If the patient is still considered a current patient with the original provider, and has active BCBSM coverage, the patient will remain eligible for care management services.
 To verify eligibility when a patient has been dropped from your list, submit an inquiry through the PGIP Collaboration Site, including the patients’ name and contract number.
 Please note that if a patient has been dropped from the list because they are no longer eligible for PDCM/MiPCT (for example, if a patient changes jobs and their new employer does not participate in Provider Delivered Care Management), future claims for these patients will not be payable

4. Code Updates PDCM Home-based care management: TBD
Add new code for Care Manager care coordination: 99489
Add new code for physician for team conferences: G9007
Oncologists will use same PDCM codes
Home-based care management: TBD
New care transition codes payable for all providers: and 99496

5. PDCM Current Billing/Coding
PDCM currently pays for 7 services delivered by qualified non-physician practitioners to approved practices or POs
PCP is generally identified as the Rendering Provider on the claim (and E&M fee uplifts for which they qualify are applied to these codes)
No cost-share is applied (except for groups with high deductible plan products with HSAs)
If any of these services are billed for members that are not PDCM eligible (i.e., the group does not participate) the service is rejected with provider liability
PCP visits are billed as regular office-visits and the member’s OV coverage/cost-share applies
Base Fee
Net P/O Component
G9001–CC fee-initiation*
$118.20
$112.64
G9002–CC fee-maintenance (indiv F2F)
$59.10
$56.32
98961—Grp educ & training (2-4 pts)
$14.77
$14.08
98962—Grp educ & training (5-8 pts)
$10.98
$10.46
98966—Telephone asst (5-10 min)
$15.16
$14.45
98967—Telephone asst (11-20 min)
$29.18
$27.81
98968—Telephone asst (21-30 min)
$43.19
$41.16
* Limit of one per year

6. New CPT Codes for 2013-Complex Chronic Care Coordination
Complex Chronic Care Coordination—Clinical staff time, directed by a physician or other qualified health care professional
Code
Description
99489
CCCC, each additional 30 minutes, per calendar month
Billed by care manager for care coordination with providers that are NOT the PCP, the primary caregiver or the patient
Two options for claim reporting: (1) on the date of service (ignore “per calendar month”) or (2) total up the time spent and quantity bill at the end of the month (i.e. 3 hours = quantity of 6)
Does this proposal meet your request from the PGIP Quarterly Meeting?
What do you think of criteria for payment for this procedure code?

7. Team Conferences
Proposed paying G9007 to physicians (e.g. $30) to encourage physicians and care management staff to formally discuss care plans
Billed by physicians only, not the care manager
Does this proposal meet your request from the PGIP Quarterly Meeting?
What type of criteria for payment would you recommend for this procedure code?

8. Under Development: Home-based Complex Care Management
Home-based PDCM
Providers would include Care Managers and Physicians
Codes already exist for Physicians, exploring options for clinical model
Current PDCM codes do not account for additional complexity/travel for home-based delivery
New CCCC codes could be adopted for home based care distinct from office-based delivery
Potential model of PDCM practices/POs contract with HHAs/Hospices (and their services are paid indirectly, i.e., reimbursement goes to the practice/PO)
How do we want to integrate with other existing home based care delivery providers? For example: HHAs and Hospice
Pay in person PDCM services at 150% when done in the home

9. New CPT Codes for All Providers in 2013 Transitional Care Management
Transitional Care Management—Services with the following required elements:
Communication (direct contact, telephone, electronic within two business days of discharge)
Medical decision making of defined complexity (see below) during the service period
Face-to-face visit, within defined days of discharge (see below)
Code
Description
99495
TCM, moderate complexity, visit within 14 calendar days of discharge
99496
TCM, high complexity, visit within 7 calendar days of discharge
Payable to all MD/DO, CNP & PA’s – not just PDCM
Treat as office visit, with cost-share applied
Fee Uplift applicable
Continue to use current G-codes to pay nurse care manager encounters (face-to-face or phone) which may occur post-discharge or pre-discharge (using location of service 1)

10. Questions?