Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Medicare Advantage Provider Delivered Care Management

Billing Guidelines

Webinar 6/27/12 and 6/2812

Presented by Maureen Brown

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Topics

• Overview of Provider Delivered Care (PDCM)• Medicare Advantage (MA) Differences• MiPCT Specifics

Care Management Training Guidelines

– Services provided by Moderate care managers are billable once care managers complete MiPCT approved self-management training.  

– Services provided by Complex care managers are billable once care managers have completed

• MiPCT approved self management training

• MiPCT Complex Care Management training or registered on line for the course

– PDCM-codes should not be billed by untrained care managers

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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

• 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.

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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 care manager who:

• Is an RN, licensed MSW, CNP or PA• Has completed a MiPCT-accepted training program• Accepts responsibility for ensuring that PDCM services being delivered by any care

management team member are appropriate and aligned with the patient’s overall plan of care

– 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

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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 – restricted to 1/patient/year– No location restrictions– Documentation demonstrating services were necessary and delivered

as reported to BCBSM• providers must maintain a reasonable level of documentation • details for documentation are identified for each procedure code

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Initiation of Care Management (Comprehensive Assessment) G9001

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

• 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

G9001 - Documentation

• Initiation of care management• Limit of one G9001 per patient per year• Contacts must add up to 30 min. of discussion• Identification of the care manager responsible for the overall care

plan - name, title• Identification of the patient’s PCP, coordination & agreement• Enumeration of each encounter to include:

– Date, duration and modality of contact• at least one visit is face to face

– If contact is made with a person other than the patient, the name of the individual and their relationship with the patient must be documented

G9001 - Documentation cont.

• Overall findings from the assessment of patient’s medical condition and personal circumstances including, but not limited to:– All active diagnoses

– Current physical and mental/emotional status • Capabilities• Limitations

– Current medical treatment regimens

– Current medications

– Risk factors• Lifestyle issues• Health behaviors• Self-management activities, etc.

G9001 - Documentation cont.

• Assessment findings – Available resources and unmet needs– Level of he patient’s understanding of his/her condition(s) and readiness for

change– Perceived barriers to treatment plan adherence

• Care Plan– Individualized short and long term desired outcomes and target goal

dates

– Anticipated interventions to help the patient achieve their goals and timeframes for follow-up

• Patient’s agreement and consent to engage/participate in care management

G9001 - Documentation cont.

• For patient’s enrolled in ongoing care management– Monitor

– Evaluate

– Revise/update care plan

– Full re-evaluation every 12 months

12Individual, Face-to-Face Care Management Visit - G9002

G9002 Coordinated 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 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

Individual, Face-to-Face Care Management Visit – G9002

•Record documentation must include:

– Date, duration of contact, name/credentials of team member performing the service

– All diagnoses relevant to the encounter

– Other individuals in attendance (if any) and their relationship with the patient

– Nature of discussion and pertinent details relevant to care plan (progress, changes, etc.)

– Updated status on patient’s medical conditions, care needs, and progress to goal

– Any revisions to care plan goals, interventions and target dates

Telephone-based Services – 98966, 98967, 98968

98966 Telephone assessment and management, 5-10 minutes98967 Telephone assessment and management, 11-20 minutes98968 Telephone 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 patient’s care plan

• Claims reporting requirements– Code selection depends upon duration of phone call– All diagnoses relevant to the encounter should be reported

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Group Education & Training Visit –98961, 98962

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

• 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)• 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

Group Education & Training Visit – 98961, 98962

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– Quantity depends upon length of session (reported in thirty minute

increments)

• Documentation requirements:– All diagnoses relevant to the encounter should be reported– Dates, duration of class, name/credentials of care manager performing

the service– Nature of content/objectives of the training– Total number of patients in attendance– Any updated status on patient’s medical condition, care needs, and

progress to goal

MA Differences

• Fee Schedule

• Patient Eligibility

• Comprehensive Assessment (G9001)

• Documentation for Comprehensive Assessment (G9001)

• Claim Submission

MA Fee Schedule

Code TOS

Quantity Reported

Medicare Advantage Fee Amount

98961 9 x $16.17

98962 9 x $12.02

98966 9 $16.59

98967 9 $31.93

98968 9 $47.28

G9001 1 $129.37

G9002 1 $64.69

Patient Eligibility

• Medicare Advantage patients must have active Medicare Advantage coverage and PDCM benefits– Some 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

Wellness Visit vs. Comprehensive Assessment

• Billing Guidelines Request that All MA patients Have Comprehensive Assessment Annually

• Is the Comprehensive Assessment (G9001) Intended to Replace the Annual Wellness Visit (G0438)? – Clarification - 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 new 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 Provider Delivered Care Management (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.

Wellness Visit vs. Comprehensive Assessment – Continued

• Wellness Visit – Performed by Physician– Purpose is for Planning and Preventive Care– Some Patients Never Take Advantage of Annual Wellness Visit

• Comprehensive Assessment (G9001) – Performed by Non-physician Care Manager– Purpose is to Assess Appropriateness of Care Management Services

• MA’s Intention is to Have All Diagnoses Identified for purposes of:– Patients Receiving Appropriate Treatment/Care– Documenting Chronic and Acute (Temporary) Conditions

Comprehensive Assessment (G9001)

• Must Include a Face-to-Face Component

• When delivered by Registered Nurse (RN) or Master of Social Work (MSW) – Must be delivered under direct supervision of the physician (i.e.,

physician and care manager provide patient care in the same office suite)

– The patient’s physician must review and sign the comprehensive assessment note

– The physician’s NPI must be reported in the Rendering Provider field on the claim

– CMS Requirements

Claim Submission – COB

• Medicare Advantage members are not eligible for PDCM services if an insurer other than BCBSM is the primary insurer

• Coordination of benefits– Bill BCBSM Medicare Advantage Directly if Medicare Advantage is

Primary

– Bill BCBSM Commercial Directly if BCBSM Commercial is Primary

Claim Submission – G9001 & Rendering NPI

• Care Manager Registered Nurse (RN) or Master of Social Work (MSW)– Rendering NPI is the Physician

– To meet CMS Requirements

• Care Manager by Certified Nurse Practitioner (CNP) or Physician Assistant (PA)– Rendering NPI is the CNP or PA

Claim Submission – G9001 & DOS

• Patients Entering into Care Management – DOS is Date Patient Enrolls in Care Management

• Patients Not Entering into Care Management – DOS is Date of Face-To-Face Component of Assessment

Claim Submission – Paper Claims orDiagnosis Limitations

• G9001 Code Only - in addition to the claim, use Medicare Plus Blue PPO 2012-Physician Assessment Healthy Advantage Rewards form

• Instructions for submission are in included at the bottom of the form.• Forms may be obtained by:

– In the MA Billing Guidelines Document clicking on the link named: 2012-Physician-Assessment

– From the MA Billing Guidelines Document, pasting the following address into your web browser:

bcbsm.com/pdf/medicare/2012/MedicarePLUS-PPO-2012- Physician-Assessment.pdf

– Sending an email to the following address to receive an email with a link to the form: marevenuemgtops@bcbsm.com

Questions?