Transcript Provider Delivered Care Management Billing Guidelines Webinar

Provider Delivered Care Management
Billing Guidelines Webinar
February 2013
Agenda
• Reimbursement Policy Design Overview
• Billing Guidelines for New PDCM Codes
– 99487, 99489, G9007, G9008
• Summary Chart of Billable PDCM Codes by Provider Type
• Clarification for Transitional Care Management Codes
• Questions
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PDCM Payment Policy Design Overview
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Fee-for-service methodology
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
No cost share imposed on members EXCEPT members with Qualified High Deductible Health Plans with a
Health Savings Account
CODE
SERVICE
FEE*
Codes for Care Management Team Services
G9001
Initial assessment
$112.67
G9002
Individual face-to-face visit (per encounter)
$56.34
98961
Group visit (2-4 patients) 30 minutes
$14.08
98962
Group visit (5-8 patients) 30 minutes
$10.47
98966
Telephone discussion 5-10 minutes
$14.45
98967
Telephone discussion 11-20 minutes
$27.81
98968
Telephone discussion 21+ minutes
$41.17
99487
Complex chronic care coordination, first hour
$85.74
+99489
Complex chronic care coordination, additional 30 minutes
$43.05
Codes for Physician Services
G9007
Coordinated care fee, scheduled team conference
$28.59
G9008
Physician coordinated care oversight services
$47.65
*Net of Incentive amount
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Code-Specific Requirements: 99487, 99489
Complex chronic care coordination services
99487
+99489
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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.
Intended as reimbursement for significant time spent coordinating with other providers
and/or agencies
Payable when performed by any qualified care management team member
The cumulative duration of communication time must be at least 31 minutes in a
calendar month to be billable
Contacts may be by phone or face-to-face
Time spent communicating with the patient’s primary care physician or caregiver is not
included
Quantity limitations:
– 99487 may only be billed once per calendar month, per patient
– 99489 may be quantity billed
Documentation must include:
– Date of contact
– 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 and pertinent details
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Time Guidelines for Billing Complex Care Coordination
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99487 should be billed for the first 31 to 75 minutes of care coordination for a
patient in a month
99489 is billed in addition to 99487 for each additional 30 minutes of interactions
A code may be billed when at least 51% of the time designated in the descriptor
is met
Total time
(in minutes)
Code(s)
to bill
Quantity
1-30
Cannot be billed
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31-75
99487
1
99487
1
99489
1
99487
1
99489
2
99487
1
99489
3
99487
1
99489
4
76-105
106-135
136-195
196-225
Code-Specific Requirements: G9007
Coordinated Care Fee, Scheduled Team Conference
G9007
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Coordinated care fee, scheduled team conference
This code is to be billed by the physician and is payable to the physician for formally
scheduled discussion
– Must include primary care physician and care manager
– May include other team members
– Patient should not be present
The scheduled discussion per patient must be at least 10 minutes in duration
Discussion must be based on need, e.g.
– Patient is not progressing
– There is a change in the patient’s status
Discussion must be substantive and focused on a patient’s individualized care plan and
goal achievement
Outcomes and next steps for each patient must be agreed upon
Claims reporting requirements:
– Separately billed for each individual patient discussed during the team conference
– Can be billed once per patient per day
Documentation must include:
– Enumeration of each encounter including:
• Date of team meeting
• Duration of discussion for individual patient
• Name and credentials of allied professionals present for team conference
– Nature of discussion and pertinent details
– Any revisions to the care plan goals, interventions, and target dates (if necessary)
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Code-Specific Requirements: G9008
“Engagement Fee”
G9008
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Physician coordinated care oversight services
This code is to be billed by the physician and is payable to the physician
Intended as reimbursement for each patient upon “enrollment” (i.e. completion of an
agreed upon care plan)
A written care plan with action steps and goals accepted by the physician, care manager,
and patient must be in place
– Care plan must be formally shared between all 3 parties
– Ideally, this interaction is face-to-face with all 3 parties present
– 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
Quantity limitations:
– May be billed only one time per patient, per physician
Documentation must include:
– Evidence of a written shared action plan for the patient developed by the care
manager that has been reviewed and approved by the billing physician
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Billable PDCM Codes by Provider Type
Provider Type
Service
Initial Assessment
Face-to-face Encounter
Care Manager
Other Care Team
Members
Physician
G9001
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G9008
G9002
*
Phone
98966, 98967,98968
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Group
98961, 98962
*
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G9007
99487, 99489
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Team Conference
Complex Care Coordination
*These encounters should be billed as E&M visits.
Informational:
Clarification for TCM Codes
Clarification for Transitional Care Management Codes: 99495, 99496
99495
99496
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Moderate complexity; patient contact within 2 business days of discharge and a
face-to-face within 14 calendar days of discharge
High complexity; patient contact within 2 business days of discharge and a faceto-face within 7 calendar days of discharge
These are not PDCM-specific codes.
Transitional care codes were released 1/1/13. These codes are not exclusive to the PDCM
program.
These codes should be billed by the physician, CNP, or PA who conducts the postdischarge follow-up visit, like an E&M service.
These codes are intended to be billed at the end of 30 days post discharge (from a
hospital, LTAC, SNF, partial hospital, etc. to home).
They are billable by only one provider in that period.
They are intended to cover just one face-to-face visit. If there is a second visit, it would be
billed separately (e.g., as a regular E&M).
Discharge day management codes (99238/ 99239 for hospitals and 99315/99316 for SNF)
can be still be billed when the TCM codes are billed.
The TCM codes may NOT be used by a physician who also reports a service to the
patient with a global period of 10 or 90 days.
If TCM codes are billed by the physician, payment is still allowed for any care
management team services billed in the time window associated with the TCM
codes.
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QUESTIONS?
Please submit additional questions through our
Collaboration Site or your BCBSM provider consultant.
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