Michigan Primary Care Transformation

Demonstration Project

March 7, 2012Webinar #2

Agenda

Patient Identification Patient Eligibility Funding Care Management Training PDCM Policy Design General Conditions of Program Delivery Billing Guidelines

2

Patient Identification and Eligibility

Attributed Assigned All patients and all payers Begin to build patient file

3

Practice Transformation, Care Manager and P4P Payments

Medicare Medicaid Blue Cross Blue Care Network

4

MiPCT Meetings

March 20, 2012 (9am-12noon or 5pm-8pm) March 28, 2012 (9am-3pm)

5

Care Manager Training

Moderate Care Manager• Self Management Training • Completed by June 30, 2012• Approved learning organization that provides

Certificate or CEU

Complex Care Manager • Geisinger Model Training

6

Care Manager Training Classroom

25 hour curriculum• Pre-work• Care Manager Project

Options• Group Orientation: March 27 or 29 (9am – 12noon)• April 7, 14, 21, 28• May 5, 12, 19, June 2• April 3, 10, 24, May 1, 8, 15, 22, 29, June 5, 12, 19• April 5, 12, 19, 26, May 3, 10, 17, 24, 31, June 7, 14

7

Care Manager Training Virtual

25 hour curriculum• Pre-work• Care Manager Project

Options• Group Orientation: March 27, 28 or 29 (9am – 12noon)• Web based interactive

•April 2, 9, 16, 23, 30, May 7, 14, 21, June 4, 11•April 4, 11, 18, 25, May 2, 9, 16, 23, 30, June 6

8

Care ManagerFinal Assessment

Two hour final assessment June 7, 8, 9, 10 or 17 (9am-10am or 6pm-8pm) Morning or evening meeting Enrollment dependent

9

Care Manager Assignment

Care Managers available• Dawn Carroll**• Dawn D’Allesandro• Margaret Kucinski**• Deb Kobayashi• Ilene Latasiewicz• Kim Roberts (Pediatrics Only)• Angie Siegmon• Deb Slocum• Pam Vaccarelli

10

PDCM Payment Policy

7 codes for services performed by qualified non-physician practitioners

Payable to approved providers only BCBSM will pay the lesser of provider charges or

BCBSM’s maximum fee•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

11

PDCM Payment Policy Design

CODE SERVICE

G9001 Initial assessment

G9002 Individual face-to-face visit (per encounter)

98961 Group visit (2-4 patients) 30 minutes

98962 Group visit (5-8 patients) 30 minutes

98966 Telephone discussion 5-10 minutes

98967 Telephone discussion 11-20 minutes

98968 Telephone discussion 21+ minutes

12

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

13

General Conditions of Payment

For billed services to be payable, the following conditions apply:

•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

14

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)

15

Services billed for non-eligible members will be rejected with provider liability.

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 participant in the care plan

16

Services billed for non-eligible members will be rejected with provider liability.

Patient 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

17

Services billed for non-eligible members will be rejected with provider liability.

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 professiona•LPN, CDE, RD, nutritionist, clinical pharmacist, respiratory therapist,

certified asthma educator, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor, certified health educator specialist (bachelor’s degree or higher), licensed professional counselor, licensed mental health counselor

18

Provider Requirements: Care Management Team

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

Only lead care managers may perform the initial assessment services (G9001)

19

Provider Requirements: Billing and Rendering Provider

RenderingProvider

Billing Provider

Practice-based Physician, CNP or PA within the PDCM-approved practice

Physician practice

Physician Organization-based PO-based billing entity

20

• 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

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

21

Billing and Documentation: General Guidelines

• 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

22

Initiation of Care Management (Comprehensive Assessment)

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 (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.

23

Individual, Face-to-Face Visit

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

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.)

24

Group Education & Training Visit

98961 Education and training for patient self-management for 2-4 patients, 30 minutes98962 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 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 patient’s condition, needs, progress

25

Telephone-based Services

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

Additional documentation requirements:• Dates, duration, name/credentials of care manager performing the call• Nature of the discussion and pertinent details regarding updates on patient’s condition, needs,

progress

26

27

Issues in 3 x

5

CommentsComments